nhs child gender reassignment

https://www.gosh.nhs.uk/news/statement-on-nhse-intention-to-develop-early-adopter-gender-identity-services/

Statement on NHSE intention to develop Early Adopter gender identity services

28 Jul 2022, 1:31 p.m.

NHSE has today announced the next steps for improving and expanding services for children and young people experiencing gender incongruence and gender dysphoria. This includes establishing two Early Adopter services which will be led by specialist children’s hospitals.

One Early Adopter service will be based in London and will be led by a partnership between Great Ormond Street Hospital for Children (GOSH) and the Evelina London Children’s Hospital, with South London and Maudsley NHS Foundation Trust providing specialist mental health support. The other centre will be a partnership between Alder Hey Children’s NHS Foundation Trust and Manchester University NHS Foundation Trust. The aim is for the Early Adopter services to be fully operational by Spring 2023.

The above providers of the Early Adopter Services will be working closely to develop the new services and have issued the following joint statement.

“We look forward to working together with our colleagues at NHS England and with other partners to develop Early Adopter services for children and young people experiencing gender incongruence and gender dysphoria.

“As leading providers of specialist health specialist mental health services for children and young people, we are all committed to developing future services that deliver an holistic approach, ensuring children and young people benefit from the range of specialist care they need and deserve.”

The full NHSE announcement can be viewed on the NHSE website .

If you have questions about the current or future service, please contact NHS England at email: [email protected] or 0300 311 22 33 .

Gender reassignment discrimination and the NHS

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NHS bodies, in their roles as both employer and service provider, increasingly find themselves subject to complaints of discrimination on the grounds of gender reassignment, due to a growing awareness and understanding within the trans community of their rights as employees and patients.

It is therefore important that NHS bodies ensure that they have adequate training and policies in place for the prevention of discrimination against transgender employees or service users.

The two key pieces of legislation that protect transsexual people are the Equality Act 2010 (EqA 2010) and the Gender Recognition Act 2004 (GRA 2004).

The Equality Act 2010

Discrimination under the eqa 2010.

The EqA 2010 provides legal protection from discrimination and harassment. Gender reassignment is one of the nine protected characteristics covered by the Act. A person has the protected characteristic of gender reassignment if that person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning their sex by changing physiological or other attributes of sex.

Under the Act, a reference to a person who has the protected characteristic of gender reassignment is a reference to a transsexual person. Therefore, a woman making the transition to being a man and a man making the transition to being a woman both share the characteristic of gender reassignment.

A key point to note about the definition of gender reassignment under the EqA 2010, is that a person who ‘is proposing to undergo’ the process of changing their sex is protected i.e. they need not have undertaken any actual steps towards the process of transitioning. Further, a person living in the opposite gender without having undergone any medical procedures will be protected. Unlike earlier legislation, there is no requirement to be under medical supervision to qualify for protection under the EqA 2010.

There are five types of prohibited discrimination in respect of gender reassignment:

• Direct discrimination – when a transsexual person is treated less favourably than others because of gender reassignment
• Indirect discrimination – where a transsexual person is particularly disadvantaged by a provision, criterion or practice which applies to everyone
• Harassment – when unwanted conduct related to gender reassignment causes an intimidating, hostile, humiliating or offensive environment for that person
• Victimisation – when a person is subjected to a detriment because they have made or supported a complaint about gender reassignment discrimination
• Absences from work – where an employee is treated less favourably in relation to absences from work because of gender reassignment. This is the only type of prohibited discrimination specific to transsexual people

Case example

One issue that employers are likely to face in relation to transsexual employees is use of single-sex facilities. For example, it is likely, and understandably so, that person will want to use the toilet facilities of the gender to which they are transitioning. In the leading authority on this issue Croft -v- Royal Mail Group plc [2003], the Court of Appeal upheld a decision of an employment tribunal that it was not discrimination to require a pre-operative male to female transsexual employee to use the disabled toilet as opposed to the female toilet facilities during the transition process.

