Hopefully everybody um can actually hear us this afternoon. So, and welcome to
this afternoon's ground round. And can I first of all welcome Dame Hillary Cass
to to this who is speaking to us um at our ground round this afternoon. Um
so for those of you who don't know me, my name is Chef Pering. I am medical director at the trust and I will be chairing today's meeting. It is a bit of a hybrid meeting. We've got a lot of people online and we've got a group of people also in the Peter Ballroom. So um I'd like to welcome everybody to this um this this grand round. First of all, can I introduce Hillary Cass who was president of the Royal College of Pediatrics and Child Health from 2012 to 2015 and then subsequently led the independent review of NHS gender identity services for children and young people um commissioned by NHS England and this was in 2020. Um the final report was published in April 2024 and made 32 recommendations that fundamentally changed how these services are delivered across England and Wales.
and her work has led to the creation of new regional services. And for Sheffield Children's, NHS England approached us um probably just over a year ago or over a year ago asking whether or not um we would be willing to develop a business case for a second northern center for this service. Um the trust board agreed to to explore this and um there is now a um a a team that have been put together who are building up that business case which is expected to go to the um trust board in February of next year. So there is that umexpectation and the reason for this session is it will help us to understand the review that Hillary undertook the recommendations from it and what they mean for children and young people particularly around safety and improving their experience of care. It is an important area of complex health care um for gender questioning children, young people and we do need to make sure that we address their mental, emotional and physical health um in any service that we put together. I'd like to personally say I saw Hillary speak and whether she remembers she spoke at the Kings Fund at the TMP alumni event um in 2024 and it was a really really good um talk that she gave and promoted a lot of um discussion afterwards. So I'd personally thank you for that but also I'm looking forward to hearing you speak again um this afternoon. Um you my understanding is you will be talking for about half an hour which gives us plenty of time for questions. Um and when we move on to questions I'll be sort of looking at them from um online and Rum who is in the Peter Ballroom will sort of be looking at any questions from there as well. So might be a little bit confusing but we'll we'll get there.
So Hillary over to you.
Brilliant. Thanks so much, Jeff. Well, I hope I hope there'll be something new for you to listen to and it won't be too too too uh too repetitive. I think I think I have got some uh different uh let me just move this out of the way. Uh so I can get into uh there we go. Um and actually let me swap that. Okay. Have you now got um Have you now got a full a
full screen display? Yes, we have. Excellent. Okay.
So, um as Jeff said, I um I retired, well, I was a president of RCPCH and then about two or three years later, I retired from clinical practice um planning to devote my life to hedgeonism and self-indulgence. Um and then NHS England rang and that plan went to hell in a hand cart. So um uh so this is how I then spent the next number of years. Um so oops and okay so what I'm going to do is um talk a bit about the background something about the patients as we understand it something about the international position and then the broader evidence but you know relevant more relevant for you um the approach and recommendations and my kind of reflections on what's happened since and um of course things are in the news again because of the puberty uh blocker study.
So, um just to say the aim of the the review that I took was very uh specifically about
children and young people who were questioning their gender identity or experiencing gender dysphoria and were walking through the door of the NHS. It was very focused on that. Although there was a lot else going on at the time around guidance in school and all sorts of other stuff, we tried to keep our head down on the actual focus and which was about the standards of care that those young people um should expect. Um and we said right up front in the report, it wasn't about defining what it means to be trans or undermining the validity of trans identity or people's rights um uh in any way. It was about
what the health care approach should be to help this group of young people.
There's been a massive understand misunderstanding internationally about independent reviews um because they used in many countries and particularly in the NHS when there are concerns about quality of care and patient safety. And so there was a fair amount of noise particularly coming from the US about the fact that I wasn't an expert in this field. But that was um um a deliberate selection that NHS England made because people who were working in the field were so polarized. But suffice to say we had massive input both from people with lived experience and clinicians working in this field. Um so um so uh that's you
know one of the significant pieces of disinformation.
What had driven the review was we already knew I did a preliminary piece of work with nice looking at the evidence base for medical treatments and nice found that that evidence base was weak and I'll come back to that but also there had been a a dramatic change in the demographic without a clear understanding of the reason. So we had more young people presenting. It had changed from being predominantly birth registered males presenting in um early years to predominantly birth registered females presenting in teen years and they had quite complex psychosocial challenges and a high proportion had
neurodeiversity and the waiting lists were completely unacceptable. And then alongside that concerns have been raised about clinical practice at the single national center um initially by whistleblowers then documented in inspection reports.
