The proposal would create new obstacles for those seeking gender incongruence services. By limiting referrals to the Child and Adolescent Mental Health Service (CAMHS) and paediatric services, respondents fear it will be harder for individuals to access the care they need, suggesting that efforts should be made to make the process as easy and accessible as possible.

There were concerns raised by some that this proposal will exacerbate the strain on CAMHS and paediatric services, which are already facing challenges in meeting demand. There is concern this could lead to significant delays in accessing gender incongruence care, putting young people at risk during a critical period of their development.

This was felt to also have a detrimental effect on other young people needing to access the services. They suggested details in the proposal gave no indication of how this will be managed, saying it could mask the true number of people waiting for gender services.

There is evidence that the majority of individuals who are referred to a child and adolescent gender incongruence service will have co-occurring mental or physical health needs. One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list. It is therefore entirely appropriate that NHS secondary care services are engaged before a referral is made to the waiting list of the gender incongruence service. The referral date into the local secondary care service will be honoured for the purpose of determining an individual’s place on the waiting list for the gender incongruence service.

NHS England will work with providers over 2024/25 and 2025/26 to identify the additional resource that will be needed to realise the Cass Review’s ambition of a matrix of local services working within a regional network of care, resulting in more children and young people being seen and cared for in secondary care services rather than by the tertiary provider.

The likely increase in referrals to CAMHS as an outcome of the new arrangements is around 0.3% – see the Equality and Health Inequalities Impact Assessment.

In March 2024 the Office of the Children’s Commissioner published its report: Children’s Mental Health Services, 2022/23.  The report concludes that overall, spending on children’s mental health services (excluding spending on mental health services for children with learning disabilities) increased every year from 2018-19 to 2022-23. Nationally, Integrated Care Boards (ICBs) spent £997 million on children and young people mental health services in 2022-23, equal to 1.02% of the total spent by ICBs. This compares to £922 million in 2021-22 – an increase of 8% in nominal terms. However, the report also highlighted that overall spending on mental health and ‘spend per child’ varies widely by area; and that when adjusted for inflation, growth has slowed from 7% between 2020-21 and 2021-22 to 1% between 2021-22 and 2022-23.

There was concern that there are transphobic opinions held within the NHS, and that this change could be considered ‘gatekeeping’, or deliberate obstruction to treatment. 

No evidence was offered during consultation that would support the claim that secondary care clinicians would seek to deliberately obstruct access to a clinical pathway. The objectives of the proposal are to increase the quality of the referral information that accompanies the child or young person into the gender service (thereby reducing the risk of unnecessary delay at the assessment stage) and to ensure that the health needs of children and young people are identified and addressed at the point of referral and while they remain on the waiting list for the gender service.

GPs should continue to have the ability to refer directly to gender incongruence services. They argued that GPs often have a broad and holistic understanding of their patients’ health and hold a good and trusting relationship with the whole family, meaning they are in a good position to assess the need for specialised gender incongruence care, without the need for additional intermediary steps.

Some respondents for the inclusion of other referral options, including self-referral, parental referral, and the ability for a wider range of professionals to make referrals, such as social workers, therapists and teachers.

The Cass Report (April 2024) observed that it would be unusual for referrals to be made to a specialist tertiary service without a prior assessment by secondary care professionals.

Too often in the past referrals were made to the former Gender Identity Development Service by primary care or other professionals, and third sector organisations, of children and young people whose significant mental and physical health needs were not addressed while they remained on the waiting list for GIDS (around 70% of referrals to the NHS Children and Young People’s Gender Service are made by GPs; April 2024). One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list.

The Royal College of General Practitioners agreed that referrals must be made through secondary care services, for the reasons set out above. GPs will maintain a key role in taking the decision – with the child, young person and family – of referring into the secondary care service for the purpose of considering a referral to a specialised gender incongruence service.

The inclusion of general paediatricians was considered by some respondents to be inappropriate as it was felt this implies that the patient has a medical or physical condition, which they said was rarely the case.  General paediatricians were said by some to lack the appropriate expertise within gender incongruence, as they are not usually involved in neurodevelopmental assessments and hold no additional experience in comparison with GPs.

The issue of conflating gender incongruence with mental illness was highlighted by some, arguing that the requirement for referrals from mental health services inappropriately pathologises transgender identities and that being transgender is not inherently a mental health issue.

CAMHS was said by some to not possess the full and necessary skill set to understand and assess transgender patients. 

The Royal College of Paediatrics and Child Health agreed with the proposal, on the understanding that local services are supported through specific guidance, as did the Royal College of General Practitioners.

NHS England will work with providers over 2024/25 and 2025/26 to identify the additional resource that will be needed to realise the Cass Review’s ambition of a matrix of local services working within a regional network of care, resulting in more children and young people being seen and cared for in secondary care services rather than by the tertiary provider.

Secondary care services are not being asked to assess or diagnose gender incongruence or gender dysphoria, and are not being asked to intervene beyond what is reasonably expected to be within their existing competence levels.

There is a need for all professionals involved in the referral process to be adequately informed and provided with evidence-based training to ensure an effective and efficient system. They raised a question of whether support and training will be provided in dealing with potentially pressurising parents and patients who may bring with them strong and convincing, gender ideological beliefs and concerns, such as suicide and time pressure issues.

NHS England will work with providers over 2024/25 and 2025/26 to identify the additional resource that will be needed to realise the Cass Review’s ambition of a matrix of local services working within a regional network of care, resulting in more children and young people being seen and cared for in secondary care services rather than by the tertiary provider.

Concerns were raised by some respondents about the feasibility of limiting referrals to CAMHS and paediatric services due to existing pressures, long waiting lists, and staff recruitment and retention issues. This was felt to have the potential to create a bottleneck effect, delaying access to gender incongruence services further. They voiced concerns that CAMHS waiting lists and pressures could lead to inappropriate referrals without exploring the case as a whole.