However, the approach in this case should not be regarded as best practice. The recruitment and retention of transgender staff guidance issued by the Government Equalities Office (GEO) Guide states that a trans person should be free to select the facilities appropriate to the gender in which they present and that when a trans person starts to live in their acquired gender role on a full-time basis they should have the right to use the facilities for that gender. Further, the Department of Health Guidance for NHS Trusts sets out that it is not good practice to require a transsexual person to use the disabled facilities and it is not acceptable to require a transsexual person to use the facilities of their assigned gender.

Exceptions: when gender reassignment discrimination may be lawful

Gender reassignment discrimination may be permitted in certain limited circumstances. The EqA 2010 provides for an ‘occupational requirement’ exception that employers can rely on in discrimination claims. This enables employers, in limited circumstances, to require that, having regard to the nature or context of the work, only people who are not transsexuals can do the job. The explanatory notes in the EqA 2010 give the following example of an occupational requirement; ‘a counsellor working with victims of rape might have to be a woman and not a transsexual person, even if she has a gender recognition certificate, in order to avoid causing victims further distress.’ This may also apply to NHS staff employed to help victims of rape or other sexual assault.

Application to the NHS

In addition to NHS employees, patients must not be subjected to discrimination by NHS Trusts. The EqA 2010 prohibits discrimination by a service provider (concerned with the provision of a service to the public) against a person requiring the service. Therefore, NHS trusts must not discriminate against transsexual patients because they have the protected characteristic of gender reassignment.

However, there is an exception in the Act for single-sex only services (for example, a group counselling session provided only for female victims of sexual assault) but NHS trusts must be certain that the provision of separate services is a proportionate means of achieving a legitimate aim.

NHS bodies must also have regard to the Public Sector Equality Duty set out in Section 149 EqA 2010, which sets out that they must have due regard to eliminating discrimination prohibited by the EqA 2010 and advancing equality of opportunity and fostering good relations between those who share a protected characteristic and people who do not share it.

Gender Recognition Act 2004

The Gender Recognition Act 2004 (the Act) allows transsexual people to gain legal recognition of their acquired gender by registering for a Gender Recognition Certificate (GRC). The application is made to the Gender Recognition Panel who will determine whether a GRC should be issued on the basis that the applicant has lived in their acquired gender for two years and intends to live the acquired gender until death. An applicant does not have to have had gender reassignment surgery, but have been diagnosed as gender dysphoric. Where a full GRC has been issued to a person, their gender becomes for all purposes the acquired gender.

Prohibition on disclosure of information

The Act has important implications for NHS trusts, particularly in relation to the provisions on prohibition of disclosure of information relating to a person’s application for a GRC or, if a GRC is issued, their previous gender. Under section 22 of the Act, it is a criminal offence for a person who has acquired, in an official capacity, protected information regarding an individual’s gender identity to disclose that information to any other person. This clearly affects NHS bodies as employers and in the supply of services to the public, as they are likely to acquire such information in relation to their employees or patients.

An example provided by the workplace and gender reassignment: Guide for staff and managers (a:gender Guide) is of someone working in HR with access to an employee’s personal file, disclosing the fact that the employee was born a different gender, without the employee’s prior consent.

Potential defences

There are a number of defences to this prohibition set out in section 22(4) of the Act. These include where the information does not enable that person to be identified and where the person has agreed to the disclosure of the information.

In addition, there is a further defence which will have particular importance to NHS bodies as service providers. The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) (No2) Order 2005 provides a defence in relation to disclosure for medical purposes. It will not be an offence under section 22 of the Act to disclosure protected information if the disclosure is made to a health professional, for medical purposes, and the person making the disclosure reasonably believes that the subject has given consent to the disclosure or cannot give such consent.

Practical considerations for NHS bodies

The a:gender Guide states that ‘it is the antithesis of the intentions of the privacy provision included in the GRA 2004 to ask or expect an individual to evidence they have gender recognition. Given the wider privacy protection applicable to all, it is best practice to assume any transsexual person has gender recognition and treat them accordingly’.

Care should be taken to use appropriate names and terminology in HR and patient records in relation to transsexual people. Where a person is transgender, it is important not to refer to this fact in patient or HR records unless the person has consented to it. In respect of employees, this may involve issuing them with a new set of HR records.

