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England Overhauls Medical Care for Transgender Youth

The National Health Service is closing England’s sole youth gender clinic, which had been criticized for long wait times and inadequate services.

By Azeen Ghorayshi

The National Health Service in England announced on Thursday that it was shutting down the country’s only youth gender clinic in favor of a more distributed and comprehensive network of medical care for adolescents seeking hormones and other gender treatments.

The closure followed an external review of the Tavistock clinic in London, which has served thousands of transgender patients since the 1990s. The review , which is ongoing, has raised several concerns, including about long wait times, insufficient mental health support and the surging number of young people seeking gender treatments.

The overhaul of services for transgender young people in England is part of a notable shift in medical practice across some European countries with nationalized health care systems. Some doctors there are concerned about the increase in numbers as well as the dearth of data on long-term safety and outcomes of medical transitions.

In the United States, doctors specializing in gender care for adolescents have mixed feelings about the reforms in Europe. Although many agree that more comprehensive health care for transgender youth is badly needed, as are more studies of the treatments, they worry that the changes will fuel the growing political movement in some states to ban such care entirely.

“How do we draw the line so that we keep care individualized while maintaining safety standards for everyone? That’s what we’re trying to sort out,” said Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the incoming president of the World Professional Association for Transgender Health, who is transgender. “It’s the people on the ground who need to make these decisions, not people in Washington or state legislatures.”

The N.H.S. said current patients at the Tavistock clinic could continue to receive care there before transferring to two new hubs at children’s hospitals in London and Manchester. The new clinics will expand the country’s gender services while making sure children are adequately treated for autism, trauma and mental health issues. The specialists will also carry out clinical research on gender medications.

There are “critically important unanswered questions” about the use of puberty blockers, wrote Dr. Hilary Cass, head of the external review of the country’s youth gender identity services, in a letter to the head of N.H.S. England last week.

Puberty blockers, which are largely reversible, are intended to buy younger patients time to make weighty decisions about permanent medical changes. But Dr. Cass questioned whether most adolescents prescribed these drugs were given the support to reverse course, should they choose to.

Tavistock received more than 5,000 patient referrals in 2021, up from just 250 in 2011. The types of patients seeking referrals have also shifted over the past decade. When the clinic opened, it primarily served children who were assigned male at birth. Last year, two-thirds of its patients were assigned female at birth.

It is unclear why the number of patients has surged so drastically or why transgender boys are driving the increase.

Transgender advocates in Britain welcomed the changes but emphasized that many questions still remained about how they would affect care for young people.

“We are optimistic, cautiously optimistic, about the news,” said Susie Green, chief executive of Mermaids, an advocacy group for transgender and gender-diverse youth. “There is a two-and-a-half-year waiting list to be seen for your first appointment. We’ve seen the distress caused to young people because of that.”

But Ms. Green, who has a transgender adult daughter, said the group was concerned about whether mental health services would be prioritized over medical care. Gender diversity, she said, should not be treated as a mental disorder.

“We would not want any further barriers to be put in place in terms of access to medical intervention,” Ms. Green said.

In 2020, a former patient at Tavistock, Keira Bell, joined a highly publicized lawsuit against the clinic. She claimed that she was put on puberty blockers at 16 “after a series of superficial conversations with social workers,” and had her breasts removed at age 20, decisions she later regretted.

A high court initially ruled that children under 16 were unlikely to be mature enough to consent to such medical interventions. But that decision was reversed in September of last year, with judges ruling that “it was for clinicians rather than the court to decide” whether a young patient could provide informed consent.

In 2020, employees at Tavistock raised concerns about medical care at the clinic, prompting the N.H.S. to commission Dr. Cass, a pediatrician in London who was not affiliated with the clinic, for an external review. Her interim report was released in February of this year.

Sweden’s national health service determined this year that gender-related medical care for young people should only be provided in exceptional cases when children have clear distress over their gender, known as dysphoria. All adolescents who receive treatment will be required to be enrolled in clinical trials in order to collect more data on side effects and long-term outcomes. Finland took a similar stance last year.

“Our position is we cannot see this as just a rights issue,” Dr. Thomas Linden, director of the country’s National Board of Health and Welfare, said in a February interview. “We have to see patient safety and precision in the judgment. We have to be really to some degree sure that we are giving the right treatments to the right person.”

While these European countries have put some limits around transgender care, their approaches are far more permissive than those in some conservative U.S. states. A recent Alabama law made it a felony for doctors to prescribe puberty-blockers and hormones to minors. In Texas, parents who allow their children to receive gender treatments have been investigated for child abuse . Both states are tied up in court battles with civil rights groups.