The referral date into the local secondary care service will be honoured for the purpose of determining an individual’s place on the waiting list for the gender incongruence service.

NHS England will work with providers over 2024/25 and 2025/26 to identify the additional resource that will be needed to realise the Cass Review’s ambition of a matrix of local services working within a regional network of care, resulting in more children and young people being seen and cared for in secondary care services rather than by the tertiary provider.

Concerns that the effectiveness of the referral process could be influenced by the personal beliefs of the referring professional. They stated that if a referrer holds strong convictions about gender identity, it might sway the decision to refer, potentially leading to biased referrals based on belief systems rather than patient needs.

These submissions do not offer reasons why NHS England should maintain the current arrangements in place of its proposal for all referrals to be made by secondary care services.  

Children under 7 are too young to understand or make decisions about gender incongruence, suggesting that early childhood should be a period of gender exploration without external influence and possible encouragement, which could lead to potentially harmful medical intervention.

Gender nonconformity in early childhood often resolves naturally without the need for intervention, and that services should focus on older children who continue to experience gender dysphoria.

Children were said to not require endocrine services before puberty begins and so any assessments before age 7 were deemed futile. 

The age limit was also felt to free up resources for the more urgent, time sensitive cases.

While agreeing with the proposal, some respondents suggest that the minimum age for referrals to gender services should be set at a higher age, based on developmental milestones showing that children older than 7 years of age lack the capacity to understand the consequences of entering a medical pathway.  Suggestions were made for an increase in the age limit to at least 10 years of age.

Concerns were expressed by these respondents regarding safeguarding in cases where they felt it was in the interest of the parents to encourage gender identity issues rather than the child’s.

NHS England had proposed for the purpose of public consultation that children under 7 years could not be expected to have the necessary cognitive or communication development to engage with health professionals in discussions around gender identity.   The majority of clinicians who responded to this question (75%) agreed with the proposal. However, in April 2024 the Cass Review recommended that a separate pathway should be established for pre-pubertal children and that services should ensure that pre-pubertal children are prioritised and are seen as early as possible by clinicians with relevant experience (Recommendation 4, Cass Report). NHS England will work with providers to establish this pathway on the basis that the primary objective is to provide support and guidance to the parents / carers rather than as a gender affirming clinical intervention for the child, while ensuring that there is experienced psychological support for the child where there is distress or impaired wellbeing.

Regarding the submission on safeguarding, Dr Cass’ recommendation for early support and guidance to parents from the NHS seeks to mitigate the risk that is described.

The age limit of 7 years is arbitrary and lacks clinical evidence, potentially excluding children who need early intervention which could lead to harm and suffering.

The number of referrals under the age of 7 is low (1.3%), this change was suggested to have little or no impact on waiting times, but the negative effects on the lives of the children that cannot access support was said to be significant. 

Some respondents believed that some children would have a strong and inherent understanding of their gender identity from a very young age, making it inappropriate to impose an age limit on referrals.

The decision should be to limit the age for the first appointment rather than the waiting list referral. Some pointed out that, should the child change their mind at any time, they can remove themselves from the waiting list. 

Setting an age limit could leave children without professionals to talk to and families without necessary guidance and support. 

For the purpose of public consultation, NHS England acknowledged that there is no firm clinical evidence to determine whether a minimum age threshold should apply. NHS England proposed that children under 7 years could not be expected to have the necessary cognitive or communication development to engage with health professionals in discussions around gender identity.   The majority of clinicians who responded to this question (75%) agreed with the proposal.

The proposal was not made with the aim of reducing waiting times – the intention was to prevent unnecessary referral of children who may be too young to understand the nature of the clinical pathway on which they had been placed.

However, in April 2024 the Cass Review recommended that a separate pathway should be established for pre-pubertal children and that services should ensure that pre-pubertal children are prioritised and are seen as early as possible by clinicians with relevant experience (Recommendation 4, Cass Report). NHS England will work with providers to establish this pathway on the basis that the primary objective is to provide support and guidance to the parents / carers rather than as a gender affirming clinical intervention for the child, while ensuring that there is experienced psychological support for the child where there is distress or impaired wellbeing.

There should also be a focus on providing comprehensive support for children and their families and peers beyond just those on the waiting list. This should include providing local services with education and resources in order to support younger children questioning their gender, without gender affirming or encouraging social transition, but instead adopting a developmentally informed ‘watch and wait’ approach.

NHS England will work with providers over 2024/25 and 2025/26 to identify the additional resource that will be needed to realise the Cass Review’s ambition of a matrix of local services working within a regional network of care, resulting in more children and young people being seen and cared for in secondary care services rather than by the tertiary provider.

In September 2023 NHS England published MindEd on-line psycho-education resources on gender incongruence in childhood and adolescence for local services and professionals.

Children and young people of any age should not receive medical treatment for gender dysphoria, instead only being offered psychological support.

In March 2024 NHS England published a clinical commissioning policy on Puberty Suppressing Hormones (PSH) for children and young people with gender incongruence. From 1 April 2024 no new recommendations may be made for prescribing PSH to children and young people with gender incongruence.

In April 2024 the Cass Report did not recommend that gender affirming hormones should be withdrawn from the clinical pathway but recommended that clinicians should exercise ‘extreme caution’ in view of the limited evidence base, pending the outcome of NHS England’s review of the use of gender affirming hormones in 2024.

Referring 17-year-olds directly to adult services could expedite their access to appropriate care due to the currently long waiting lists in both children’s and adult services.

In practice, 17-year-olds were unlikely to be seen by children’s services before they turn 18, advocating for immediate referral to adult services.