In relation to transgender patients, NHS/Department of Health guidance is that they should be issued with a new set of medical records to reflect their new gender status. NHS trusts may find themselves in a difficult position when there are medical reasons why a transgender patient’s previous gender needs to be referred to. In these circumstances, the medical professionals should seek consent from the patient for their gender history being recorded in their notes and steps should be taken to ensure that access to those notes is limited to those who need to be aware of the patient’s gender history for clinical reasons.

Department of Health guidance recommends that all staff are trained on these issues in relation to transgender patients and employees. Our specialist employment team can provide training on the legislation in this area and its implications for NHS bodies.

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Why the Tavistock gender identity clinic was forced to shut ... and what happens next

The clinic at the heart of a heated national debate formally closes this weekend. The journalist who told the inside story of its practice reflects on those it leaves behind

I t was a report in this newspaper that sparked my real interest in Gids – that made me ask “what’s going on?”. It was November 2018 and the article, by Jamie Doward, revealed that the Gender Identity Development Service, to use its full title, was undertaking a review. The details were scarce, but a senior member of staff had claimed that the service was “failing to examine fully the psychological and social reasons behind young people’s desire to change gender”.

In the week that Gids’s 35-year history has finally ended , I’ve been thinking about that time. How it set the scene of what would unfold over the next few years, and how things could have been so different. What if NHS England had acted when it saw a report of those concerns? It didn’t, and the service remained open for another six years. A service which referred children for puberty-blocking drugs, without robust data to support that this was beneficial, and that shut down the concerns of a growing number of its own staff.

Those professionals never questioned the identity of the young people they saw, nor the intensity of their distress. What they questioned was whether the NHS service they worked in was providing safe, evidence-based care for thousands of vulnerable children, or whether they might, in fact, be witnessing a medical scandal unfold.

In February 2019, just a few months later, more details emerged – in the Sunday Times , and then in the Observer . The senior staff member mentioned was Dr David Bell, a highly respected psychiatrist and psychoanalyst. These weren’t his claims and concerns per se – though he clearly shared them – but, rather, 10 members of clinical staff from Gids had gone to him with their worries about how the service was operating.

NHS whistleblowers are uncommon. To have 10, from one small clinic, is unheard of. I didn’t know if what they were saying was true, but the claims were extremely serious. I wanted to find out more.

And that started a process resulting in a series of films for BBC Newsnight , together with my then colleague Deborah Cohen, and later a book chronicling this extraordinary episode in NHS history.

The clinicians had sought out Bell after repeatedly raising concerns within Gids and the wider Tavistock itself to no avail. They told him how the service was unable to cope – the number seeking its help had increased tenfold in just five years. There was enormous pressure to “process referrals rapidly”, or, more bluntly, refer children on to endocrinologists who would prescribe puberty-blocking drugs.

Sometimes – though not often – this would happen after just an hour or two, staff said. Procedures for gaining consent to these potentially life-altering treatments were inadequate, and many of these children, staff explained, were vulnerable. Many were autistic. Many had been bullied, in some instances after coming out as gay. Most were unhappy. These children had complicated lives, and sometimes had suffered horrendous abuse or trauma. But this wasn’t always explored properly before referring for medication.

In a small minority of cases, it’s difficult to properly convey just how troubled these children were. Some were non-verbal. Some could not read or write. Others even identified as another race.

The official review that followed Bell’s report didn’t give Gids a clean bill of health, but the Tavistock trust told the press that the service had been found to be “safe and operating in line with the best practice in this field internationally”. The trust’s chief executive insisted that “none of the concerns around safety or safeguarding [highlighted by Dr Bell] were upheld by our medical director”. This wasn’t true. And the message underpinning these public statements was symptomatic of how the trust was responding to the difficulties Gids was facing.

The Tavistock told this newspaper in November 2018 that it was “concerned by the tone and manner in which these allegations have been made”, and that they revealed “a negative attitude to gender dysphoria and gender identity”.