So this is the graph that um uh people kind of um have probably seen before just showing this you know significant in increase in in adolescent females and the overall numbers had gone up from about 50 a year to ultimately three and a half thousands a year. So just to understand the context of this, gender care for children and young people was originally based on a counseling and therapeutic model. The first um centers opened up in the 1970s to 80s. Um and it wasn't until the early 2000s that Peggy Cohen Katennis um who
had worked in adult services felt that her patients were not doing well from a mental health point of view. and she felt that a lot of that was probably because they were not passing in their identified gender uh particularly um the trans females. Um so she introduced the
idea if we could uh block their puberty um then uh they would they wouldn't go through those irreversible particularly changes that the um birth registered males were going through um and also it might buy them time to think.
So they had really tight inclusion criteria. Whoops. Which are on the on the left there. Um so then from 2011 in the UK there was an attempt to replicate the Dutch protocol. Uh the by the sorry the Dutch had found just a modest increase in in um in me improvement in mental health scores but no changes in the dysphoria or any other aspects. So in 2011 in the UK they started what was called the early intervention study to see if they could replicate the Dutch results but in 2014 before they had their results they moved off protocol and started routinely prescribing puberty blockers and they were then given to a much wider group of patients who wouldn't have been eligible in the Dutch protocol. this newer group of um birth registered females um in 201516 they already knew that they had not replicated the Dutch results that that group of young people had not improved in their mental health and in fact as many had got worse had got better and some had become more suicidal um in their ideation um but they didn't publish until 2020 and by that time um there was a very strongly held belief that um puberty blockers, you know, were highly
effective.
So, the the things that informed the review, um, I mean, as I think all of you will be aware, we we commissioned a series of systematic reviews from the University of York. They put in a competitive tender and they also did um some qualitative and quantitative research for us. Um, and then we we listened to people from a very wide range of clinical backgrounds. uh well a professional background.
So we had we spoke every couple of weeks to the clinicians working in the JID service but we also spoke to um people working in broader children's mental health and pediatric services. We spoke to social workers. who spoke to teachers and then I had regular listening uh sessions every week um where any um one who had what I called skin in the game which was either they were a service user, a family member or carer or a professional working in the field could speak to me.
We had focus groups with children and young people and we spoke regularly about every six weeks to the main support and advocacy groups and some people sent us personal narratives and then we also reviewed what was going on internationally in terms of guideline guidelines and um and clinical approach. Um so um particularly that um just to say within the clinical engagement we had some some roundt discussions about things like impact of um um mental health on how young people were fairing.
We had something about safeguarding. Then we had a round table on lived experience. Um, so it was a very wide engagement program, which is why it's unbelievably irritating uh when people say we didn't speak to any uh trans people um uh when we were doing that
pretty much every week. So um in terms of the patient cohort, um we were asked to look at why there'd been the um increase in referrals in this this this new group. Um and it is a
a very heettogeneous group as I said. Um there are higher rates of neurodeiversity but also higher rates of adverse childhood experiences of family uh trauma and stresses and and and a range of mental health issues. But we had to see that also um these young people were not existing in a bubble. We had to look at that in terms of what was happening to other young people in Gen Z. And they were also having a significant deterioration in their mental health which got worse after COVID and females were being um adversely affected more than males.
Um there was increasing um concern about social media having a negative impact on mental health which um I'm sure everyone's um you know it's that's uh still huge at the moment as a as a concern and um and particularly girls uh were having an expectation of violence in sex. Well, both sexes were actually um and um and um uh uh some sort of fairly adverse experiences, cyber bullying um and um and and body image um concerns. And we are also seeing an increase in physical manifestations of mental distress including ticks and pseudo seizures and medically unexplained symptoms, an increase in body dysmorphic syndrome. Um, and but against that background, generational perceptions about gender expression and fluidity were very different in in Gen Z. And they had a much more um fluid um they they did not see um uh gender as in the binary model that older adults had seen. And so um people were much more likely to be gender non-conforming um or possibly see their gender as non-binary.