Importance of ensuring a seamless and barrier-free transition from children’s to adult services,

In April 2024 directed the adult Gender Dysphoria Clinics to defer starting new assessments of young people aged 17 years of age until their 18^th birthday, in response to the Cass Report. NHS England’s review of the service specification for adult gender dysphoria services will consider extending the age threshold for access into the adult gender service above 17 years of age.

Consequently, NHS England will maintain the current arrangement that referrals may be added to the waiting list for the Children and Young People’s Gender Service of individuals up to the age of the 18^th birthday, though referrers will be informed that young people who reach 17 years and 9 months and who will not be seen by their 18^th birthday will be removed from the waiting list.

There was a call from some participants for increased training and support to staff in adult services to ensure they can meet the needs of young adults transitioning from children’s services, especially to support those with additional needs, like neurodiversity and learning difficulties.

NHS England’s service specification for adult gender dysphoria services (adopted April 2020) requires commissioned providers to establish a Multi-Disciplinary Team that includes “good professional knowledge of neuro-developmental conditions, including autistic spectrum condition and of adjustments to facilitate optimal communication with affected people” and for the MDT to have access to “expertise in the care of people with learning disability and other special needs including Autistic Spectrum Conditions …”. However, NHS England will review clinical workforce and training needs within its planned review of the adult gender services in 2024/25 including in the context of the various recommendations and findings of the Cass Review (2024).

This age group are not yet adults and as such should not be excluded from the care they are entitled to in youth services because of poor management and a lack of resources.

These two services work to different clinical models.

Some stated that Adult services lack expertise with adolescents and do not offer the appropriate holistic assessments or psychological support, potentially commencing medicalisation without adequate safeguards.

The act of singling out an age group (17-year-olds), was said by some participants to have a negative impact on vulnerable individuals, while continuing their access to children’s service could be crucial for their mental health, emotional wellbeing, and feeling of validation.

Some suggested that many of these children will be autistic, taking longer to mature. It was put forward that those with an autistic diagnosis should be delayed in moving into adult services until they are ready.

The age threshold for access into adult gender services (17 years) was adopted in 2020 following an extensive process of public consultation, respondents to which included clinical and professional bodies.

The service specification for adult gender services does describe an approach for assessment that addresses all aspects of the patient’s history and presentation and are conducted by an MDT that includes clinicians with expertise in mental health co-morbidities, autism and neurodiversity. There is a clear requirement in the adult service specification for the MDT to consider and assess the impact of co-morbidities including psychological problems and autism.

In any event, NHS England will maintain the current arrangement that referrals may be added to the waiting list for the Children and Young People’s Gender Service of individuals up to the age of the 18^th birthday, though referrers will be informed that young people who reach 17 years and 9 months and who will not be seen by their 18^th birthday will be removed from the waiting list.

A few participants suggested the need for a new, transitional service to be created for 17 to 21/25-year-olds, stating this would bridge the gap between children and adults. 

NHS England is working up a proposal for a pilot service to deliver a “run through” pathway for 17- to 25-year-olds, with a view to assessment as to whether a referral to an adult clinic for gender affirming hormone treatment was indicated, in line with the recommendation of the Cass Review (April 2024)

For some respondents, there was a conditional agreement that all adult services must commit to promptly accepting 17-year-olds and that their place is not put on hold until their 18^th birthday. They felt there should be safeguards put in place to prevent a care gap and that a watertight process should be put in place which makes sure all clinicians are fully aware of the new referral pathway to prevent patients falling between the gaps.

Some respondents placed emphasis on preventing a care gap, making sure 17-year-olds continue to receive the care they need during moves between services. 

There was concern from some contributors about creating additional steps in the process and potential barriers for 17-year-olds who already face long waiting times, and the impact this would have on them.

Although referrals may still be made to an adult Gender Dysphoria Clinic of individuals who are aged 17 years, NHS England has directed the providers of adult gender services to defer the commencement of new assessments until an individual has reached 18 years of age, to reflect the findings and recommendations of the Cass Review. NHS England’s review of the service specification for adult gender dysphoria services will consider extending the age threshold for access into the adult gender service above 17 years of age.

The root problem is the underfunding and understaffing of gender services and that this change fails to address such issues.

Some believe that the proposal won’t change the fundamental issue of long waiting times.

NHS England has significantly increased financial investment in gender services in recent years; in 2024/25 investment in the children and young people’s service has more than doubled and further investment will be made this financial year as more new providers become operational from November 2024. The main constraint in building clinical capacity is the limited workforce potential.

Considering the current waiting times, some respondents felt that all young people aged 15 or 16 and over should be added to the adult services since they are very likely to be seen before turning 18 too.

NHS England’s service specification for adult gender services does not enable a referral to an adult Gender Dysphoria Clinic before the age of 17 years. NHS England has no plans for proposing a reduction in this age threshold.

Suggestions were made for the young person to be added to both the children and adults services waiting lists and to be seen by whichever is available first.

For now NHS England will maintain the current arrangement that referrals may be added to the waiting list for the Children and Young People’s Gender Service of individuals up to the age of their 18^th birthday, Referrers therefore have a choice as to which waiting list is appropriate for the individual, though referrers will be informed that young people who reach 17 years and 9 months will be removed from the young person’s waiting list and advised to consider a referral to an adult service.

The importance of honouring the original referral date when transferring to adult services was highlighted by some as being essential in ensuring continuity of care and fairness in the system, stating that they felt the proposal would be unacceptable without it.

The original referral date to the children and young people’s service will be honoured for those individuals who ‘age out’ from the waiting list and who are subsequently referred to an adult gender service.

