Gender identity services and advocacy for children and young people

There has been growing interest in how the NHS should most appropriately assess, diagnose and care for children and young people who are questioning their gender identity or experiencing gender incongruence. This page provides more information for College members about NHS care for children who are gender questioning, including updates from a legal perspective and other areas of advocacy.
Last modified
10 April 2024

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 High Court judgment delivered in December 2020 (PDF) 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 Court of Appeal said 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 the High Court ruled 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.

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 Cass Review Terms of Reference and publications to date are available on its website. The final Cass report 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.

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 interim specialist service for children and young people with gender incongruence was published in 2023 following public consultation. NHS England is now seeking views 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 interim clinical policy on puberty blockers (PDF) 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 ‘Knowing Our Identity’ service. 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 eLearning module 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 draft non-statutory guidance 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