Some American doctors worried that the changing standards in Europe would bolster the notion that gender treatments are dangerous for young people.

“My fear is that this is going to be interpreted as another notch against providing gender-affirming care for kids,” said Dr. Angela Goepferd, medical director of the Gender Health Program at Children’s Minnesota hospital. More services are needed, they said, not less. “That’s our challenge here.”

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

How to find an NHS gender dysphoria clinic

Trans and non-binary people's general health needs are the same as anyone else's. But trans people may have specific health needs in relation to gender dysphoria.

Your particular needs may be best addressed by transgender health services offered by NHS gender dysphoria clinics (GDCs).

All NHS GDCs are commissioned by NHS England, who set the service specifications for how they work.

A GP or another health professional can refer you directly to one of the GDCs. You do not need an assessment by a mental health service first. Neither does the GP need prior approval from their integrated care board (ICB). 

The websites of the clinics listed on this page also have useful information for you to think about before you see a GP. 

Children and young people's gender services

Children and young people should be referred to the National Referral Support Service for the NHS Children and Young People's Gender Service .

These NHS services specialise in helping young people with gender identity issues. They take referrals from anywhere in England.

Gender dysphoria clinics in London and the southeast

The Tavistock and Portman NHS Foundation Trust: Gender Dysphoria Clinic for Adults

Lief House 3 Sumpter House Finchley Road London NW3 5HR

Phone: 020 8938 7590

Email: [email protected]

The GDC website has an overview of information useful for anyone with gender identity needs, not just those in the area.

Gender dysphoria clinics in the north

Sheffield Health and Social Care NHS Foundation Trust Gender Dysphoria Service

Porterbrook Clinic Michael Carlisle Centre 75 Osborne Road Sheffield S11 9BF

Phone: 0114 271 6671

Email: [email protected]

The  Sheffield clinic's website includes information about referrals, clinic opening hours and links to eligibility criteria.

Leeds and York Partnership NHS Foundation Trust Gender Dysphoria Service

Management Suite 1st Floor The Newsam Centre Seacroft Hospital York Road Leeds LS14 6WB

Phone: 0113 855 6346

Email: [email protected]

The Leeds clinic's website covers referrals, commonly used medicines and information on the clinic's Gender Outreach workers.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northern Region Gender Dysphoria Service

Benfield House Walkergate Park Benfield Road Newcastle NE6 4PF

Phone: 0191 287 6130

Email: [email protected]

The Northern Region Gender Dysphoria Service website has a range of leaflets, including information about referral, hormones and support groups.

Gender dysphoria clinics in the Midlands

Northamptonshire Healthcare NHS Foundation Trust Gender Dysphoria Clinic

Danetre Hospital H Block London Road Daventry Northamptonshire NN11 4DY

Phone: 03000 272858

Email:  [email protected]

Visit the  Northampton clinic's website for more information about how to get a referral and the role of the GP.

Nottinghamshire Healthcare NHS Foundation Trust The Nottingham Centre for Transgender Health

12 Broad Street Nottingham NG1 3AL

Phone: 0115 876 0160

Email: [email protected]

Visit The Nottingham Centre for Transgender Health website  for more information about how to get a referral.

Gender dysphoria clinics in the southwest

Devon Partnership NHS Trust West of England Specialist Gender Dysphoria Clinic

The Laurels 11-15 Dix's Field Exeter EX1 1QA

Phone: 01392 677 077

Email: [email protected]

The Laurels' website has information about the types of services on offer and the help available during transition.

New gender dysphoria services in 2020

In 2020 new NHS gender dysphoria services for adults will open in Greater Manchester, London and Merseyside.

These services will be delivered by healthcare professionals with specialist skills and based in local NHS areas, such as sexual health services. Full details will be available once each service is opened.

Initially, access to these services will be available to people who are already on a waiting list to be seen at one of the established gender dysphoria clinics.

NHS England will assess how useful these new pilot services are.

Page last reviewed: 13 May 2020 Next review due: 13 May 2023

The NHS Ends the "Gender-Affirmative Care Model" for Youth in England

Following extensive stakeholder engagement and a systematic review of evidence , England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth <18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. The abandonment of the "gender-affirming" model by England had been foreshadowed by The Cass Review's interim report , which defined "affirmative model" as a "model of gender healthcare that originated in the USA."

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning , and following an explicit informed consent process . The NHS states that puberty blockers can only be administered in formal research settings, due to the unknown effects of these interventions and the potential for harm. The NHS has not made an explicit statement about cross-sex hormones , but signaled that they too will likely only be available in research settings. The guidelines do not mention surgery , as surgery has never been a covered benefit under England’s NHS for minors.  