Um so it's a very different way of um seeing things. Now people want simple answers. So the you know one one side was it's all social contagion and people need to pull themselves together. Uh some people said you know all of these young people were born trans and they were being denied um um um medical care. Other people were saying um it's all about um uh trauma or confusion about sexual orientation. And none of those really simple explanations really cover it. It's much more complex, much more nuanced uh than that. And so attempts to oversimplify are really really unhelpful. And we just drew this you
know sort of biocschosocial map of how we thought you know things may be that you have some kind of predisposition. You go through puberty and that is a time when you know people are vulnerable and h become distressed about their um mental health their their
body and their their mental health is vulnerable. Um there are social stressors. There's the uh cultural lens um about how you see yourself.
Um, so some people may have become been gender in congruent from when they were tiny and continue to be gender in congruent through adolescence and would continue
into adulthood. And others would go through a period of questioning their gender um and maybe resolving that um by by remaining gender non-conforming, gender fluid. Um, and some would go on and um uh want a medical transition. And so you you could come into this in in in these many different ways on the left and you know come out again in many
different ways on the right. Um and it was almost like we wanted the strap line of the review to be every child and young person on the right pathway for them as an individual.
But what we do know is gender identity takes um a while to stabilize out. And this was from a study last year about gender non-contentedness. And uh you about um uh 78% of the population, this blue group um uh never have gender non-contentedness. There's about 20% who have gender non-contentedness that peaks um at around 11 and gradually uh drops off into mid20s. And then there's another group about 2% who have increasing gender non-contentedness as they get older.
So what was going on internationally? Well, um, our team looked at, um, lots of guidelines, lots of papers about how services were set up, lots of studies of assessment tools, lots of international survey data, and um, uh, don't worry about um, this uh, busy graph too much,
but these on the left are all the guidelines, and they were assessed using a a standard tool. And suffice it to say that most of them, you can see there's a lot of red, scored pretty badly on um on um this standardized um tool. Um the ones that scored best were the uh and you can you can have this afterwards and it's in all the papers or in the public domain, but the ones that scored best um were actually the Swedish guidelines and the guidelines from Finland. um and they were recommending a more cautious approach.
Um so there those were the only two that you were unanimously recommended for use in practice. As I say, don't worry about the details of this because you're welcome to have any of this later. But but the thing that we'd found was that international guideline development hadn't followed standard evidence-based approaches. Hardly any of them used systematic reviews except the Nordic ones. the W path. This one had influenced most of the other uh guidelines um and um and uh that they hadn't taken account of this change in the population. So when we looked at the broader evidence um it was all pretty poor.
Um we looked at evidence around social transition. It wasn't clear that it had either positive or negative effects on on on mental health in children. And the evidence is weak in adolescence, but there is some suggestive evidence that if you socially transition early, that may change the trajectory of your gender development. And we had a multi-professional review group which was looking at children and young people who were being put forward for puberty blockers. Um, and and they'd reviewed about 200 cases. And the children who were in most distress who were the ones who were in stealth because they were really anxious about being outed which was driving the urgency for puberty blockers. The young people who seem to be much less um stressed were the ones who were um either being flexible about their gender.
I spoke to the mom of a little boy who was still using he him pronouns, but he would sometimes go to school in a dress, sometimes in more male typical clothes and um and he and his parents and the children around him were quite relaxed and his options were sort of more open. He and and he was sort of generally much less anxious than the young people in stealth. So um one of the recommendations is that if people are making early decisions about social transition um it's really important that they get some professional help and support to try and work through that and work through what's going to happen about support in school and and so on.
the evidence for use of psychological interventions um specifically focused on dysphoria were just as as poor as the evidence underpinning the medical uh treatment. But the real problem for this group of young people who were sitting for years on a waiting list and they were often bypassed by local services and you know people were not intentionally um excluding these young people but that was the net effect because um CAMS is overwhelmed as you know and so there were two reasons to refer them direct to the Tavisto dot. One was well this is a specialist service so you know anyone who's questioning their gender we should refer directly to them and the other was um we have huge waiting lists and actually there was a third one which is I'm frightened and I don't know how to um manage this young person because it's all so special and different so we sort of you know disempowered local services but then these young people could sit for two and three years on a waiting list with nobody doing anything about their depression their anxiety helping if they were wanting to have a diagnosis around neurodeiversity.
And so the thing to say is that psychological therapies that any other young person who's depressed or anxious should get should be available to these young people as well because we know those do work. But importantly, psychosocial intervention is not designed to change the person's perception of who they are. It's about working with them to explore their concerns and experience and alleviate their distress. Because whichever way you slice it, and an adult um a trans adult said this to me, a few hormones do not deal with dysphoria that you've had since you were small. You need a much more um uh you know, a much better psychological wraparound um a package.