While in agreement, some called for an automated and direct transfer process from the children to the adult service as soon as it becomes clear that the young person will be over the age of 18 by the time they are seen by the gender service.

NHS England has decided that is not clinically appropriate to directly transfer a young person onto the waiting list of an adult Gender Dysphoria Clinic because, as a commissioner of health services rather than a provider, it has no direct knowledge of the aims and intentions of the individual young person in regard to their gender identity, nor to how – and the extent to which – those personal aims and intentions may have changed while they were on the waiting list. The individual’s GP is better placed to support the young person in considering the appropriateness of a referral to an adult gender service, being particularly mindful that the adult service provides a pathway to irreversible surgical interventions which may not have been in the child / young person’s contemplation, or that of their parents / carers, when they were originally referred to the Children and Young People’s service.

Some respondents felt that transferring 17-year-olds to adult services could result in faster access to care, considering the long waiting lists in both children’s and adult services. They felt the key goal should be to ensure people are assessed by the most appropriate service as quickly as possible and to guarantee that no young person is lost during the referral process.  

Young people who reach 17 years and 9 months and who will not be seen by their 18^th birthday will be removed from the waiting list. NHS England has made this decision partly in response to the recommendations of the Cass Review for the establishment of a ‘pass through’ service from the young people’s service into a new adult pathway for individuals up to 25 years of age, and because the review of the service specification for adult gender dysphoria services will consider extending the age threshold for access into the adult gender service above 17 years of age.

Some respondents emphasised the need for adult services to be prepared to address the diverse needs of transitioning individuals, including those with neurodiversity or learning disabilities. The need for additional resources and training in adult services was mentioned to attempt to meet these needs adequately.

NHS England’s service specification for adult gender dysphoria services requires commissioned providers to establish a Multi-Disciplinary Team that includes “good professional knowledge of neuro-developmental conditions, including autistic spectrum condition and of adjustments to facilitate optimal communication with affected people” and for the MDT to have access to “expertise in the care of people with learning disability and other special needs including Autistic Spectrum Conditions …”. However, NHS England will review clinical workforce and training needs within its planned review of the adult gender services in 2024/25 including in the context of the various recommendations and findings of the Cass Review (2024).

There was a call from some contributors for clear policies about the transition process, including better communication between services, patients, and their families to ensure everyone is informed about their options and the steps involved.

NHS England will ensure that there is clear communication with young people, their families and referrers about any interim changes that are made to the pathway.

The potential psychological impact of long waiting lists and the challenges of transitioning between CYP and adult services was a concern which tempered their views of some that agreed with this proposal. It was said that this process could exacerbate stress, anxiety, and mental health issues, therefore there was a call for more supportive measures to be put in place during the transition period to help minimise the negative impact on wellbeing. Some suggested making the transfer optional for patients while being informed of the waiting times for both services. 

In April 2024 NHS England asked every local CYP mental health service in England to provide support to children and young people who are on the waiting list for gender incongruence services. This will provide everyone on the waiting list with an assessment of mental health needs and risks, so that local secondary care services can address an individual’s overall health needs while they wait to be seen by a gender service.

Some felt that patients should never be ‘removed’ from a waiting list because of NHS waiting times, nor should they require a second referral, this was seen as an unfair and an unnecessary burden that could delay care or act as a barrier and create further stress for the patient as well as adding pressure and workload to overstretched GPs.

Young people who reach 17 years and 9 months and who will not be seen by their 18^th birthday will be removed from the waiting list. NHS England has made this decision partly in response to the recommendations of the Cass Review for the establishment of a ‘pass through’ service from the young people’s service into a new adult pathway for individuals up to 25 years of age, and because the review of the service specification for adult gender dysphoria services will consider extending the age threshold for access into the adult gender service above 17 years of age.

Since there are contrasting acceptance criteria between the two services, and excessive waiting times for adult services, there is concern that this change will mean that patients will be dropped from the service.  This group argued for a more direct and guaranteeing approach, ideally using automatic transfers that do not require additional referrals.

Most other specialist services in the NHS continue to offer a place after a patient ‘ages out’ a paediatric service, or automatically transfers the referral to the adult service, some respondents were questioning as to why gender services were adopting a different approach.

It is not appropriate for NHS England to effect a direct transfer because as a commissioner of health services rather than a provider, it has no direct knowledge of the aims and intentions of the individual young person in regard to their gender identity, nor to how – and the extent to which – those personal aims and intentions may have changed while they were on the waiting list. The individual’s GP is better placed to support the young person in considering the appropriateness of a referral to an adult gender service, being particularly mindful that the adult service provides a pathway to irreversible surgical interventions which may not have been in the child / young person’s contemplation, or that of their parents / carers, when they were originally referred to the service.

A few suggestions were made for the transition to be optional and that if there is a chance for an individual to be seen within the year, the transfer should not be made.

The age threshold for removal from the young people’s waiting list has been extended to 17 years and 9 months.

Some respondents emphasised that at the age of 17, young people are still considered to be children by law and, in addition to this, may not be developmentally ready to attend adult services. Respondents highlighted the importance of age-appropriate care and the potential legal implications of transferring care based on age alone rather than on an assessment of need. 

The age threshold for access into adult gender services (17 years) was adopted in 2020 following an extensive process of public consultation, respondents to which included clinical and professional bodies.

However, NHS England’s review of the service specification for adult gender dysphoria services will consider extending the age threshold for access into the adult gender service above 17 years of age.

Simply transferring a young person to an adult waiting list, especially without a guaranteed timely follow-up, risks leaving them without critical psychological and medical support during a formative and potentially vulnerable period of their lives.

The potential risks to mental health if young people are denied timely and appropriate care at a vulnerable stage in their development were raised by respondents. They felt the impact of service transitions on the wellbeing of young people emphasised the need for additional mental health support during transition.

