The interim findings of The Cass Review are likely to have significant consequences for children with gender dysphoria and for their families, as well as for those who commission and run gender identity development services. It is the view of the Association of Clinical Psychologists UK (ACP-UK) that an evidence-based framework will be required to ensure that regional services are able to offer appropriate and timely care to this vulnerable group. We offer a number of reflections which we believe are crucial to that process.

A note on language: this document relates to children with gender incongruence or dysphoria. It does not relate to adults seeking to undergo gender reassignment.

The closure of the Gender Identity Development Service (GIDS) at the Tavistock and Portman Trust: the context

The publication of the interim findings of The Cass Review in February 2022 found the following:

• GIDS took an approach that was predominantly affirmative, rather than exploratory
• Assessment was not standardised
• Mental health and neurodevelopmental assessments were not conducted comprehensively, leading to ‘diagnostic overshadowing’ whereby gender dysphoria was attended to without taking into account any co-existing diagnoses
• Safeguarding processes were lacking

Psychologically informed reflections on considerations for the future

The closure of the GIDS service was precipitated by a number of systemic failings. It is the view of ACP-UK that the new, regional services will have to offer a radical alternative to meet the needs of all young people with gender dysphoria.

The scale of the demand for services

• There is evidence that a significant proportion of young people with gender dysphoria have comorbid neurodevelopmental conditions[1] and/or mental health difficulties[2]. They are also more likely to have experienced trauma[3] and other psychosocial difficulties than age-matched peers[4]. The new, regional services will need to offer robust, holistic and systemic multidisciplinary assessments in order to ascertain exactly what support and treatment each child and adolescent will need.
• As of May 2021, there were over 4000 young people on the GIDS waiting list[5], many of whom had waited up to three years for an assessment[6]. The closure of the service will substantially increase their anxiety and distress. Those young people – and their families – will need significant psychosocial support as the new services and pathways are developed.

Psychological and social factors

• Until 2011, the majority of young people referred to GIDS were male. Recent years have seen a sharp increase in the number of females presenting with gender dysphoria, with the most recent data indicating a ratio of approximately 3:1[7]. Psychologists will need to consider a complex array of social, political and cultural factors, as well as individual factors, when developing clinical formulations of distress with young people and their families.
• As psychologists, we are aware that many young people who experience same-sex attraction will, at some stage, question their gender identity or experience gender dysphoria[8]. They are also likely to behave in gender-nonconforming ways[9].
• Homophobia persists to some extent both within health and social care settings[10], and in wider civil society[11]. We need to better understand the possible relationships between the experience of homophobia and gender identity exploration and/or dysphoria in some young people[12].
• It is now clear that a proportion of young people who transition will detransition or have regrets later in life, possibly already having undergone irreversible pharmacological or surgical intervention[13]^,[14],[15].
• The health and social needs of this group are also likely to require input from a broad range of specialist services as they navigate the detransition process[16].

Research and evidence-based practice

• There is little evidence which allows clinicians reliably to predict whether a child who presents with gender dysphoria will continue to experience gender incongruence in adulthood, whether their incongruence will desist, and/or whether they will come to identify in another way. In short, there is as yet no reliable way to predict whether transitioning will alleviate any young person’s distress or further contribute to it.
• There is a lack of robust, high-quality evidence regarding the safety and effectiveness of using puberty blockers and cross sex hormones to treat gender dysphoria in adolescents[17]. The long-term consequences of such treatment are also unknown[18]. Our view is that high-quality, longitudinal data is required to help determine when a medical intervention is or is not indicated, and to identify which groups it is appropriate for.

Funding and investment

• We are aware that providing psychologically informed, evidence-based services which have the right skills mix to work with this degree of complexity requires significant investment from government. Provision for gender dysphoric young people must be offered in a timely manner, and input will, in some cases, be required over a long period of time.
• Our view is that funding for this very vulnerable group must be ringfenced, and that funding and service provision must be reviewed as the evidence base emerges. It will be imperative that any research into this area is funded via sources that are able to maintain impartiality on the outcomes.