For some who had contributed to Bell’s report, this confirmed what they had been saying all along: that if you raised concerns, you would face accusations of transphobia. That word wasn’t used in the statement, but it’s how staff interpreted it. When Bell’s report was leaked, the trust claimed that it “ presented hypothetical vignettes , rather than actual case studies”. This was also untrue. Some were so appalled by the statement that they resigned. Others who stayed at the trust say it sent a message: if you spoke out, you would be vilified.

When, in June 2020, Newsnight broadcast parts of transcripts of official interviews clinicians had held with the Tavistock’s medical director as part of that review, the trust’s claims didn’t stand up. A sizeable minority of staff had, in fact, told him that Gids’s model of care was unsafe, and that some children were being harmed.

At about the same time, legal proceedings against the Tavistock trust questioned whether children could properly consent to treatment with puberty blockers. Keira Bell, the lead claimant, was referred for the drugs after just three or four appointments. She was also prescribed testosterone while under Gids’s care. A double mastectomy followed via adult services and, aged 22, she regretted it all. No alternatives had been explored by the service at the time, she said.

The case was ultimately lost on appeal , but it showed how, over 30 years, Gids appeared to have collected no meaningful data on its patients or its core treatment pathway. It could not tell the court how many children had been referred for puberty blockers, how old they had been, what sex they were, or if they had gone on to take hormones.

Change quickly followed Newsnight ’s broadcast and the start of litigation. In September 2020, NHS England announced that paediatrician Dr Hilary Cass would undertake an independent review of gender identity services for children and young people. The Care Quality Commission (CQC) inspected Gids a month later. It rated the service inadequate and, in a damning report, upheld most of the concerns clinicians had been raising for years.

Contrary to denials from the Tavistock, the CQC found examples of two-session assessments (the trust would later concede that one-session assessments had occurred too). The watchdog noted that Gids did not always adequately manage risk; that consent was not recorded routinely; and that some staff “felt unable to raise concerns without fear of retribution”. In some cases, it said, “there was no clear rationale for clinical decision making”.

Cass’s interim review, published in February 2022, marked the beginning of the end for Gids. The “single specialist provider model is not a safe or viable long-term option”, she wrote; a “fundamentally different service model” was needed.

Once children with complex needs were identified as having gender-related distress, those other important healthcare issues were sometimes overlooked, she said. There were “significant gaps in the research and evidence base”, and Gids’s “clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced”, the report explained. Cass was referring, diplomatically, to NHS England allowing Gids to routinely refer children as young as nine for puberty blockers from 2014 onwards, without insisting on any robust data to support the policy.

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On 28 July 2022, NHS England announced its intention to close Gids. It would be replaced, initially, by two new regional services – one in London, the other in north-west England. They would follow a very different model of care , offering more “holistic treatment”, “a range of pathways”, and with the primary intervention being “psychological support” – not medication. NHS England confirmed on 12 March that puberty blockers would not be available going forward because there was not enough evidence to support their safety or clinical effectiveness. Blockers will not be prescribed on the NHS unless and until a research trial has been established.

NHS England has updated its policy around hormones accordingly. Previously, someone could start hormones at “around their 16th birthday” (interpreted by Gids staff as 15 years and nine months) only if they had been on blockers for 12 months beforehand. Otherwise, they would have to wait to access adult services. NHS England’s new policy – largely copy-and-pasted from the previous one, complete with out-of-date document references – confirms hormones will now be available without the need for prior treatment with puberty blockers. A new safeguarding measure has been introduced whereby a national clinical team will have to agree the young person meets all relevant criteria for the drugs. The policy will be reviewed following Cass’s final recommendations, so may well be short-lived.

The opening of the new youth gender service has been beset by delays ; the aim was to have the first two clinics running by spring 2023. They will finally open on Monday, while a third is being set up in the Bristol area. Over time, there may be up to eight operating across England.

But it won’t be easy. Great Ormond Street hospital, one of the trusts involved in the London services, has found it so difficult to recruit staff that it took to offering a £500 “refer a friend” bonus as part of its most recent recruitment drive. “Our two new providers on their own are not going to be able to make a significant dent immediately in that waiting list,” John Stewart, NHS England’s national director for specialised services, has confirmed. There is little to smile about for the 6,000 or so children on the waiting list for help. Some have already waited five years, and no one will be coming off that list soon – if ever.