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

The key highlights of the NHS new guidance are provided below.* 

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

• The NHS has eliminated the “gender clinic” model of care where children are seen solely by a specialist gender dysphoria practitioner, replacing it with standard care in children’s hospital settings.
• Rather than “affirming” a transgender identity of young person, staff are encouraged to maintain a broad clinical perspective and to “embed the care of children and young people with gender uncertainty within a broader child and adolescent health context.”
• “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”
• Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.
• Treatment pathway will be shaped, among other things, by the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
• The care plan articulated by the Service will be tailored to the specific needs of the individual following careful therapeutic exploration and “may require a focus on supporting other clinical needs and risks with networked local services.”

2. Classifies social gender transition as an active intervention eligible for informed consent

• The NHS is strongly discouraging social gender transition in prepubertal children.
• diagnosis of persistent and consistent gender dysphoria
• consideration and mitigation of risks associated with social transition
• clear and full understanding of the implications of social transition
• a determination of medical necessity of social transition to alleviate or prevent clinically significant distress or impairment in social functioning
• All adolescents will need to provide informed consent to social gender transition.

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

• All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.
• Extensive focus has been placed on careful therapeutic exploration, and addressing the broader range of medical conditions in addition to gender dysphoria.
• For those wishing to pursue medical transition, eligibility for hormones will be determined by a centralized Service, upon referral from a GP (general practitioner) or another NHS provider.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

• The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.
• The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.
• Surgery is not addressed in the guidance as the NHS has never considered surgery appropriate for minors.

5. Establishes new research protocols

• All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.
• The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.
• The research will track the children into adulthood.

6. Reinstates the importance of “biological sex”

• The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.
• The NHS guidance refers to the need to track biological sex for research purposes and outcome measures.
• Of note, biological sex has not been tracked by GIDS for a significant proportion of referrals in 2020-2021.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

• The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence."
•  The NHS guidance states that treatments should be based on the DSM-5 diagnosis of “gender dysphoria.” 
• Of note, WPATH SOC8 has made the opposite recommendation, instructing to treat based on the provision of the ICD-11 diagnosis of “gender incongruence.” “Gender incongruence” lacks clinical targets for treatment, beyond an individual’s own desire to bring their body into alignment with their internally-held view of their gender identity.

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

• The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.
• neurodevelopmental disorders such as autistic spectrum conditions
• mental health disorders including depressive conditions, anxiety and trauma
• endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria
• risky behaviors such as deliberate self-harm and substance use
• complex family contexts including adoptions and guardianships
• a number of additional requirements for the multidisciplinary team composition and scope of activity have been articulated by the NHS.

9. Establishes primary outcome measures of “distress” and “social functioning”

• The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning .
• This is an important development, as it establishes primary outcome measures that can be used by researchers to assess comparative effectiveness of various clinical interventions. 

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

• Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.
• Those choosing to take hormones outside the newly established NHS protocol will not be supported in their treatment pathway by NHS providers.
• Child safeguarding investigations may also be initiated if children and young people have obtained hormones outside the established protocols.

With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH guidelines and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.

The full text of the NHS guidance can be accessed here .

 * This is a transitional protocol as the NHS works to establish a more mature network of children’s hospitals capable of caring for special needs of gender dysphoric youth. A fuller service specification will be published in 2023-4 following the publication of the Cass Review’s final report .

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• Education, training and skills
• School curriculum

Research commentary: teaching about sex, sexual orientation and gender reassignment

Chris Jones, Ofsted’s Director, Corporate Strategy, discusses research on teaching about the protected characteristics of sex, sexual orientation and gender reassignment in England’s schools.

The Equality Act 2010 was the culmination of a decade-long uplift in equality legislation. The uplift began in 2001 with changes to race discrimination law following the recommendations of the Macpherson report. It continued through into disability discrimination law in 2006 and gender discrimination in 2007. The 2010 Act consolidated these and also brought in other characteristics, most of which already had some protection under previous legislation: age, marriage and civil partnership, pregnancy and maternity, sex, sexual orientation, religion and belief and (for the first time) gender reassignment status.

This legislation set a new role for public authorities through the concept of ‘duties’. The 2010 act created a ‘public sector equality duty’ ( PSED ). This requires every public authority to have due regard to the following:

• the need to eliminate discrimination, harassment, victimisation and other conduct prohibited by the Act
• advancing equality of opportunity between people who shared a protected characteristic and those who do not
• fostering good relations between people who share a protected characteristic and those who do not

In practice, the Act gives all public authorities a degree of responsibility for encouraging and promoting equality in relation to protected characteristics. The PSED guidance from the Equalities and Human Rights Commission ( EHRC ) states:

” … the general equality duty therefore requires organisations to consider how they could positively contribute to the advancement of equality and good relations. It requires equality considerations to be reflected into the design of policies and the delivery of services, including internal policies, and for these issues to be kept under review.”