Supporting Staff

• Finally, consideration must be paid to the GIDS staff, including those who have since left the service. They were given significant responsibility for managing the distress of thousands of gender dysphoric young people and their families, despite overwhelming pressure on their resources and a limited evidence base for the treatment they were providing. The findings of The Cass Review make it clear that they received inadequate support and guidance. The closure of the service, and the media reports surrounding it, will have impacted them significantly.
• In this context, mistakes should not be made twice. It is highly likely that staff at the new, regional gender identity development services will also experience heightened levels of political, social, ethical and clinical pressures. We recommend that appropriate and robust staff support and training, plus processes for external scrutiny and clinical governance, are built into the new service design from the very beginning.

In summary, it is the view of ACP-UK that all interventions for this very vulnerable group be grounded in evidence-based practice. Accountability, data collection, evaluation and routine clinical best practice will be vital if the new services for gender dysphoric young people are to be fit for purpose.

[1] Butler G, De Graaf N, Wren B, et al. Assessment and support of children and adolescents with gender dysphoria. Archives of Disease in Childhood 2018;103:631-636.

[2] Stephen Feder, Leanna Isserlin, Emily Seale, Nicole Hammond & Mark L. Norris (2017) Exploring the association between eating disorders and gender dysphoria in youth, Eating Disorders, 25:4, 310-317, DOI: 10.1080/10640266.2017.1297112

[3] Giovanardi G, Vitelli R, Maggiora Vergano C, Fortunato A, Chianura L, Lingiardi V and Speranza AM (2018) Attachment Patterns and Complex Trauma in a Sample of Adults Diagnosed with Gender Dysphoria. Front. Psychol. 9:60. doi: 10.3389/fpsyg.2018.00060

[4] Kozlowska K, McClure G, Chudleigh C, et al. Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems. 2021;1(1):70-95. doi:10.1177/26344041211010777

[5] Dyer C. Gender dysphoria service rated inadequate after waiting list of 4600 raises concerns BMJ 2021; 372 :n205 doi:10.1136/bmj.n205

[6] https://www.whatdotheyknow.com/request/gids_wait_times

[7] https://tavistockandportman.nhs.uk/about-us/news/stories/referrals-gender-identity-development-service-gids-level-2018-19/

[8] Churcher Clarke A, Spiliadis A. ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clin Child Psychol Psychiatry. 2019 Apr;24(2):338-352. doi: 10.1177/1359104518825288. Epub 2019 Feb 6. PMID: 30722669.

[9] Xu, Y., Norton, S., & Rahman, Q. (2021). Childhood gender nonconformity and the stability of self-reported sexual orientation from adolescence to young adulthood in a birth cohort. Developmental Psychology, 57(4), 557–569. https://doi.org/10.1037/dev0001164

[10] https://www.mentalhealthtoday.co.uk/news/inequality/health-and-social-care-discrimination-faced-by-lgbt-people

[11] https://www.gov.uk/government/statistics/hate-crime-england-and-wales-2020-to-2021/hate-crime-england-and-wales-2020-to-2021

[12] DeLay D, Lynn Martin C, Cook RE, Hanish LD. The Influence of Peers During Adolescence: Does Homophobic Name Calling by Peers Change Gender Identity? J Youth Adolesc. 2018 Mar;47(3):636-649. doi: 10.1007/s10964-017-0749-6. Epub 2017 Oct 14. PMID: 29032442

[13] Littman L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav. 2021 Nov;50(8):3353-3369. doi: 10.1007/s10508-021-02163-w. Epub 2021 Oct 19. PMID: 34665380; PMCID: PMC8604821

[14] Elie Vandenbussche. (2021) Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, pages 1-19

[15] Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: Retrospective case-note review. BJPsych Open, 7(6), E184. doi:10.1192/bjo.2021.1022

[16] Butler, C., & Hutchinson, A. (2020). Debate: The pressing need for research and services for gender desisters/detransitioners. Child and Adolescent Mental Health, 25(1), 45-47. https://doi.org/10.1111/camh.12361

[17] https://cass.independent-review.uk/publications/interim-report/

[18] https://cass.independent-review.uk/publications/interim-report/

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