Initially, the only children who will be seen by the new services will be those whose care is being transferred from Gids. But only 250 of them. According to Tavistock board minutes , 58 patients will require a face-to-face handover because of “complexity and/or risk”. Anyone already receiving puberty blockers or cross-sex hormones, or who has been referred to endocrinology but not begun treatment, will not have their care overseen by the new services. This is about 400 children and young people, NHS England told me. Some are eligible to be transferred to adult clinics; the others will receive a “wraparound service” from Nottinghamshire Healthcare NHS foundation trust.

There are few details about the arrangement, which I first revealed in the New Statesman . The BBC has reported that job adverts for senior roles in this new service only closed to applicants the week before last. The choice of Nottinghamshire is also somewhat surprising: its CQC ratings are currently suspended because of a series of problems.

Others have stepped into the void created by a stagnant Gids (about half the clinical and administrative teams have left since its closure was announced) and the absence of new services, recognising that there are high levels of distress and huge demand for interventions.

It seems that some GP practices are sidestepping NHS guidance in their approach to young people aged between 16 and 18. One prescribes hormones to 16-year-olds at their first appointment, and says it follows an informed-consent model of care. As a rationale, the practice cites “Gillick competence” – the legal principle that a child may be sufficiently informed to consent to treatment on their own – and rules over interim “bridging prescriptions”, saying it is a harm-reduction measure while patients wait to be seen at a specialist gender clinic. It is not at all clear that this is correct: GMC guidance states bridging prescriptions only apply to “doctors treating adults”, and they are not generally used to start treatment.

The private sector has seized the opportunity, too. Gender Plus, a private service, currently lists 10 Gids workers, or those who have worked in endocrinology services connected to Gids, on its team. Predominantly aimed at the 16-25 age group, Gender Plus will prescribe hormones to those 16 and older. Under-18s will need to have about six appointments, spanning six months, before being eligible for hormones, with each hour-long appointment costing £275.

The Gender Plus team have stated their opposition to NHS England’s plans to end the routine prescription of puberty blockers. And while its own hormone clinic won’t prescribe puberty blockers to under-16s, it will inform them of those that will. Gender Plus argues that its approach to care is in line with best practice, as demonstrated by NHS England’s recent policy update on hormones.

Cass’s long-awaited final report and recommendations on youth gender identity services will be published in the next fortnight. There is an opportunity to change the way gender-questioning young people are cared for – with compassion and underpinned by research and evidence, just like other areas of healthcare. This approach will no doubt be challenged, while private providers and NHS GPs alike continue to do their own thing.

NHS England will have to do far better than it has in the past at providing oversight to ensure Cass’s recommendations are followed. It knew of serious concerns about Gids from at least 2018. Thousands of distressed young people have been badly let down and are now lingering on a waiting list, wanting help. Many will believe what “experts” have told them – that puberty blockers are the only thing that can take away their pain – and be distraught that these are now unavailable. There will be no quick fixes.

Hannah Barnes is associate editor at the New Statesman . The updated paperback edition of her book, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children (Swift Press), was published on 28 March

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NHS loophole allows puberty blockers for children

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An NHS loophole allows puberty blockers to be prescribed to children who want to change gender despite the drugs being banned following a landmark review.

Prescribing drugs that stop children from developing physically and neurologically was banned by the NHS last month following advice from an interim review led by Dr Hilary Cass, a leading consultant paediatrician.

Her final review into care for children who want to change gender, which is due to be published this week , is expected to reiterate that puberty blockers are harmful and should not be given except during research trials.

However, it is not expected to address a loophole which allows doctors to apply for special dispensation to prescribe the drugs under exceptional circumstances.

Liz Truss is leading demands from MPs and campaigners that the loophole is closed, amid fears that vulnerable children are not being safeguarded.

The former prime minister, who is backing a law that would ban the controversial drugs altogether , told The Telegraph: “In schools, hospitals and the courts, extremist activists have exploited loopholes in the law time and time again. Without primary legislation, the practice of prescribing puberty blockers to children will continue, despite the evidence of harmful consequences.