In April 2024 NHS England asked every local CYP mental health service in England to provide support to children and young people who are on the waiting list for gender incongruence services. This will provide everyone on the waiting list, who choose to accept the offer, with an assessment of mental health needs and risks, so that local secondary care services can address an individual’s overall health needs while they wait to be seen by a gender service.

Some participants urged for an urgent review of the differences between the clinical models used in the CYP Gender Incongruence Service and Gender Dysphoria Clinics for adults. They believe that specialised support and safeguarding tailored to the needs of young people would be inadequate in adult services.

The service specification for adult dysphoria services was adopted in 2020 following an extensive process of public consultation, respondents to which included clinical and professional bodies. The service specification for adult gender services does describe an approach for assessment that addresses all aspects of the patient’s history and presentation and are conducted by an MDT that includes clinicians with expertise in mental health co-morbidities, autism and neurodiversity. There is a clear requirement in the adult service specification for the MDT to consider and assess the impact of co-morbidities including psychological problems and autism.

The scope of NHS England’s review of the adult gender services will be published in due course.

Some respondents suggested the need for a transitional service model that bridges the gap between child and Adult services, offering continuity of care up to the age of 25, that is sensitive to the developmental stages of young people. 

NHS England is working up a proposal for a pilot service to deliver a “run through” pathway for 17- to 25-year-olds, with a view to assessment as to whether a referral to an adult clinic for gender affirming hormone treatment was indicated, in line with the recommendation of the Cass Review (April 2024)

Respondents highlighted the need for a seamless and integrated approach to transferring from child to adult services. They stated this should be about continuity of care, by ensuring adult services are prepared to accept new referrals efficiently. They wanted to make sure a streamlined, reliable, and well managed system was in place to transfer patients between services, they suggested offering a direct transfer to the adult service rather than requiring a burdensome re-referral, which would also reduce administrative pressures on GPs and make it less likely that patients are lost in the system.

It is not appropriate for NHS England to effect a direct transfer because as a commissioner of health services rather than a provider, it has no direct knowledge of the aims and intentions of the individual young person in regard to their gender identity, nor to how – and the extent to which – those personal aims and intentions may have changed while they were on the waiting list. The individual’s GP is better placed to support the young person in considering the appropriateness of a referral to an adult gender service, being particularly mindful that the adult service provides a pathway to irreversible surgical interventions which may not have been in the child / young person’s contemplation, or that of their parents / carers, when they were originally referred to the service.

Some respondents gave conditional acceptance of the proposal, as long as there was a commitment to make specific improvements to the system. These conditions included ensuring young people are added to adult waiting lists, that their original referral dates are honoured, and that there are safeguards to maintain the integrity, quality, and continuity of care. It was also said to be essential that GPs and clinicians are fully informed of the changes to the process and patients are given up-to-date information on waiting times.

The original referral date to the children and young people’s service will be honoured for those individuals who ‘age out’ from the waiting list and who are subsequently referred to an adult gender service. NHS England will ensure that there is clear communication with young people, their families and referrers about any interim changes that are made to the pathway.

While there was support for the service, some respondents were also concerned that it might create an additional barrier to care or that the service could become a gatekeeping mechanism rather than a support system, therefore there was a call to keep it a short and efficient process. 

The consultation service was welcomed for the support and expertise it could provide to community paediatric and CAMHS services that will be dealing with gender-related issues with CYP and their families. 

The service, it was suggested by some, could provide an important safeguard against moving too quickly to medical treatment without fully exploring other issues and comorbidities. It was stated by some respondents that this would enable a ‘watch and wait’ approach whilst providing psychoeducation regarding cases where gender incongruence naturally resolves itself following puberty. It was also considered important to these respondents to fully inform patients and family of the significant risks as well as benefits of the treatment. 

The purpose of the pre-referral consultation service is to ensure that a child or young person’s overall health needs are addressed at the point of referral to the gender incongruence service; and to support the child, family and local professionals in containing clinical risk while the child / young person remains on the waiting list.

While there was approval for the services, some participants considered it important for this to be well resourced, offering a high standard of care, and staffed with experienced and sufficiently trained personnel. There was also a recognition that local support networks’ quality might depend on each area, potentially impacting the effectiveness of the consultation service. 

Some who supported this proposal also raised concerns about the consultation service reaching its operational capacity quickly and becoming less effective over time as the service becomes stretched. 

The pre-referral consultation service will be staffed by trained clinicians working in the Children and Young People’s Gender Services. Adoption of the proposal will be deferred to 2025/26 while the new providers build clinical capacity through ongoing recruitment and training of new clinical staff.

Some respondents felt that the pre-referral consultation service added unnecessary steps and complication in the referral process, thereby acting as a delay or barrier rather than as an aid. They emphasised that immediate referral should be prioritised for mental health reasons, suggesting that additional layers in the process could delay care and ultimately be detrimental to the patient.

Support for patients experiencing distress whilst on the waitlist was considered valuable and was welcomed by some respondents. However, they stated this should not come at the cost of a place on the waiting list and should be offered alongside a referral to the gender service rather than being an extra step before being granted access to the service.

The purpose of the pre-referral consultation service is to ensure that a child or young person’s overall health needs are addressed at the point of referral to the gender incongruence service; and to support the child, family and local professionals in containing clinical risk while the child / young person remains on the waiting list.

One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list.

A significant concern raised by some was the perception that the pre-referral service would function as gatekeeping, limiting young people’s access to the gender services they need. These respondents argued that creating more gates was counterproductive to providing support. Support should be offered, they said, alongside the current referral process, and should not cost a patient their place on the waiting list. 

It is not clear why respondents have suggested that children and young people who meet the criteria for referral to the Children and Young People’s Gender Service would not be added to the waiting list for the gender service.