‘Public authorities’ includes state-funded schools and other education providers, as well as Ofsted. Therefore, our inspectors assess the extent to which settings take steps to promote equality and diversity as well as to prevent any form of discrimination against those with protected characteristics.

The Act was contentious from the outset for certain groups, particularly in relation to characteristics relating to sex, sexual orientation and gender reassignment. The increasing political sensitivities in these areas have made it harder for schools to handle equalities well. For example, school staff can occasionally confuse the legal, the moral and the political, and so (often inadvertently) bring overtly political materials into their curriculum and teaching without acknowledging it as such, despite the statutory requirement of political neutrality. We have also seen recent examples of schools and parents being unable to see eye-to-eye on the content and age-appropriateness of curriculum materials used to teach primary school pupils about same-sex relationships.

The Department for Education’s ( DfE ) statutory guidance on relationships, health and sex education deals with schools’ responsibilities in this area. It came into force in September 2020.

Ofsted has carried out research that aimed to identify good practice in teaching some of these more contentious issues. This commentary summarises our findings in a way that we hope will be beneficial to schools as they implement the DfE ’s guidance. It builds on the findings of our review of sexual abuse in schools and colleges , which highlighted the importance of strong teaching of relationships, health and sex education.

Research context

There is some guidance, from the DfE and the EHRC , to help schools with the PSED . There is also some research into the effectiveness of specific support initiatives, for example from NatCen , the Institute of Physics and Lifting Limits .

However, there is a significant lack of research into how schools promote respect and build understanding in pupils around sex, sexual orientation and gender reassignment issues.

Therefore, the purpose of our research was to show how respect is promoted and how discrimination and harassment are challenged and minimised in state-funded primary and secondary schools that do this successfully.

Our guiding research question was: ‘What characterises good practice in promoting respect on the basis of sex, sexual orientation and gender reassignment?’

Methodology

At each school, we had group discussions with:

• staff (senior leaders, middle leaders and teachers with teaching assistants, respectively)
• pupils (secondary school pupils as well as Year 5 and Year 6 primary school pupils)

Questionnaires for secondary school pupils complemented the group discussions. Given that we have relied on discussions with school staff and pupils, we cannot be sure whether each school’s approach was supported by parents, which is an important limitation.

The sample is purposive. It consists of 24 state-funded schools that were deemed by informants (Her Majesty’s Inspectors ( HMI ) across the Ofsted regions and external organisations or associations) to be the most successful at promoting respect across the protected characteristics of sex, sexual orientation and gender reassignment. We visited:

• 8 primary schools
• 14 secondary schools
• 1 special school
• 1 all through school

Eleven of the schools had a religious character: 4 Roman Catholic, 3 Church of England, 1 Jewish, 1 Muslim and 1 Sikh.

Given that the findings are based on schools chosen as examples of good practice, they are not likely to be reflective of schools more generally but may provide helpful examples to others. Even within the specially chosen sample, alongside the good practice, we have identified here some areas for improvement.

School culture

Despite the legal underpinning of the Equality Act, we found that staff promoted a culture of respect across the protected characteristics mainly for what they described as moral rather than legal reasons. They intended to improve pupils’ mental health, well-being, safety, academic outcomes and breadth of future career choices, as well as to prepare them for diversity in wider society. They described an inclusive and accepting school culture as a necessary condition for this, with school ethos and/or religious ethos to underpin shared values. The religious schools in our sample gave faith as a reason for promoting respect for pupils and others with different protected characteristics, including sex, sexual orientation and gender reassignment.

The message of acceptance came out strongly in school culture, teaching, extra-curricular activities and pastoral support.

“School culture is everything. With the right culture, you will be able to navigate sensitive subject areas. Culture is supported by policies, procedures and systems. Our staff sign up to a value statement, which commits them to the values but also gets them to agree to behaviours that we expect and those we wouldn’t tolerate.” (Senior leaders in a secondary school)

Even though an accepting ethos provides a solid grounding for successfully promoting respect, it may not be enough to ensure continuing success. Therefore, staff in several schools said they had a culture of continuous improvement to help them meet the evolving needs of pupils and society. In these schools, self-critique was enabled by listening to staff, pupils and parents.

