TWO WEEKS AGO the NHS in England confirmed it will close its current gender identity centres for children and young people and replace them with a regional network.
The Gender Identity Development Service (GIDS) at the Tavistock & Portman NHS Foundation Trust, known as ‘the Tavistock’, has also been used to treat Irish children and young people who had been diagnosed with gender dysphoria.
Let’s take a look at what these changes will mean for trans healthcare provision in Ireland.
What services are provided by the clinic?
The UK’s Gender Identity Development Service (GIDS) for children and adolescents provides specialist assessment, consultation and care, including psychological support and physical treatments to help reduce the distressing feelings associated with gender dysphoria.
The NHS defines gender dysphoria as a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity.
On its website it notes: “Some people with gender dysphoria, but not all, may want to use hormones and sometimes surgery to express their gender identity.
“Gender dysphoria is not a mental illness, but some people may develop mental health problems because of gender dysphoria.”
Treatments can include the provision of puberty blockers for young people who are referred through the NHS system. For Irish children or young people referred to the service, a recommendation relating to treatments will be made, but a decision on the provision of, for example, puberty blockers will be made by clinicians in Ireland.
The GIDS also provides support to the family or carers of clients.
Why is the clinic closing?
The decision to close the Tavistock clinic follows recommendations from Dr Hillary Cass, who has been leading an independent review into Gender Identity Services for children and young people in the UK.
In her interim report, released in March, she wrote that in recent years GIDS has experienced “a significant increase in referrals which has contributed to long waiting lists”.
The report noted that this increased demand and the long waiting lists had led to growing concern about how the NHS should most appropriately assess, diagnose and care for this population of children and young people.
“It has become increasingly clear that a single specialist provider model is not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand,” the report stated.
The NHS has said it is taking steps to establish two services led by specialist children’s hospitals in London and the north-west of England and that these services will be fully up and running by Spring 2023, when the Tavistock clinic will close.
Dr Cass’ report also pointed to knowledge gaps around the use of puberty blockers and warned that without research the evidence gap “will continue to be filled with polarised opinion and conjecture, which does little to help the children and young people, and their families and carers”.
The report stated that the NHS needs to know more about the population being referred and about outcomes.
“There has not been routine and consistent data collection, which means it is not possible to accurately track the outcomes and pathways that children and young people take through the service,” it notes.
It also stated: “Within the UK, the single specialist service has developed organically, and the clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced.
“Many of the challenges and knowledge gaps that we face in the UK are echoed internationally, and there are significant gaps in the research and evidence base.”
The NHS has said it will carry out clinical research that will track under-16s who are on puberty blockers into adulthood. While the research is ongoing patients will continue to be able to access treatment.
The full report can be read here.
What will this mean for Irish children and young people?
Tavistock has teams in London, Leeds and Bristol, but Irish children and young people are mainly referred to the London clinic.
Ireland does not have a dedicated psychiatric service for gender dysphoria so Irish children and young people are referred to Tavistock under the Treatment Abroad Scheme.
Currently the first step in the healthcare pathway is an approach by the child or young person and their family to their GP. The GP may then refer them to the local Child and Adolescent Mental Health Service (Camhs).
The child or young person will then be seen by a Camhs team and following an assessment they may be refrerred to Tavistock in London for further specialist psychological/psychiatric evaluation .
On average, 21 children and young people from Ireland are referred to the clinic in London a year.
The Camhs consultant makes an application for funding via the Treatment Abroad Scheme (TAS). This application requires the signature of both parents for consent purposes.
After this, Tavistock does a number of assessment sessions with the patient and the final sessions are done in consultation with the endocrinologist in Children’s Health Ireland (CHI).
Having made recommendations to the endocrinologist in Ireland, the Tavistock involvement ends. The clinicians in Ireland ultimately decide on treatment pathway.
A child or young person will not receive medication or a prescription for medication at the Tavistock clinic, rather Tavistock will make a recommendation relating to potential treatment, including ongoing psychological care or hormone therapy.
A final decision will then be made by doctors in Ireland before treatment, overseen by clinicians in Ireland, begins.
The HSE has said Irish children and young people with gender dysphoria will continue to be referred to the Tavistock clinic in London while it is still open.
Concerns had been raised in the media by a HSE psychiatrist, Dr Paul Moran, working for the National Gender services, who spoke about his concerns about the quality of care from the clinic. The HSE noted in response that the Tavistock service has not been deemed unsafe, and that it will continue exploring other options in this area.
Dr Siobhán Ní Bhriain, the HSE’s national lead for integrated care, told RTÉ’s Morning Ireland that the HSE will monitor the situation closely, but she said if the service had been deemed unsafe it would have been closed immediately.
She said that while Ireland does have community consultant adolescent mental health service teams who can carry out an initial assessment, the HSE does not have a specialist psychiatric service for children with gender dysphoria.
Dedicated service in Ireland
The HSE is aiming to set up a service in Ireland, but attempts to recruit a consultant psychiatrist to lead a multidisciplinary team have failed.
Approval has been given for the recruitment of a full time consultant, non-consultant hospital doctor (NCHD), clinical psychologist, social worker, clinical nurse specialist and administration support. The service will be located in CHI Crumlin and Linn Dara.
In a statement to The Journal, the HSE said it has finalised the premises and allocated multidisciplinary staff for the Camhs service.
“The appointment of a consultant psychiatrist to manage this service is required,” it said.
“The post has been advertised twice without success. We are working on different options to resolve this problem and will continue to try and recruit appropriately trained staff to develop our own service in Ireland.
“The HSE is committed to developing a seamless and integrated service for those with gender identity issues on an ongoing basis and are focused on providing a high quality and safe service to an often extremely vulnerable patient group.”
In its statement, the HSE said its main concern is to ensure that the services it provides are streamlined, integrated and seamless.
“We are experiencing long waiting times in both children’s and adult services,” it said. “This is due to a significant difficulty recruiting expert staff, a very significant increase in demand for the service, and the fact that matching the development and training in providing this service has been challenging in the face of multiple competing demands for children and young adults during and following the pandemic.
The HSE monitors the services undertaken by Tavistock closely whilst the service is being built up in Ireland and has been examining alternative services over the last number of years; the HSE’s preference being to set up a specialist Camhs Mental Health service for children and young people with gender dysphoria in Ireland, that will work alongside the other specialist services for these children.
The Transgender Equality Network Ireland (Teni) has said it is “cautiously optimistic” about the plans to expand services in Britain, beginning with the new regional centres which will replace Tavistock services.
In a statement this week Teni pointed out that the Tavistock service could not cope with the numbers of young people waiting to attend the service and the independent review “recognised that a three year waiting list is too long for children and young people”.
Teni also said it would be “delighted” to see something similar happen in Ireland.
“Young people have been waiting a long time for an Irish child and adolescent service to be created,” it said. “The post of a consultant psychiatrist to start this service was advertised over a year ago and still has not been filled. How long do our families need to wait?
“It was unacceptable that families were forced to travel to the UK to access these services in the first place, and now that avenue is closed, the need for child and adolescent services is even more urgent.”
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