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Puberty blockers and consent – rulings from the Courts

In October 2019, a legal complaint (a request for judicial review) was lodged against the Tavistock & Portman NHS Foundation Trust. In Bell v Tavistock, the  said it was highly unlikely that a child aged 13 or less would be competent to give consent to the administration of puberty blockers, and that it was doubtful that 14- or 15-year-olds could understand the long-term risks and consequences of this form of treatment.

Following this judgment, the Tavistock & Portman NHS Foundation Trust sought to challenge the decision and was subsequently granted permission to appeal. The that "it was for clinicians rather than the court to decide on competence" to consent to receive puberty blockers, overturning the High Court decision that children under 16 years lack the capacity to consent to the use of puberty blockers.

AB v CD and others is a separate case involving the Tavistock & Portman NHS Foundation Trust on the related matter of whether parents can give legal consent to their child receiving puberty blockers. In 2021 that parents are able to give such consent "save where the parents are seeking to override the decision of the child". The case did not overrule, nor have any legal effect on, the judgment in Bell v Tavistock.

Puberty blockers banning order - information 

On 3rd June 2024, came into force, banning the prescription and supply of medicines for the purposes of puberty suppression in those experiencing gender dysphoria or incongruence in England. This applies to UK private prescribers, UK pharmacies and prescribers registered in the European Economic Area (EEA) or Switzerland. This ban was , and additionally extended to Northern Ireland, coming into force on 27 August 2024.
 
Children who were already on puberty blockers before 3 June 2024 can continue to access these. for starting the use of puberty blockers in children and young people with gender dysphoria. This is due to commence in January 2025.
 
The government has set out further information for anyone who is unsure how the ban applies to their circumstances in a . Every child on the waiting list for Gender Identity Services should have received this letter.
 

The Cass Review

The Independent Review of Gender Identity Services for Children and Young People (The Cass Review) was commissioned by NHS England and NHS Improvement in autumn 2020 to make recommendations about the services provided by the NHS to children and young people who are questioning their gender identity or experiencing gender incongruence.

The aim of the Cass Review is to ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria, and who need support from the NHS, receive a high standard of care that meets their needs and is safe, holistic and effective.

In March 2022, Dr Hilary Cass published an interim report focusing on three areas: capacity, safety and standards; treatment decisions; and data and audit. The report provided advice to NHS England that in order to meet rising demand and provide a more holistic and localised approach to care, gender identity services for children and young people needed to move from a single national provider to a regional model. Further advice from the review was shared with NHS England in July 2022, setting out essential components of a new model of care was needed to improve pathways of care, individual support for all children and young people, and improvements to research and information sharing.

Information about the . The was published on 10 April 2024. You can read our initial response to the report; we are currently considering the report’s recommendations and will update this page with any subsequent responses.

Calls to evaluate the Cass Review - RCPCH response

5 August 2024

RCPCH is aware that the Cass Review has received academic criticism, and that some members of the medical profession are calling for a pause in implementation of the new Gender Identity Services until further reviews have taken place. The closure of the previous service has resulted in unacceptable waiting times for Gender Identity Services, which were already high before the closure.

The College is clear that pausing the implementation of the Cass report recommendations would be a backwards step for Gender Identity Services, as this will again delay care and therefore risks causing further harm to this patient population. It is our absolute priority that this group of children receive timely, holistic and high-quality care.

We are in regular contact with NHS England to offer input into the development of the new Gender Identity Services. As a part of this engagement we will encourage NHSE to consider emerging criticisms of any chosen approach, as would be the case in the delivery of any other children's health service.

We are mindful that changes to Gender Identity Services have a significant impact on our members, their patients, and also the members of other Royal Colleges. The College continues to work with NHSE to understand what the emerging changes mean for our members in England and potentially across the UK, and will develop further communications on this in due course.

The Academy of Medical Royal Colleges, of which the RCPCH is a member, has additionally .

Care in the NHS

In 2021/22 there were over 5,000 referrals into the Gender Identity Development Service (GIDS) run by the Tavistock and Portman NHS Foundation Trust in England. This compares to just under 250 referrals in 2011/12. The Tavistock and Portman NHS Foundation Trust has been the main provider of gender affirming care for children and young people, and will close at the end of March 2024.

Following advice from the Cass Review in July 2022, NHS England set out plans for how it would start building a more resilient service by expanding provision and enhancing the focus on quality in terms of clinical effectiveness, safety, and patient experience. It was agreed to establish two new nationally networked services to be led by specialist children’s hospitals – referred to as the North and South hubs. On 1 April 2024, these new services will take over clinical responsibility for seeing children and young people on the national waiting list as well as providing continuity of care for the GIDS open caseload at the point of transfer.

The was published in 2023 following public consultation. on a service specification that describes the process for making referrals into the Children and Young People's Gender Service and the process for managing the national waiting list. You can read the College response to this consultation in March.

NHS England published an  in March 2024, which will be kept under review in light of any further emerging evidence and recommendations from the independent Cass Review and its research programme.

In Wales, access to the national specialist gender incongruence service is through referral by CAMHS. All referrals are managed by the National Referral Support Service which is provided by NHS Arden and Greater East Midlands Commissioning Support Unit.

In Scotland, the Young People’s Gender Service  is provided from Glasgow. The service provides clinical input for young people and their families from across Scotland, as well as consultation and training to professionals and other agencies. Referrals are accepted from a variety of sources, including GPs, Child and Adolescent Mental Health Services (CAMHS), schools and social work. The service also accepts self-referrals, either by email or phone call.

In Northern Ireland, children and young people with gender dysphoria can be referred to the . Referrals usually come from CAMHS and learning disability services.

The role of paediatricians for children who are gender questioning

It is likely that local general paediatric services will play a key part in the future model of care for children in England who are gender questioning or with gender incongruence. It is currently proposed that general paediatricians will not determine a diagnosis of whether there is gender incongruence or gender dysphoria, but will make an assessment as to whether the child or young person is experiencing gender related distress in the context of their holistic needs. NHS England is consulting on the referral pathways of care for children and young people, and more advice will follow from NHS England on the role of general paediatricians.

The NHS has produced an within the Royal College of Psychiatrists, MindEd and eLearning for Healthcare programme, which has been created for health care professionals in primary and secondary care settings to explore how to apply existing clinical skills and to examine some common scenarios when supporting children and young people.

Guidance for schools and colleges for children who are gender questioning

The Department for Education has been seeking views on for schools and colleges about children questioning their gender. You can read the College response to this consultation. 

Supporting LGBTQ+ children and young people

The College advocates for the rights of LGBTQ+ people and has published a principles statement to eliminate discrimination and stigma, better understand the needs of LGBTQ+ children and young people, and support health professionals in their role of providing support to LGBTQ+ children and young people.

Find out more about this advocacy and our commitments as a College.