“There is no sense of complacency. We have staff meetings where we challenge ourselves and it isn’t always comfortable. When you look at everyday sexism, everyone thinks it’s done and dusted – and it isn’t. It is a systematic self-challenge. To be an inclusive school is something we hope to be, but never say we are.” (Senior leaders in a primary school)

Teaching across the curriculum

Teaching about matters related to sex and gender stereotypes, sexual orientations and sometimes gender reassignment was often planned and integrated across the curriculum. It was part of personal, social, health and economic (PSHE) education, religious education ( RE ), relationships and sex education ( RSE ), English, languages, science, history, music, art, technology and so on. In schools with a religious character in our sample, teaching about sexual orientation and gender reassignment was often done alongside teaching about faith perspectives.

Different teaching methods were used, such as direct instruction, discussion and debate, research, books, stories and documentaries, workshops, making posters and displays, visiting speakers and role models. Staff and pupils highlighted the importance of learning through discussion and openly asking and responding to questions. Being aware that some pupils were unlikely to do this at home, staff enabled pupils to ask questions. They also saw this as a way of promoting independent thought. Staff were open to honest or difficult conversations with their pupils.

The selection of topics and how they were approached were generally well tailored to pupils’ age and maturity. Research has shown that children become aware of gender stereotypes from a very young age. In view of this, it is positive that some schools began challenging gender stereotypes early. This was done through stories like ‘Prince Cinders’ or ‘Dogs Don’t Do Ballet’, and through using puppets or similar activities. Some schools also felt it was appropriate to introduce the concept of different types of family from the same early age. For example, in a primary school farm, children sometimes had Mr and Mrs Farmer, but also Mr and Mr Farmer or Mrs and Mrs Farmer.

Many pupils and staff commented on the impacts of teaching about these issues. These impacts included:

• pupils gaining more knowledge – in many schools, later primary school (Years 5 and 6) and secondary school pupils are able to explain the basic terms (straight, gay, bisexual or trans)
• pupils having broadened views – as a result of knowing more, pupils said they had become more accepting
• pupils using appropriate and sensitive language
• pupils having improved behaviour – staff said they very rarely saw incidents of homophobic, biphobic or transphobic bullying

When pupils were not exposed to these topics, they frequently resorted to learning from social media and the internet, and in some cases from friends and family. Even though the internet holds a range of good-quality resources, it also contains content that is not of a sufficient quality or accuracy, and parents are often unable to control the age-appropriateness of what children are viewing. Therefore, there are inherent risks when pupils use online content or non-expert friends and family as the main sources of information about, for example, being lesbian, gay, bisexual, transgender ( LGBT ).

Some pupils who struggled with finding or accepting their identity, or who were not accepted by other pupils, told us that insufficient knowledge had contributed to their low well-being and mental ill-health.

As a result of not learning enough at school, some pupils expressed concern that they ‘would not know how to help someone who came out to feel comfortable in a friendship group’ or admitted that they would struggle with accepting someone with a different sexual orientation or someone who is trans:

“I would definitely need to have a better understanding in order to accept them properly.” (Pupil in a secondary school)

As well as thinking about carefully planning their RSE curriculum, staff in the schools we visited used the established pastoral support systems to provide individual support:

“If you are encouraging pupils to be open and giving the opportunity to ask questions, you need to ensure the appropriate networks are in place. We have created a culture of it being an open school. Various levels of support. All teachers and SLT try to be very approachable and know that the pupils can talk to them.” (Senior leaders in a middle school)

From conversations with pupils in schools, 3 main features emerge as important for individual support:

• “Most students have a good relationship with the teachers. They can trust them.”
• “We feel comfortable with heads of year or form tutors. It has to do with the relationship you have with the teacher rather than about their knowledge of sexuality and gender.”
• “We have a personal teacher to talk to and a safe space.”
• Some pupils also like form time as an outlet for more comfortable group discussions.
• “… knowing there is someone you can talk to in school.”

Teaching about sex and gender stereotypes

Many schools in our sample worked hard on minimising sex and gender stereotypes through their teaching. Staff saw breaking entrenched and negative social stereotypes as a way of broadening horizons and teaching children that ‘gender should not be an obstacle to anything you can achieve in your life’.

School staff reported that their focus on sex and gender stereotypes is important because of:

• visible differences in the representation of women and men in organisational leadership and in different academic disciplines or professions
• an early divergence between boys’ and girls’ career aspirations
• the acknowledged harmfulness of some sex and gender stereotypes

Schools’ work on sex and gender stereotypes could also help pupils who do not conform to those stereotypes, including some LGBT pupils. For example, it may contribute to reducing homophobic, biphobic and transphobic bullying if bullying originates from stereotypical notions of boys and girls.

