Every gender-questioning child or young person in the UK who asks for help and support from the NHS must receive the assistance they need in order to access the appropriate pathway for them as an individual. Children and young people who experience gender incongruence or dysphoria must receive the same standards of clinical care, assessment and treatment as every other young client who accesses health services, as well as being able to obtain psychological support. Support and understanding are key if this group is to be enabled to explore their gender without reproach.
Gender dysphoria describes the distress experienced by those who feel their identity is at odds with aspects of their body and/or the social gender role assigned to them at birth. The sense of unease can be so intense that it can lead to depression and anxiety and have a harmful impact on daily life.
Most people will identify as male or female, referred to as binary identities. However, some feel their gender identity is different from their biological sex: they may have male genitals but not identify as male or feel masculine; they may have female genitals and breasts but not identify as a female or feel feminine. Others do not define themselves as having a binary identity and, for them, the concept of gender is irrelevant to their identity. Gender identity may be fixed, fluid, neutral or non-binary. Every child and young person is different, there is no single narrative.
In recent years the NHS Gender Identity Development Service has seen a substantial increase in referrals, contributing to long waiting lists and increasing concern about how the NHS appropriately assesses and cares for this population of children and young people. At one point there were over 4600 young clients on the waiting list, with some waiting over 2 years for a first appointment.
The service provider was rated inadequate in 2020 by the Care Quality Commission (CQC) (2021) when concerns were raised by whistleblowers. Enforcement action was initiated by the CQC, requiring monthly updates on waiting-list numbers and actions to be taken to reduce them. It was determined that services were difficult to access and concerns raised as to how those on the waiting list were being managed, with many deemed vulnerable and at risk of self-harm. It was noted that staff did not always assess and manage risk well. The size of the waiting list meant staff were unable to proactively manage the risks for those waiting for a first appointment (CQC, 2021).
The increase in the number of children needing support and the complexity of case-mix suggest that the current clinical model is not viable in the longer term. As the specialist service has grown in response to demand, the clinical approach and service design has not always been subjected to the quality controls often used when new treatments are being introduced.
An independent review has been commissioned by NHS England/NHS Improvement with the aim of making recommendations on services provided to children and young people exploring their gender identity or experiencing gender incongruence. The interim Cass review (2022) was released to raise and address some of the issues these young clients may face, and it makes a number of points to ensure that the services provided are appropriately designed and properly monitored. A very different service model is required, more in line with other paediatric services, to offer timely and appropriate care for children and young people who need support concerning gender identity, including support for any clinical presentations the child or young person may have. Responding to the challenges noted in the interim report will require significant service transformation.
The care of children and young people, including this group, is everyone's business. Nurses and other clinicians however, must be provided with the wherewithal to respond to the need for improvements in assessments, operating systems and processes.