“Non-statutory guidance and reviews are not enough. A change in the law is needed to protect children. I urge the Government to back my Bill which will stop puberty blockers and cross-sex hormones being supplied to under-18s, both in the private sector and the NHS.”

The 2022 interim review by Dr Cass, the former president of the Royal College of Paediatrics and Child Health, led to the closure of children’s gender services at the controversial Tavistock clinic as well as the ban on puberty blockers.

Dr Cass warned that the drugs may permanently disrupt the brain maturation of adolescents, potentially rewiring neural circuits in a way which cannot be reversed.

Following her initial findings, the NHS launched a consultation on banning them, under which it proposed that doctors could prescribe them to children under 17 in “exceptional circumstances”.

Last month, in a move welcomed by ministers, the health service announced that they would be banned altogether, with NHS doctors only allowed to give them to children in clinical trials and not in any other circumstances.

However, The Telegraph can reveal that officials made that decision because a protocol already exists that allows doctors to apply for a treatment that is not routinely available to be funded by the NHS.

Doctors are able to submit “individual funding requests” to NHS England for any patient they believe would benefit from a specialised service treatment and justify why the “clinical circumstances are exceptional”.

‘Loophole is abhorrent’

Dr Louise Irvine, a GP and co-chair of the Clinical Advisory Network on Sex and Gender, said it should be “impossible” for doctors to justify the exceptional circumstances for giving out puberty blockers because “the whole rationale for stopping the prescription of puberty blockers is that there is no evidence of benefit”.

Others warned that the loophole risked “insufficient impartial medical scrutiny”, with Dr Caroline Johnson MP, a paediatrician and Conservative member of the health select committee, saying: “There is a risk of irreversible harm and irreversible changes with these drugs.

“If the NHS plans to allow them for children by individual applications – the question is how high is the threshold of benefit which must be met? How well must risk be understood? What is the burden of proof?”

Nick Fletcher, a Tory MP, described the loophole as “abhorrent”.

“We shouldn’t be providing any puberty blockers to children,” he said. “I’ve called it out so many times but unfortunately so many of our organisations have been captured by this. We’re setting young people up for a lifetime of misery.”

Both MPs are among a dozen Tories backing Ms Truss’s law that would ban the controversial drugs altogether. However, she has faced opposition over her policies, which also include protecting women’s single-sex spaces, with Labour accused of filibustering last month when Parliament ran out of time to debate her proposals.

It is understood that Kemi Badenoch, the equalities minister, had wanted to back large sections of the Bill but was prevented from doing so by Cabinet colleagues, and blamed Labour MPs for wasting “parliamentary time to discuss ferret name choices” instead.

“Keir Starmer is terrified of debate on safeguarding and his MPs actively work to ignore the concerns of constituents,” she tweeted.

Dr Cass’s final report, which is set to be published on Wednesday, is expected to look more closely at cross-sex hormones and social transitioning among schoolchildren, with warnings that children face grave psychological consequences if they are allowed to change gender at school.

Campaigners are pleading for Dr Cass to make recommendations to protect children turning 17 who are currently sent on to adult gender clinics where they can be prescribed cross-sex hormones.

Stephanie Davies-Arai, a director at Transgender Trend, which advocates for evidence-based treatment of children, said the adult clinics “employ the model of ‘affirmation and informed consent’ that was found to be unsafe for children at the Tavistock”.

She warned that those aged between 17 and 25 “are especially vulnerable” and said: “We would like to see Cass recommending a transitional pathway that continues the same standard of care for this age group.”

Cass findings ‘should apply in private clinics’

The Cass review’s remit is limited to NHS services for children and young people, but charities and support groups believe her findings should be applied across private clinics too.

A spokesman for Bayswater Support Group, which provides support for parents whose children have a transgender identity, said he hoped the review would “spur regulators and the Government to remove all loopholes that allow medical mistreatment of children and recognise that it may be necessary to legislate for this”.

Helen Joyce, director of advocacy for the charity Sex Matters, said there was a risk the drugs “continue to be prescribed by private clinics, including some based abroad”.

“Dr Cass’s limited remit also means she may not have fully considered the knock-on impact of her recommendations for schools,” she said.

