The formation of the welfare state and the establishment of the NHS in the post-war period is, to me, the crowning achievement in British history. We looked at the horror and suffering of the Second World War and said, “enough is enough”, we made a commitment to provide healthcare as a human right to everyone in this country. Even now in 2022 the NHS remains the largest non-military public organisation on earth, with values designed to improve the lives of every single person in the UK… Unless, it seems, you’re transgender.
As trans people we’ve all faced challenges with the NHS, whether it be the unacceptable waiting times of almost five years[1] for a first Gender Identity Clinic appointment, dealing with being misgendered and deadnamed or doctors who don’t understand our basic health needs.
It’s these experiences that made me want to be a mental health nurse. So that I, as a trans person, can be on the frontlines enacting change. I knew it wouldn’t be easy, but recent progress such as trans affirming GPs[2], regional clinics[3] and inclusive language[4] had given me hope for the future.
That’s why when I read the new NHS guidance for under 18s seeking gender affirming healthcare[5] I was floored. Rather than improving the healthcare we offer, the new NHS approach is taking us back to the dark ages.
The reaction within the trans community has been of universal condemnation. On Twitter Mermaids, the trans youth charity, immediately responded that “many of the proposals are seriously concerning”.
Dr Helen Webberley, of Gender GP, wrote “It is absolutely disgusting that the UK is not keeping up with current best practice… people are suffering intolerably”.
One user, a parent of a trans child, raised that neither the Cass review nor the new guidance had listened to any of comments from the trans service users and their families who had been consulted.
Bad Faith, Bad Sources
The guidance seems to have been written in bad faith from the start.
For instance, it cites “the conclusion of the Endocrine Society’s Clinical Practice Guidelines… “[that] gender incongruence of a minority of prepubertal children appears to persist in adolescence””. This has then been disingenuously reported in the press as the NHS stating that most transgender children as just “going through a phase”[6].
What the document fails to mention at any stage is a significant number of respected, long-term studies[7] which supports gender identity in trans adolescents persisting into adulthood with rates above 95%. In summarising the evidence regarding trans adolescents the World Professional Association for Transgender Health (WPATH) states “no clinical cohort studies have reported on profiles of adolescents who regret their initial decision or detransition after irreversible affirming treatment”[8].
Given medical treatment like puberty blockers and Hormones (HRT) are only relevant when a young person has started puberty, I cannot think of a reason for the NHS to focus on lower persistence of dysphoria in pre-pubescent children. It’s the extremely high persistence of trans adolescents that seems to be most relevant given this is the group that would be candidates for medical intervention. Yet this has been completely ignored.
The outlandish decisions continue with an attempt to classify “social transition”, allowing a teenager to wear the clothes they like, explore pronouns and alternative names, as a form of clinical treatment. Stating that social transition should only be allowed after “Gender dysphoria has been diagnosed” and where social transition is “is necessary for the alleviation, or prevention of, clinically significant distress or impairment in social functioning in the individual”.
The NHS hasn’t cited any evidence as to why such a higher barrier to a purely social, i.e. non-medical, transition is necessary. When you think about what this means it’s ludicrous. An assigned male at birth (AMAB) person shouldn’t be allowed to wear make up and a skirt unless they’ve already been assessed by two psychiatric professionals and have already reached a state of ill mental health. Are we really saying we can’t fund pay rises for nurses, but we can pay clinicians to ensure no one buys clothes in the “wrong” section?
Blocking the Blockers
Following discussion of social transition, we reach the most concerning statement regarding treatment.
“NHS England will only commission GnRHa in the context of a formal research protocol. The research protocol will set out eligibility criteria for participation.”. GnRHa are types of drugs which prevent the body from producing sex hormones, such as testosterone and oestrogen.
In trans young people they are used to delay or prevent puberty to provide time for the adolescent to socially transition and live in their gender identity prior to making irreversible choices, more commonly known as “puberty blockers”. They can then either decide to progress onto HRT or to cease taking blockers and to allow the body to undergo the puberty of their chromosomal sex.
The discontinuation of providing puberty blockers was one of the biggest concerns for trans people, allies and their loved ones following statements made in the Cass Review earlier this year. Now the NHS has formally confirmed that they will no longer be used as standard treatment for transgender adolescents.