So, uh puberty blockers in the news again at the moment as you know. What are they supposed to do? Well, the idea is you know the question is do they help with mental health? Do they improve the dysphoria? Do they help you pass in later life? And do they buy you time to think? Those are what people hoped were the uh positives. But what we less clear about is the impact on on physical health, particularly bone density. um whether they interfere with frontal lobe development which um is at least partially dependent on the presence of sex hormones during adolescence. What impact it has on social development to be uh falling a couple of years behind your peers in terms of that that sort of aspect of your development um and um and what impact it therefore has on your psychosexual and gender development.
And the other um worry from the urologists is if you puberty block birth registered males too soon, they don't develop adequate penile tissue to fashion a vaginoplasty later. And there have been some really poor surgical outcomes for those people in later life. But because you know we just don't know the out the you know where whether the benefits um outweigh the negatives um I recommended that there should be a research program as indeed has just been um uh released this week.
So the evidence base um is weak, but why is it weak? And there was another kind of series of disinformation in the media um um you know saying that I I discarded anything that was wasn't a randomized control trial. In fact, if we'd only looked at randomized control trials, it would have been a really short report because there were only a couple of them. But the reason it was the this was weak um is we would have loved a good cohort study but there were the cohort studies the pre-post studies were not good because they didn't take account of the change population follow-up was inadequate. There was a loss of loss of um um long a loss of uh um uh children to follow up. They didn't follow up for long enough. They didn't document the other interventions. They didn't document the characteristics of the children.
So there was it was just bad studies not um just lack of RCTs and we tried to do a study to link what was happening with the children into adult uh life but the adult gender clinics wouldn't cooperate. So that makes it much harder to for to to consent young people because it's really hard to describe to them what the risk benefits are of the interventions. And just to show you those green blobs were the two highquality studies and all the rest were moderate or poor. But we did include all the moderate ones in the analysis. So we did include at least half the studies in the analysis. So that's um masculineizing and feminizing hormones. That green blob is the one um high quality study.
So faced with all that what did we say? The main thrust of the recommendations is we just need to normalize the care of these children and young people and give them the same standard of care that every other child and young person would expect. So having one center um was not adequate. We needed more centers closer to home. Um um that I said they needed to be based within broader services for children and young people where there were pe where there were autism services and broader mental health services. um
OT's physios um other services that they needed that professionals should get better training that we needed better data and better research and evidence and I don't think anything about that is rocket science really and the central aim of the approach is to help young people to thrive and achieve their life goals um to address distress and barriers to participation in uh everyday life.
So for example, one of the young people who moved to the new center um the mom was just delighted because um uh there that young person had been out of school for a long time. So there's a lot of help to get them back into school to start managing their depression um to um help the little brother who was um really struggling with what was going on in the family. um because you need to be in um a a stable enough state to be making those broader decisions about whether you're going down a medical pathway or not. Um so we worked with this clinical expert group that we convened to develop a holistic assessment framework to assess immediate risk and determine what the complex needs were of the children that were being seen. Um and all of the new centers are working to the same holistic assessment framework. So they're all taking the same approach and collecting the same data. The challenge is however careful your assessment is is really difficult to work out to have any know way of knowing which young people are going to go on and have an enduring trans identity. But if you come into this program, this is the model that you would be working in. um these uh regional centers and each of them are working uh we want to be able to work closely with local services having staff working across um sort of flexibly between maybe a secondary service and the regional center because that shares skills both ways um and but most critically working um coherently together so that everybody's getting the same uh standards that research is operating together that um that data is being collected together and that that this the decisions are being made by a national multiddisciplinary team. So it shouldn't matter if you walk into a center in Sheffield or London or Manchester, you should get the same standard of care um in each of those places.
Um so what I said about the evidence is that puberty blocker trial shouldn't exist in a vacuum by itself that we need to understand the characteristics and the interventions and the outcomes for every person presenting to the services. So at the moment everyone's being prospectively uh consented to be prospectively followed up into adulthood. Um so we understand it's just as important to understand what happens to those who do choose to go on a medical pathway as uh those who do not.
So my reflections why has it been a perfect storm? Society is hugely polarized about this. We've got a weak evidence base. Tavistock was a really challenged organization. Um they were in the media spotlight. Um there were significant breakdowns between the staff. Um they had a completely unmanageable waiting list. They were working in isolation without any peer support which is never good for any organization. So they were it was really tough on them. And then you have children and young people were also caught in the crossfire of adult gender wars about you know sports and safe spaces and prisons and everything else. I think it's really important to just hang on to this.