“If even a small number of children continue to be supported in so-called ‘social transition’ by gender clinics, the risk is that schools think they must accommodate that under ‘doctor’s orders’. But the plain fact is that schools cannot treat any male pupil as a girl, or any female pupil as a boy, without creating serious safeguarding risks for that child and all other pupils.”

An NHS England spokesman said: “Following an expert review of available evidence we recently confirmed that NHS services will not offer puberty suppressing hormones to young people seeking treatment and support for gender incongruence or gender dysphoria.

“As with all specialised services, doctors are able to apply for individual exceptions to be made, but these requests are only ever approved if there is clear clinical evidence that the patient would benefit more than others with the same condition.”

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Tennessee hires Marshall's Kim Caldwell as women's basketball coach

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Apple’s second-generation AirPods Pro are back on sale for $190

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Think your child might be trans or non-binary?

If your child seems confused about their gender, it's usual for parents to also feel puzzled or worried. But there is help available to support you and your child.

It's common for children to show an interest in clothes or toys that society tells us are associated with a different gender.

With toy stores dedicating floors to colour-coded boys' or girls' toys, as an example, parents may expect a child to closely match expectations of how male and female genders should behave.

You may worry that your child's exploration of different gender preferences and behaviours is not "normal". However, this is not the case.

A young child's exploration of different gender identities is quite common. However, for some children this may continue into later childhood and adolescence.

Some people see gender as existing on a spectrum. This includes male, female and a diversity of gender identities such as non-binary and agender (no gender).

When should I seek help for my child?

If your child is strongly identifying with a different gender and this is causing significant distress to them or your family, see a GP.

Signs of distress in a child can include anxiety , withdrawal, destructive behaviour or depression . It's also possible that such behaviours will have been noticed at school.

You may seek support for your child before puberty starts, which can begin as young as age 9 or 10. The physical changes that occur at puberty, such as the development of breasts or facial hair, can increase a young person's feelings of unhappiness about their body or gender.

Who can help?

Your child's GP can refer them to the National Referral Support Service for the NHS Children and Young People's Gender Service . Other NHS professionals, teachers, local support groups and relevant charities, and counsellors can refer them too.

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

After an initial assessment with you and your child, the team at the gender service:

• works with family members, children and young people to help manage anxieties and ease emotional, behavioural and relationship troubles associated with gender identity
• will help you keep your child safe and reduce any stigma around exploring their gender identity
• will discuss with you the support they can offer to your child's nursery or school, and local Child and Young People's Mental Health Services (CYPMHS), if appropriate

If your child continues to be upset or confused about their gender identity and is nearing puberty, you and your child may be seen more often by the team.

Each child or young teen will have different needs and goals for how they wish to express their gender.

Hormone therapy

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Will my child grow up to be trans or non-binary?

In many cases, gender-variant behaviour or feelings disappear as children get older – often as they reach puberty.

Children who do continue to feel they are a different gender from the one assigned at birth could develop in different ways.

Some may feel they do not belong to any gender and may identify as agender. Others will feel their gender is outside of male and female and may identify as non-binary.

Some children who have continuing, strong feelings of a different gender identity will go on to live full-time in a gender different from their sex assigned at birth.

How can I support my child?

Children sometimes worry that if they tell you how they feel, you will not love them anymore. It's important to accept your child and let them know you love and support them, whatever their gender identity is.

If you feel anxious or uncomfortable, you're not alone.

Many young people and parents find talking to other parents and children who have had similar experiences a great help.

It's also important to remember that you, as a parent, need support too. You may be experiencing feelings of loss at your child wishing to live in another gender, or you may be anxious about their future and the effect on the rest of your family.

The charities listed on the TranzWiki page on the Gender Identity Research & Education Society website are there to help you, too.

Get more advice on gender identity for teenagers

NHS England review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the services for children and young people.

Page last reviewed: 12 November 2021 Next review due: 12 November 2024

Stop COVID Cohort: An Observational Study of 3480 Patients Admitted to the Sechenov University Hospital Network in Moscow City for Suspected Coronavirus Disease 2019 (COVID-19) Infection

Collaborators.