Some participants expressed concern that paediatric and mental health staff within the pre-referral service would not have the appropriate expertise to make informed decisions about referrals. They were concerned that there may be bigoted or transphobic views which would create barriers for vulnerable patients seeking help. Referral was said to require the knowledge and understanding of gender specialists and was, therefore, seen as a flawed approach.

The pre-referral consultation service will be staffed by trained clinicians working in the Children and Young People’s Gender Services.

Some respondents expressed concern that the pre-referral service could obscure the actual size of the waiting list for gender services. By not placing individuals directly on the waiting list, they felt it may be challenging to track demand and allocate resources appropriately. Some see the pre-referral service as a way to artificially reduce the appearance of long waiting times without addressing the core issue of service demand and capacity.

The purpose of the pre-referral consultation service is to ensure that a child or young person’s overall health needs are addressed at the point of referral to the gender incongruence service; and to support the child, family and local professionals in containing clinical risk while the child / young person remains on the waiting list.

NHS England has more than doubled financial investment in children and young people’s gender services in 2024/25 and will deploy additional investment this year as new services become operational; and it will continue to do so in future years as NHS England’s realises its ambition to have up to eight new providers established by 2026.

Some respondents disagreed with the proposed pre-referral consultation service because they saw it as an inefficient use of limited healthcare resources. Some have had negative experiences with using pre-referral services because they are difficult to access, time-consuming and often end in referrals not being accepted. There was a sense among some that the functions of the pre-referral service might duplicate the work already being done by GPs, which they believed could be sufficient for making referrals without additional layers of consultation. They suggested that it would be more beneficial to directly improve the existing Gender Incongruence Service. 

One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list.

NHS England has more than doubled financial investment in children and young people’s gender services in 2024/25 and will deploy additional investment this year as new services become operational; and it will continue to do so in future years as NHS England’s realises its ambition to have up to eight new providers established by 2026.

The stance of the professional involved in the pre-referral process is highlighted as a significant factor by some participants that could impact on the effectiveness of the service. There was an understanding that the effectiveness of the service would largely depend on the expertise and approach of the professionals employed. Some raised concerns that GPs had previously been offered e-learning modules which may have been biased, suggesting that primary care providers needed re-training through neutral modules, to ensure bias is taken out of all health services. Suggestions were made to monitor such a service to ensure that all advice given is in keeping with the most up-to-date evidence base. Some felt there should be more detail regarding the ‘local support’ offer, to ensure that only appropriate organisations support and train professionals.

The pre-referral consultation service will be staffed by trained clinicians working in the Children and Young People’s Gender Services.

There were concerns voiced by some that the pre-referral consultation service could risk unnecessary removal from the waiting list if it became another barrier in the process rather than a facilitator.

It is not clear why respondents have suggested that children and young people who meet the criteria for referral to the Children and Young People’s Gender Service would not be added to the waiting list for the gender service.

The referral process, it was suggested by some, must be transparent – with the wellbeing of the CYP at the heart of it. Therefore, they stated that the pre-referral consultation meeting and decision making should include the CYP and their family, as this would allow them to understand the process and pose questions. They were concerned that exclusion could have a negative effect on their wellbeing.

The aim of the pre-referral consultation service is to support referrers (from NHS general paediatric services and NHS children and young people’s mental health services) support their patients when considering a referral to the Children and Young People’s Gender Service. It does not involve direct clinical intervention with the child or family. It intends to facilitate timely understanding and care of children and young people referred to the gender service, including if the child or young person may otherwise benefit from specialist advice or targeted local care whilst spending a potentially extended period waiting for direct care.

One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list.

Staffing and Resources (n=53)

Concerns were voiced by some respondents about understaffing and underfunding of services, stating that the service specification fails to address these fundamental issues and that without them, service improvements and lowering of wait times cannot be achieved. There were calls for increased investment and training for healthcare professionals. Views were expressed around the specialist nature of the service and the requirement for expert clinicians to provide the best and most appropriate care for this vulnerable group of patients.

NHS England has more than doubled financial investment in children and young people’s gender services in 2024/25 and will deploy additional investment this year as new services become operational; and it will continue to do so in future years as NHS England’s realises its ambition to have up to eight new providers established by 2026.

Access and Referral Process (n=29) 

Some participants provided comment sharing concerns over the referral process, which they perceived as overly complex and potentially discriminatory, especially towards neurodiverse individuals. There were calls for direct, less bureaucratic referral pathways and the avoidance of additional gatekeeping barriers. Some suggested there was a lack of information in the specification on the appeals process or how to go about gaining a second opinion. There were also some questions regarding joint referral between CYP mental health services and paediatric services and who would be responsible for care arrangements while on the waiting list.

It is unclear why respondents would suggest that the pre-referral consultation service is discriminatory to neurodiverse individuals.

The aim of the pre-referral consultation service is to support referrers (from NHS general paediatric services and NHS children and young people’s mental health services) support their patients when considering a referral to the Children and Young People’s Gender Service. It does not involve direct clinical intervention with the child or family.

There is no ‘appeal process’. It is not clear why respondents have suggested that children and young people who meet the criteria for referral to the Children and Young People’s Gender Service would not be added to the waiting list for the gender service.

Patient Autonomy and Self-Referral (n=19) 

There were calls from some for greater autonomy for young people, including self-referral options, referral from non-healthcare professionals, and advocacy for the Informed Consent Model. They suggested this would help young people navigate services independently, or provide another trusted person to talk to, which would be especially important for those who may not have parental support.

Mental Health and Holistic Care (n=19) 

The need for a holistic and integrated approach to care that includes mental health services and a broad spectrum of support was highlighted by some respondents. They suggested that current services were not comprehensive enough, and too fragmented, which could lead to people falling between the gaps in services.