Teachers in most schools reported covering a range of topics in class, such as:

• male and female roles across societies and time
• changing sex and gender roles, for example parents choosing to take shared parental leave
• women’s rights and the women’s suffrage movement
• important women across academic disciplines and professions
• domestic violence
• healthy relationships
• sexist language

In some schools, pupils were also taught about specifically male mental health problems and peer pressure. This addresses misconceptions, such as that ‘boys don’t cry’, or helps boys avoid harmful stereotypical behaviours dictated by their peer groups.

A middle leader from a primary school described how they challenged stereotypes through a task involving a phone call with a female scientist:

“We asked the children to draw a scientist and it was exactly as you’d expect: an old person with glasses on. So, I questioned them: why did you think that? When you start questioning them, they realise perhaps what they put down is not what they do think. That may be the first image in the head, but when you ask, pennies drop. So, I told them: we are going to have a phone call with a scientist now. Who do you think is going to call us? [And on the other end of the line is…] my cousin, a scientist, a biochemist, a girl.”

The impact on pupils’ knowledge was apparent to teachers and pupils. Interviews with pupils revealed that they were aware of different aspects of past and present inequalities and that they had open-minded attitudes about sex and gender. Staff were aware of what their pupils knew and noticed that they picked up on stereotypes in texts or exercises.

Teaching about different sexual orientations and gender reassignment

Most schools we spoke to taught about LGBT equality in group or whole-school exercises, including lessons, assemblies and guest speakers. Pupils were taught about the importance of respecting all, and not judging people because of sexual orientation or gender reassignment.

In many primary schools in our sample, pupils were introduced to LGBT role models, such as historical or present influential LGBT people. They were taught, in an age-appropriate way, about:

• different types of family, for example with a mum and dad, 2 mums or 2 dads
• appropriate language to use to refer to LGBT people
• bullying, including homophobic, biphobic and transphobic bullying

In some primary schools we visited, they were also taught about same-sex marriage and how the law protects people with different characteristics. This was also covered in many secondary schools but with more nuance and detail, in view of pupils’ age.

Secondary school pupils in many of the sampled schools were taught about:

• the rights of LGBT people across time and societies
• current national and international issues
• the Equality Act and EHRC
• how to accept themselves for who they are
• how to support and have empathy for pupils with different protected characteristics

Successfully engaging with parents

Following the introduction of mandatory relationships education at primary, and relationships and sex education at secondary, schools are legally required to consult parents in developing and reviewing their policy for these subjects. Through consultation, most schools and parents can work together to build broad consensus and to ensure that the policy meets the need of pupils and parents and reflects the community the school serves.

However, while there are many parents who happily support curriculum choices like the ones described above, and reinforce at home what children learn in school, some do not. Parents have the right to educate their children as they see fit and it is a family’s right to have conservative faith or cultural values. Though, when parents choose to send their children to a state school, and home and school are not aligned on values, pupils sometimes grapple with mixed messages. This can result in confusion, and potential upset.

Staff navigated these issues in different ways, but what linked them all was communication – proactive and reactive. For example, if parents individually expressed dissatisfaction at their child being taught about LGBT matters, staff reported talking to them about exactly what it is they teach at school. This helped dispel misconceptions that parents may have had, although it may not have solved the fundamental disagreement.

To pre-empt misunderstandings, staff in some schools proactively communicated with parents. This is especially important in view of social media, where misinformation can spread quickly. Proactive communication took different forms, such as:

• sharing policies and the curriculum on the website
• providing information in booklets
• signing a home–school agreement to uphold the shared values
• promoting the values of the school through community events at school or through workshops and drop-ins for parents to inform about the curriculum on LGBT matters

Rather than just inform parents, staff should also engage with them on the changes they plan to implement or – in the words of senior leaders from a secondary school – ‘about values, what they mean and how these feed into the curriculum’.

Faith schools

In all the schools we spoke to, staff said they promoted a respectful and inclusive culture for moral reasons. In addition, staff in the schools with a religious ethos said that their ethos was the reason for acceptance and respect of pupils with different protected characteristics, including sex, sexual orientation and gender reassignment:

“The faith background gives us a common ethos. As a Catholic school, we know what the vision is. There is the outside challenge: family, society, confusion about sexuality and gender. We are made in God’s image and nothing should be stopping any child from getting as far as they possibly can. The ambition for them is there. Any bad behaviour is not accepted. Sexist attitudes – all stamped out.” (Senior leaders in a Roman Catholic school)

“[We] promote the British, school and faith values and monitor closely. Faith-based school is all about being respectful and tolerant. We have an Islamic saying of the week which is all about the holistic view of a child. That helps them to understand whoever is homosexual/trans, it is absolutely fine.” (Teachers in a Muslim school)

The message of acceptance came out strongly through school culture, teaching, extra-curricular activities and pastoral support.