• Sechenov StopCOVID Research Team : Anna Berbenyuk ,  Polina Bobkova ,  Semyon Bordyugov ,  Aleksandra Borisenko ,  Ekaterina Bugaiskaya ,  Olesya Druzhkova ,  Dmitry Eliseev ,  Yasmin El-Taravi ,  Natalia Gorbova ,  Elizaveta Gribaleva ,  Rina Grigoryan ,  Shabnam Ibragimova ,  Khadizhat Kabieva ,  Alena Khrapkova ,  Natalia Kogut ,  Karina Kovygina ,  Margaret Kvaratskheliya ,  Maria Lobova ,  Anna Lunicheva ,  Anastasia Maystrenko ,  Daria Nikolaeva ,  Anna Pavlenko ,  Olga Perekosova ,  Olga Romanova ,  Olga Sokova ,  Veronika Solovieva ,  Olga Spasskaya ,  Ekaterina Spiridonova ,  Olga Sukhodolskaya ,  Shakir Suleimanov ,  Nailya Urmantaeva ,  Olga Usalka ,  Margarita Zaikina ,  Anastasia Zorina ,  Nadezhda Khitrina

Affiliations

• 1 Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 2 Inflammation, Repair, and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.
• 3 Soloviev Research and Clinical Center for Neuropsychiatry, Moscow, Russia.
• 4 School of Physics, Astronomy, and Mathematics, University of Hertfordshire, Hatfield, United Kingdom.
• 5 Biobank, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 6 Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 7 Chemistry Department, Lomonosov Moscow State University, Moscow, Russia.
• 8 Department of Polymers and Composites, N. N. Semenov Institute of Chemical Physics, Moscow, Russia.
• 9 Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy.
• 10 Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany.
• 11 Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 12 Department of Intensive Care, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 13 Clinic of Pulmonology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 14 Department of Internal Medicine No. 1, Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 15 Department of Forensic Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 16 Department of Statistics, University of Oxford, Oxford, United Kingdom.
• 17 Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
• 18 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
• 19 Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom.
• 20 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• PMID: 33035307
• PMCID: PMC7665333
• DOI: 10.1093/cid/ciaa1535

Background: The epidemiology, clinical course, and outcomes of patients with coronavirus disease 2019 (COVID-19) in the Russian population are unknown. Information on the differences between laboratory-confirmed and clinically diagnosed COVID-19 in real-life settings is lacking.

Methods: We extracted data from the medical records of adult patients who were consecutively admitted for suspected COVID-19 infection in Moscow between 8 April and 28 May 2020.

Results: Of the 4261 patients hospitalized for suspected COVID-19, outcomes were available for 3480 patients (median age, 56 years; interquartile range, 45-66). The most common comorbidities were hypertension, obesity, chronic cardiovascular disease, and diabetes. Half of the patients (n = 1728) had a positive reverse transcriptase-polymerase chain reaction (RT-PCR), while 1748 had a negative RT-PCR but had clinical symptoms and characteristic computed tomography signs suggestive of COVID-19. No significant differences in frequency of symptoms, laboratory test results, and risk factors for in-hospital mortality were found between those exclusively clinically diagnosed or with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR. In a multivariable logistic regression model the following were associated with in-hospital mortality: older age (per 1-year increase; odds ratio, 1.05; 95% confidence interval, 1.03-1.06), male sex (1.71; 1.24-2.37), chronic kidney disease (2.99; 1.89-4.64), diabetes (2.1; 1.46-2.99), chronic cardiovascular disease (1.78; 1.24-2.57), and dementia (2.73; 1.34-5.47).

Conclusions: Age, male sex, and chronic comorbidities were risk factors for in-hospital mortality. The combination of clinical features was sufficient to diagnose COVID-19 infection, indicating that laboratory testing is not critical in real-life clinical practice.

Keywords: COVID-19; Russia; SARS-CoV-2; cohort; mortality risk factors.

© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected].

Publication types

• Observational Study
• Research Support, Non-U.S. Gov't
• Hospitalization
• Middle Aged

Grants and funding

• 20-04-60063/Russian Foundation for Basic Research