How restrictive this approach will be remains to be seen, but it undoubtedly ensures that accessing puberty blockers and progressing onto HRT is going to be harder for trans adolescents. This appears to be despite an ever-growing body of evidence which supports the use of these drugs as crucial to the mental, physical and social wellbeing of teens experiencing gender dysphoria. In fact,
The same guidance from the endocrine society cited in the NHS document explicitly states “We suggest that clinicians begin pubertal hormone suppression… [after the patients] first exhibit physical changes of puberty. We recommend that… GnRH analogues are used to suppress pubertal hormones.”.[9] Additionally, WPATH guidance explicitly states, “We recommend health care professionals prescribe… [a] GnRH agonist for transgender and gender diverse adolescents.” And that GnRH agonists “have been studied in multiple transgender populations”.
Ironically, a few days after the NHS published their proposed guidance a new large scale longitudinal study on transgender adolescents was published in the Lancet medical journal[10]. The study followed over 700 transgender teens undergoing treatment with puberty blockers and HRT in the Netherlands over an average period of approximately 6 years. It found that 98% of these trans adolescents persisted with HRT into adulthood.
We are also only discussing the usage of GnRHa drugs within the specific context of the trans population. These are standard NHS drugs listed on NICE’s BNF which have been used to treat cisgender people (including adolescents) experiencing endometriosis, cancer and early puberty for decades. We are talking about drugs long established as safe, are completely reversible and have shown significant health benefits for trans teens.
This new guidance is not only incorrect but seems to be wilfully ignoring a scientific body of evidence supporting the usage of puberty blockers as treatment for transgender adolescents.
First, Do no harm
Sadly, we know the consequences of not providing appropriate care to transgender young people. Depression, anxiety, social isolation and suicide attempts ten times higher than the average population[11].
We also know how wonderful and life saving these treatments can be for trans kids growing up. This video[12] filmed by the amazing Mygenderation shows how puberty blockers enabled a trans boy, Kai, to focus on being a normal boy and living his life. For older trans people like myself who experienced the trauma of going through the wrong puberty, seeing the benefit of blockers for kids like Kai is nothing short of miraculous. To take that away would take away years of progress and condemn another generation of transgender kids and teens to entirely preventable suffering.
As nurses we have a duty of candour to tell our patients when they aren’t receiving the care they should. Kath Melia, in her book “Ethics for Nursing and Healthcare Practice”, talks about the scared relationship between a nurse and their patient based on trust. We are taught to hold the so called “6 C’s of care”, Care, Compassion, Competence, Communication, Courage and Commitment as crucial to being a good nurse.
Yet what the NHS is proposing for trans children and adolescents violates all these principles. It is a fundamentally dishonest document that wilfully ignores the substantial evidence base advocating for affirmative care. It sacrifices the care of our patients for political ends. As a student nurse, and a trans person, I have a duty to speak up.
We still have time and the opportunity to do so. Until 4th December you can submit your response to the NHS consultation. If you are a trans person, a parent or an ally please take the time to let the NHS know that we demand better. That we refuse to allow another generation of trans kids to be failed by those who should care for them.
[1] Waiting times – Gender Identity Clinic – GIC
[2] Trans Health Hub (wellbn.co.uk)
[3] Home | Indigo Gender Service
[4] Brighton NHS Trust introduces new trans-friendly terms – BBC News
[5] b1937-ii-specialist-service-for-children-and-young-people-with-gender-dysphoria-1.pdf (england.nhs.uk)
[6] NHS says most children who identify as transgender are going through a phase | UK | News | Express.co.uk
[7] Two Dutch studies report low rates of adolescents (1.9% and 3.5%) choosing to stop puberty suppression (Brik et al., 2019; Wiepjes et al., 2018)
[8] Pg. 547 WPATH Guidelines 2022
[9] Gender Dysphoria/Gender Incongruence Guideline Resources | Endocrine Society
[10] Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands – The Lancet Child & Adolescent Health.
[11] LGBT in Britain – Health (2018) (stonewall.org.uk)
[12] Transgender Boy: Kai, Age 14 – Filmed for 5 years – YouTube