There is evidence that the majority of individuals who are referred to a child and adolescent gender incongruence service will have co-occurring mental or physical health needs. One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list. It is therefore entirely appropriate that NHS secondary care services are engaged before a referral is made to the waiting list of the gender incongruence service.

Puberty Blockers and Hormone Treatments (n=11)

There was a clear division of opinion amongst respondents regarding medical interventions such as puberty blockers and hormone treatments for young people. Some emphasised the safety and reversibility of these treatments, citing long-term international use, while others expressed strong reservations, deeming them unsafe or ‘ideologically driven’ without sufficient evidence of their long-term safety.

This is outside the scope of the matters on which NHS England is holding this public consultation.

‘Ideological’ Bias and Professional Conduct (n=10) 

Some expressed their view that there was an ‘ideological’ nature to both the working and wording used within the service specification. There was concern expressed about ideological bias among clinicians, suggesting that staff with these viewpoints should not work with CYP with gender incongruence, while others call for the exclusion of ‘gender affirmation’ pathways and ‘experimental treatments’ altogether.

The pre-referral consultation service will be staffed by trained clinicians working in the Children and Young People’s Gender Services.

Communication and Information Clarity (n=9) 

Responses from some indicated that there was a lack of clear communication and detailed information provided about the services, which they said could contribute to confusion and potentially poor service utilisation. 

NHS England will consider the communications issues around the adoption of the new arrangements as part of the implementation plan.

Service Distribution and Local Support (n=8) 

Some felt that the service specification suggested patients could be referred far outside of their geographical area, which would act as a barrier to care. Instead, respondents called for a more distributed and local service that reduces travel burdens and offers more immediate support. 

The pre-referral consultation service will be staffed by trained clinicians working in the Children and Young People’s Gender Services. Currently there are three designated providers – in the North-West and London (both operational from 1 April 2024) and in the South-West (will be operational from November 2024). These first-wave of the new providers will initially act as national services, seeing patients from the national waiting list in chronological order. As up to eight new services are established by 2026, they will develop into regional services serving a regional population.

Insufficient Reference to Safeguarding (n=5)

Comments were made by some respondents about the lack of reference to the role of safeguarding within the service specification, despite the encouragement by Dr Hilary Cass as an effective way to reduce risk, improve decision making, and manage uncertainty. This was said to be a particular concern for CYP being referred with comorbidities and those with homophobic parents or from pressurising and influencing environments.

This service specification is ancillary to NHS England’s Interim Service Specification for Children and Young People’s Gender Services that describes the importance of safeguarding.

Equality of Treatment (n=2) 

Some respondents acknowledge that the EHIA addresses the need for equal treatment for all service users, but there is a suggestion that prioritisation by certain characteristics could lead to further inequality, including the characteristic of being transgender.

It is unclear what amendments to the EHIA are being suggested by these respondents.

Age (n=22)

Some respondents noted that by altering the minimum age of referral to 7 and adding extra steps and re-referral for those aged 17, a number of patients would now be subject to additional barriers to care or risk falling through the gaps. They also argued that there is no scientific evidence for the minimum age requirement, as the proposal states.

NHS England had proposed for the purpose of public consultation that children under 7 years could not be expected to have the necessary cognitive or communication development to engage with health professionals in discussions around gender identity.   However, in April 2024 the Cass Review recommended that a separate pathway should be established for pre-pubertal children and that services should ensure that pre-pubertal children are prioritised and are seen as early as possible by clinicians with relevant experience (Recommendation 4, Cass Review). NHS England will work with providers to establish this pathway on the basis that the primary objective is to provide support and guidance to the parents / carers rather than as a gender affirming clinical intervention for the child, while ensuring that there is experienced psychological support for the child where there is distress or impaired wellbeing.

Disability (n=13)

It was noted by some contributors that a high proportion of those questioning their gender identity are also neurodiverse. They voiced concerns about the lack of detail of how the new service would protect those with disabilities and reduce any of the identified adverse impacts. Additionally, it was pointed out that mental health services are already overwhelmed, and that restricting referral could exacerbate existing inequalities for people with disabilities. 

The EHIA notes that a high proportion of children and young people with gender incongruence will also present with other significant comorbidities and other presentations, and in particular neurodiversity.

The EHIA concluded that earlier intervention from local services will be to the advantage of those children and young people who have co-existing mental health issues, or who have autism or who are otherwise neurodiverse or who have other presentations. This arrangement helps to respond to the concerns of the Care Quality Commission about the lack of support or risk assessment around children and young people while they remain on the waiting list of the former Tavistock GIDS.

Ethnicity (n=12)

Some participants raised the point that the EHIA acknowledges that those from minoritised ethnic communities are less likely to access health services but lacks solutions on how to address this.

The EHIA describes that NHS England’s new interim service specification for CYP Gender Incongruence Services (published June 2023) describes the importance of routine and consistent data collection, analysis and reporting. NHS England expects providers to report demographic data for the purpose of continuous service improvement initiatives, including to identify whether any particular groups are experiencing barriers in access to service provision. NHSE will consider how to use the outcome of this enhanced approach to data collection and analysis to inform its future approach to the commissioning of these services, including for the purpose of identifying inequalities that may exist in access to the service.

The EHIA also describes that NHS England will produce guidance for primary care and local secondary services about the support that should be offered to children and young people with gender incongruence, and this guidance will include a consideration of issues around preventing and addressing health inequalities.

Sexual Orientation (n=6)

Some respondents were concerned over the lack of regard for the protected characteristic of sexual orientation, despite acknowledging that a higher percentage of gender diverse identify as homosexual than the general population. The EHIA was said to lack relevant data on the subject and there was concern about the appropriateness of the language used within the sexual orientation section.