Moring common did a report in 2022 and um they said that most Britons are really aware of the challenges that trans people face. They mostly don't come to this from rigid political or ideological lenses. They just see there's real practical problems to be solved. Um most people's instinct is live and let live. They believe that trans people should be respected and supported. Um they recognize the discrimination and difficulty and they're proud that things have improved in recent years. Um although I'm going to put a qualifier on that. Um um and um where most are happy for children to self-identify what the thing that they were concerned about was young people making changes to their bodies without fully understanding the consequences.
Things did change during the lifetime of the report and we can't ignore the the the context. Um um when Liz Trust came in there was a very dramatic swing to the right. the media got um more um you know um you know more aggressive to the trans population. Um uh when Brena Guy was was was killed. Um uh we were speaking to as I say the support and advocacy groups we knew how frightened um young trans and gender questioning people were through that period. Um and uh it I think the politics of this has got you know it's not it's had es and flows but it's definitely more challenging than it was even when I started this. But the Labor government um uh um uh lines up with the uh Conservative government in supporting the review and then these other things have been supposed to be going on in the background um and they rumble along.
But I think in terms of the approach, you you had to have massive engagement. Um you had to try and hear from all sides. Although we couldn't always get everyone in a room together, it was really important that we had this multimodal um um information sources and that we didn't stay in a dark room for four years. We shared recommendations as we went along. It was really important to hear from younger team members who were sort of closer, not Gen Z, but closer to Gen Z. And it was important that I had no future career ambitions because it sort of dominated my life since really. There has been this funded disinformation campaign and as I say the criticisms don't really reflect what the report said. It's clear that some of those criticisms are driven by um people who haven't read the thing. Um and politics we can't ignore.
And the legal context has changed again in that as you know there's been um the UK Supreme Court ruling which you know I am concerned about the impact of that on you know adult there are many adults particularly trans women who've been using women's toilets completely unnoticed for many years and it would be um uh completely um unconscion I can't say that word but you know it's it's completely unacceptable to um expect that they should now be using male toilets. That would be putting them at risk. We need to, you know, we need to have some common sense on this.
And then obviously the situation in the US continues to um uh um have an impact over here. When America sneezes, we all get a cold. Um but the BM the apart from the BMA, the key medical bodies have been supportive. We've got our three new centers open. We've got our research team. We've got training for all staff to ensure consistency of approach and the networking between the new centers is absolutely crucial. So um um we need to see these young people as just you know young people with the same ambitions and fears and expectations as any other young person.
They're not you know some extraordinary different kind of group that we should exceptionalized. Um, and I think if we can get the service right for adolescence and more
broadly, we can get it right for this population of of young people. Um, um, and you know, that's a real area for improvement in the NHS. So, I shall stop there.
Um, and I think we're I'm pretty much on time. That's perfect. No, thank you very much Ellie and thank you for for taking us through what is a very complex um sort of position and obviously a complex um report that that you took through um developing it. Um I think it's listening again the thing that keeps coming through I think there are two things for me. One is the evidence base is really limited and which bits of the evidence base you use and don't use and I know there'll be questions about that. you know, how you use that evidence base is is difficult when there are only three that you call high quality um you know, sort of papers. It really does limit some of that sort of evidence base that you have. But I think overall the thing that comes through from from what you're saying is that there's a a group of children and young people who have really complex needs and those needs need to be met and somebody needs to meet those needs. Yes. So I think to me that's that's that's
what comes through. Um, we did ask for some questions in advance. So, I've got a couple of questions there whilst people think if there are any questions that they might have. Um, those of you online, please put your hands up and we'll get to you. And Rum is in the room
if there's anybody in the Peter Ballroom as well who wants to ask a question.
But one of the questions that uh we had online was around um how the service ensures that people providing the care welcome input from trans people and concerns about people who are gender critical being a a safeguarding risk to children. Um I know that there was considerable patience and and public engagement in the review. Can you tell us more about this process and how diverse the views were?