Previous research also suggests that some schools with a religious character have stronger pastoral care systems in place for pupils and place equality at the centre of their ethos because of their religious beliefs. Most of the schools we spoke to used guidance published by their respective religious authorities, for example from the Church of England Education Office , The Office of the Chief Rabbi and the Catholic Education Service . In those documents, teaching about and supporting LGBT -related matters are seen as compatible with religious belief and a duty to LGBT inclusion is acknowledged because of religious values, such as acceptance or respect for others.

However, we must acknowledge that there can be tension between the protected characteristics of sex, sexual orientation, gender reassignment, and religion and belief, and that is a challenge for some schools and/or parents. We visited schools in the state sector for this research, and we are aware that these issues can play out very differently in the relatively small number of independent faith schools we inspect.

Guidance and support for schools and teachers

Most schools we spoke to would like clearer guidance from the DfE and other agencies on how to approach what can be sensitive and difficult subjects. A small number of staff were positive, to an extent, about the freedom they have under the current RSE guidance. They appreciated being ‘given space’ to:

• ‘choose how to deliver the agenda’
• teach what they think is age appropriate
• adapt what they teach

However, the overwhelming majority of schools were asking for much more specific guidance about sexual orientations and gender reassignment, both for schools and for parents:

“Guidance is too woolly – take it out or give us better guidance – [we need] greater clarity over what should be taught by when.” (Middle leaders in a primary school)

There was a lot of confusion around schools’ teaching obligations. This stemmed from:

• the lack of a detailed central curriculum
• the grey areas (awareness that primary schools can opt not to teach LGBT issues if they do not deem this age-appropriate and after consultation with parents)
• perceived contradictions in the information published by the DfE

Leaders were mostly asking for information on what should or should not be taught at each age. Headteachers were left to decide when something should be taught, but some perceived this as a lack of support from DfE .

There was confusion among schools about what the various pieces of guidance required teachers to teach in relation to LGBT matters in particular. Guidance identifies a minimum requirement, but does not contemplate any ceiling on what can be taught at what age, so there can be pressure to go further, potentially causing conflict with some parents.

There is also a scarcity of research that could inform teaching or pastoral support:

“It would be useful to have more research. There is so little out there.” (Middle leader in a primary school)

This was also why staff wanted the DfE and Ofsted to share good practice. They wanted to learn from other schools, similar or different to their own, and would like opportunities for learning discussions.

There is a lot of choice among external training and resource providers, but school leaders are often unsure of their quality or alignment with the law. A headteacher in a secondary school explains that they are:

“… very nervous of other providers. Would love someone to filter this for us instead of finding out the hard way. Someone comes in with completely inappropriate tone. I like the idea of having a national standard… These people crop up and get funding from wherever… emailing schools the whole time. There is a place for people with specific skills who can deliver better than the teachers. Would be nice to have a bank that we can dip into that’s already been vetted.”

Similar issues exist with the wealth of available teaching resources. Given the lack of expertise and training, staff needed help with the selection or adaption of resources for different year groups and would like ‘a pool of quality resources for schools’. A similar message came through in a large-scale study from the DfE .

Many of the above issues were also identified in a National Education Union (NEU) and National Society for the Prevention of Cruelty to Children (NSPCC) survey . This showed that the main barriers to teaching compulsory RSE lessons were:

• lack of teacher confidence in the subject
• competing workloads
• the cost of training
• difficulty in finding high-quality training and quality approved resources
• lack of clearer guidance

As we have shown in this commentary, many schools we visited were successful in this area and were doing well in fulfilling their legal duties and what they saw as their moral obligation. For those schools that need a bit more support, we hope this report has been a useful starting point.

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The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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Schools in England and Wales using ‘gender toolkit’ risk being sued by parents

Leading barrister warns that the kit – used to support gender-questioning children – is likely to be in breach of equality laws and could violate pupils’ rights

Schools in England and Wales have been warned by one of the country’s leading equality and human rights barristers that the “toolkit” many of them use to support gender-questioning children is unlawful.

The toolkit , introduced by Brighton and Hove council in 2021 and subsequently replicated by a number of other local authorities, says schools should “respect” a child’s request to change their name and pronoun as a “pivotal” part of supporting their identity, as well as other changes such as switching to wearing trousers or a skirt.

It emphasises that schools “will want to involve parents and carers in discussions”, and recommends a “watch and wait” policy when a young person first comes out to a “trusted” teacher, not pushing them in any particular direction.

But a legal opinion by Karon Monaghan of Matrix Chambers concludes that schools and councils using the toolkit are very likely to be in breach of equality and human rights legislation, and at risk of being sued by unhappy parents.