NHS England does not hold data on the sexual orientation of individuals who were referred to or seen by the former GIDS. The website of the former GIDS at the Tavistock and Portman NHS Foundation Trust described the challenges in collecting this information from children. NHS England’s new interim service specification for Children and Young People’s Gender Services (published June 2023) describes the importance of routine and consistent data collection, analysis and reporting. NHS England expects providers to report demographic data for the purpose of continuous service improvement initiatives, including to identify whether any particular groups are experiencing barriers in access to service provision. The interim service specification also describes the importance of building research capabilities for the purpose of continuous quality improvement initiatives. Working with the new configuration of service providers and academic partners, NHSE will consider how to use the outcome of this research to inform its future approach to the commissioning of these services.

Gender Reassignment (n=5)

It was felt by some that the EHIA implies that not everyone who is referred to the service would be assigned with the protected characteristic of gender reassignment, at least until a clinical diagnosis had been made. This was seen as incorrect and that an individual should be protected, even if they only have the intent to transition or have socially transitioned.

In response to submissions on this point, NHS England has correctly applied the law. In considering the application of Equality Act 2010, section 7, to this service, the High Court in R (AA) v NHS Commissioning Board (2023). found that not every child or young person referred to a specialised gender incongruence service will have the protected characteristic of gender reassignment. The Court held that children and young people who are referred to such a service do not – at the point of referral or while they remain on the waiting list – share the protected characteristic of ‘gender reassignment’ as a class or cohort of patients. The whole cohort of patients cannot be treated as “proposing to undergo” a process (or part of a process) for the “purpose of reassigning” their sex “by changing physiological or other attributes of sex” as a class. However, as the Court found and as NHS England accepts, many children and young people in this position will, individually, have the protected characteristic of gender re-assignment at this stage although determining that will involve a case-specific factual assessment.  

Socioeconomic Factors (n=5)

There was a call for more thought to be given for those without contact with parents or from low-income backgrounds which add barriers to referral either through a lack of parental consent or difficulty in attending appointments.

Rural Living (n=3)

A few respondents comment on a lack of support and acknowledgement for those in rural living situations who struggle to access care, especially CYP who may lack the approval of their parents.

Individuals who meet the eligibility criteria for the NHS Low Income Scheme or who are in receipt of certain benefits will be eligible for reimbursement of travel costs under the Health Care Travel Costs Scheme.

By 2026 the new providers of Children and Young People’s Gender Services will work as regional providers serving a defined regional population. The planning assumption is for eight new services located in major cities across England, therefore improving access and reducing excessive travel for many families compared to the previous configuration of premises used by the former Tavistock GIDS. 

The EHIA has been amended to read that in April 2024 the final report of the Cass Review recommended the establishment of a configuration of regional networks in which a matrix of local services would work alongside the Children and Young People’s Gender Service; this model will aim to deliver care more locally to more children and young people, reducing excessive travel.

Additional Gatekeeping (n=9)

Some respondents were concerned that the proposed changes introduce more gatekeeping steps which could exacerbate existing health inequalities and that such decisions would not have been made in services relating to any other type of care. 

The proposals that were subject to public consultation are not unique in their nature or aims to Children and Young People’s Gender Services. One of the areas of concern identified by the Care Quality Commission (the independent regulator of health services in England) in its focused inspection of the former Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust (2021) was the absence of any structured approach for identifying clinical risk on the waiting list and addressing the health needs of children and young people while they remained on the waiting list. It is therefore entirely appropriate that NHS secondary care services are engaged before a referral is made to the waiting list of the gender incongruence service.

The EHIA addresses the point that the requirement for a referral to a tertiary specialised service to be made by a clinician in a secondary level health service is a routine arrangement in commissioning NHS specialised services. Therefore, the proposed requirement for a referral into the CYP Gender Service is consistent with that for comparator groups that may comprise children and young people who are referred to other highly specialised NHS services.

Political Influence Over Healthcare (n=7)

Some respondents were concerned that the changes are being driven by political rather than healthcare considerations, potentially leading to discrimination against LGBTQIA+ individuals.

NHS England has clearly described the rationale, aims and benefits of the various proposals, which are clinically driven. NHS England refutes any suggestion that the proposals are discriminatory, and the reasons for that conclusion are set out in the EHIA.

Insufficient Data and Lacking Detail (n=18)

Some respondents highlighted a lack of detailed information and data as a reason for their ambivalence, suggesting that more robust research or a better understanding is necessary. The EHIA is perceived as too vague by some respondents, who find it difficult to anticipate the full impact of the proposed changes without more specificity.

Inadequate Rationale for Changes (n=4)

Some felt that the rationale provided for not addressing concerns about inequalities was not robust enough. Some suggested that there is a lack of solid data and evidence for what has been cited and that more or better research needs to be carried out.

While the EHIA is informed by the evidence that is available, NHS England agrees that there is a need to build an evidence base for how gender incongruence services for children and young people are delivered. To that end NHS England has established a National Research Oversight Board to ensure that research is embedded at the heart of the new CYP gender services as they are shaped and developed.

Lack of Trans Involvement (n=3)

There was a suspicion that the EHIA was not developed with adequate input from trans people or consideration of their needs.

The EHIA was, correctly, developed by NHS England as the responsible public body who formed the proposals for the purpose of public consultation with stakeholders and the public.

Lacks Information on Specific Actions (n=3)

For some, the EHIA lacked information on specific actions the NHS will carry out as a means to combat the inequalities mentioned.

NHS England has described mitigations and actions where this is possible, and progress in this regard will be monitored through NHS England’s National Programme Board for Gender Dysphoria Services.