Yeah, I mean the re the views in the in in in the course of the review, you know, went from kind of east to west as it were. I mean, they couldn't have been more diverse. But I think all of the new services um um have um a PPI um uh group where they're developing their PPI groups with them. Um we have uh PPI representation on the um research oversight board. There's um also a PPI group um um working with a research team. Um there's qualitative research going on about young people's perspectives on um on how services should be designed and operated. Um and that was a that was a really critical thing for us. Um we had 18 focus groups which are run through the support and advocacy groups and they they really informed quite a lot about the recommendations that uh that um I made. Um, I mean the thing that the the you know the thing that young people found frustrating was the very poor training of people um who were were seeing them in in various settings and and and and the sort of trans broken arm thing that you know um anything that was going on got attributed to them being trans. And you can you can be trans and have other issues that you know people are not pro you know that diagnostic overshadowing that people are not taking account of that.
Um so and then the other important group we've got is one through the James Linds Alliance which is again a group of service users and um and professionals who are working together to inform um the um the the uh research plans going forward. So I think we have um PPI engagement throughout the sort of clinical and research um interface. Um and um I think you know within there are that you know there are regular discussions about cases to make sure that people are that people don't kind
of fall into extremes but that people you know have a a proper a proper kind of um um shared view and um and a multi-disiplinary view. So, so one of the things that's been helpful has been having OT's and speech therapists which obviously you know the um the other service the good service couldn't access you know to take that that to you know address those wider needs.
So yeah thank
you very much. Um, and do you want to ask your question?
And Smith, [Music] have your hand up.
Whilst we're trying to sort that, I'll see whether that where we go with that. Um could I ask a um a question from um again that was coming in advance um which was about psycho education and concerns about conversion therapy. You'd mentioned it slightly in your your your slides. Um could you explain how the comprehensive assessment approach actually works to sort of take us through that?
Yeah. Yes. So I don't think it will be you know um rock rocket science or unusual to anyone who is used to doing a holistic assessment on young people. It it does look at all aspects of their um development and um and um you know the different facets of of uh how they're
functioning, their school relationships, their relationships at home etc etc. Um um and um and then the idea is with the young person to design a um um an assess a um a formulation a a a plan of um everything that needs managing. So as I say it might be helping somebody in school if they're being bullied. It might be um um um um I mean if if
somebody is going to bind their breasts, there's a nurse in UCL who will teach them how to do that safely because it's really important that you know that that they they do do that safely. Um um uh so if they're not going to go on puberty blockers, they may actually want to go on the pills to suppress their periods. Um so it's it's it's really wide ranging and hugely individualized. Um the point of the psycho education program is plainly not to um uh not to convert anybody. It's to um have a a a very broad and deep understanding of the um
uh you of of all the aspects of what um what a medical transition might involve and um to make sure that if somebody does go down that that pathway, they are as informed as they can be. Bearing in mind that there's lots of things that we don't know that we can't tell them. Um but it's absolutely not a a conversion therapy uh uh approach.
Thank you very much. And managed to get her um question into the um into the chat and it's what do you think is the impact of extremist groups such as trans kids deserve better on the outcome of of your report?
Yeah, I think I think it it is very worrying. Um um I know that that particular group had a a die in outside um where's streeting's office with cardboard coffins and so on. I I think that's you know it's it's it's really it's really unhelpful because I think it's frightening to other young people. Um and um and we've been really, you know, looking incredibly carefully at suicidality as you know, Jeff, and there's been no increase in um in in in no signal, no increase in suicidality related to changes in in in prescribing. So I think I think that there we've spoken to some fantastic trans advocacy groups during the course of the review who are providing really good support for young people um and advocacy and and also helping them um with sort of care navigation and and actually in some instances you know telling them I which is what a number of young adults told us you know to take their time about decisions and not rush Because you know um when we the young adults said to us first of all they wish they'd known there was more ways of being trans than just a binary medical transition and secondly their advice to their younger self would be don't rush but their younger self wouldn't have listened to that. So so um so so I think that you know some of the groups have been fantastic but I think anything that frightens young people you know is a worry.
Thank you very much. U we've got another question here which is I'm sorry just and that's the Applebee report you're referring to isn't it around suicide in in in young people which was published in July of this year. Um another question that we have is um that whilst the they appreciate that the origins of gender dysphoria are complex in a climate where violence against women and girls is reported as a significant concern in schools with a likely contribution to this issue. Should we be treating this as public health issue and putting equivalent if not greater resources into prevention?