She argues that the Equality Act affords protection not only to trans-identified young people, but also to those who are gender-critical. Requiring everyone in school to use a child’s chosen pronouns would, she said, “be in direct conflict” with the beliefs of staff and children who are gender-critical, and might “violate their rights”.

The 75-page document tackles issues including toilets, sport and changing facilities. Monaghan says the toolkit is wrong to suggest that a trans pupil has a legal right to choose to use toilets designated for the opposite sex, and argues that allowing a trans girl to use a girls’ changing room could violate other pupils’ right to privacy or put them at “physical risk”.

“There is a worrying lack of appropriate guidance on safeguarding in the toolkit,” she says.

“There is an emphasis on supporting children through social transition without highlighting any of the risks that may be associated with that. As the interim report of the Cass review stated, this may not be thought of as an intervention or treatment, because it is not something that happens within health services.

“However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning.

“It anticipates that trans-identified children will access single-sex toilets, changing rooms and residential accommodation designated for children of the opposite sex. These are key milestones in social transitioning and there is no guidance on establishing the appropriateness of these steps, or any indication that external support from a clinician should be sought first.

“And nor is there any recognition or understanding of the best interests and welfare of the child who may be psychologically impacted by social transition.”

In response, Councillor Lucy Helliwell, co-chair of Brighton’s children, families and schools committee, said: “Our Trans Inclusion Schools Toolkit has been developed in order to support schools, teachers, gender-questioning young people and their parents on a case-by-case basis.

“As a local authority that works to ensure all our children and young people live happy, safe and positive lives, we’ll always be committed to providing support that protects and promotes their welfare.”

The row over legal advice comes at the end of a week in which a landmark review into the medical treatment of gender-questioning children was published. The Cass review said children and young people had been let down by a lack of research and “no good evidence” on the long-term outcomes of medical interventions to manage gender-related distress, in a debate that has become exceptionally toxic.

But while the findings of the Cass review were broadly welcomed by the main political parties, medical ­professionals and prominent transgender commentators, the debate over how to deal with children who wish to socially transition is more polarised.

The issue of how to deal with children who choose to socially transition does not involve any medical intervention, but relates to questions including whether a school should refer to a child using a different pronoun or name, what uniform they wear and access to single-sex or unisex toilets and changing facilities.

The new legal analysis by Monaghan was commissioned by a family in Brighton who are arguing that their child’s school helped their child to socially transition without their consent, because it was using the toolkit. The family wrote to the council on Friday threatening possible legal action if it does not withdraw the guidance within two weeks.

The child’s mother, who asked not to be named in order to protect the identity of her child, told the Observer : “Our child was socially ­transitioned at school by a group of teachers who are quite active in the trans rights arena, despite our child’s complex mental health needs, trauma and autism.”

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She said she and her husband “thought we had agreed a unique plan with the head” that the school should support only what she called a “pre-transition phase” until the child left secondary school. Instead, she said, they had been “shocked” to discover the school had supported their child socially transitioning. The family is now estranged from their child.

The mother said it was understandable that teachers were “looking for a safety net” and for advice to follow in navigating an increasingly fraught and contested area.

But she warned: “This toolkit is not just a little bit wrong, or only wrong in certain limited respects: it is catastrophically wrong from top to bottom.”

A spokesperson for the Department for Education said: “It is unacceptable for parents to be excluded from decisions regarding their children.

“Our draft guidance reflects the law, which schools have a duty to follow.

“The guidance already reflects the principles from the final Cass review, making clear that social transition should be extremely rare and any steps towards social transition should be incredibly cautious, taking account of available clinical evidence and any special educational needs, and prioritising parents’ wishes.”

Meanwhile, in a sign of how fraught the issue has become in schools, teaching unions warned that the government’s own guidance on how to deal with gender-questioning children could also lead to schools facing legal action.

It states that there is “no general duty” on schools to follow pupils’ wishes to socially transition, including using different pronouns or names, and that parents must almost always be told if their child talks to a teacher about such things.

The National Association of Head Teachers union said: “We are particularly concerned that, as it is currently drafted, aspects of the guidance may leave schools at ‘high risk’ of successful legal challenges.”

Margaret Mulholland, an inclusion specialist at the Association of School and College Leaders (ASCL) union, said: “Schools are doing their best to navigate this complex territory in the best interests of all the children and young people in their care.” She said this was difficult “in a climate of polarised views and risks of legal challenges”.

The union said the government’s failure to mention the mental health and wellbeing support that gender-questioning children might need was a “significant oversight”.

The ASCL told the Observer this weekend that it had called on the government “to take on and represent any legal challenges against schools” which are following its guidance.

• The Observer
• Transgender

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