Yes. Well, so so I think you know we don't so I again there are some people who are going to be gender dysphoric from when they're little and um will continue to be and will continue to be in adulthood and um for them a medical transition you know is potentially going to be the only thing that makes them able to live comfortably um in you know in in their body as it were. And we're not trying to prevent that. But what we do want to try and do is I mean I well this is a whole other thing. I'm really worried about the impact of social media more broadly on young people and it's another thing I'm lobbying on in parliament. In fact I think I've been deemed to be a nuisance by the um the science and technology ministers because I've been summoned to see them for I'm going there after this. Um but I think we got a problem in that there's a disconnect between what is happening in the department for science innovation and technology and the you know excitement about AI and that and what's happening downstream which is happening in health and education where young people are having all sorts of adverse effects and and um and you know perhaps thinking that um a transition is the answer to the problems of being scared about your puberty and all of that is also also a factor you know that is the case I've certainly spoken to young people who approaching puberty tried to come out as gay and that was the other huge revelation for me I think I was naive growing up in North London where there was nothing very extraordinary about someone coming up as coming out as gay when I was growing up and um and there seems to be more homophobia than I'd understood and particularly against uh lesbians more more than I think more than gay men and so I have spoken to
young people who came out as gay who didn't feel comfortable with their body who who were frightened about puberty and you know and then came out as trans for a while and that didn't fit them and you know it had seemed like an answer um and then you know gradually either went back to being gay or maybe straight but I mean you know it is a such a confusing time and it's just made more confusing using by social media. Um but we are seeing you know whilst it's really hard on a population level to prove cause effect between social media and mental health because it's much more complicated. There is no doubt that people are sitting in clinics seeing young people who are out of school addicted to gaming um being cyberbullied being traumatized by having seen having PTSD after seeing beheadings at quite a young age. um being uh you know suffering from sex totion um um you know there's just we had a meeting of the Academy of Medical Royal Colleges and just the level of concern from all medical Royal Colleges was really alarming. Thank you very much me off on a rant.
No, no, that's lovely and um good luck with the minister this afternoon. That's all I can say for that one. Um in in terms of your report there has been obviously in in literature some um criticisms of it particularly I think there's one in the BMJ and one in the um Australian medical journal. How do you um sort of work with those and um understand the um I'm going to say the criticisms that are there?
Yeah, I mean any any report that is is written any view is should or should be open to criticism. that's healthy and it's the right thing. So I say the thing that frustrates me is when they just say things that are not true. So one of the things they well as as I said they said that we ignored 98% of the evidence. So we didn't we in we we included all of the orange and all of the green um um studies. We just discarded the ones that were just really poor quality. Um they said that um uh there's a they say things like um um no that I didn't reveal the names of all the other authors of the reports or there were no other authors of the reports. That's how it is. It's like the Kennedy report. It's a single author. You know, I'm responsible for everything that's that that's written in that for my sins. Um they said I didn't speak to any trans people. So you know a lot of the criticisms are are not well founded and
a number of papers have been written that rebutt the the criticisms. Uh they queried the methodology of the York reviews the York systematic reviews although they've been replicated since by McMaster with the same outcomes. So there's quite a there's a number that of of papers that have been written to rebut those things that are just plain wrong but then they just get repeated in the next paper.
So, you know, beyond a point, I think it's really hard to to move forward. Um um but I did speak to one of the centers in the US. I won't say which at this point. um uh which has a quite affirmative approach and wanted to talk to me about um our approach and actually they were surprised to find that there's more in common than is is different that we've got quite a shared understanding of things and you know potential and this is a you know an affirmative clinic and a blue state and
that they are quite interested to work with us and if we could start to just dispel some of those myths about the services that would be a real blow for freedom.
Thank you very much. Um, so another question here is taking into account everything that's been said about the weak evidence that we just talked about, could there still be an argument that some young people could still reasonably choose themselves to proceed with more medical interventions even though the risk is effectively unknown? Uh they might be willing to take that risk.
Yes. Yes. Abs. I mean, you know, and some and uh you know, as it is, some young people are going on a medical pathway. Um um and uh you know, the the National MDT, you know, is approving people to go through and I think they'll be approving young people to go on to the puberty uh blocker trial. Um I I think all you know people I think I know the trans community were you know were worried that for example we want to talk to dransitioners to in order to kind of undermine the choice to have a medical transition. In fact, it's just like it it's really like I mean supposing you have cardiac surgery, what you want to know is what are the risk factors that may make my outcome poorer or you know that I don't have such a good outcome as the next person. Um but you tell people that you know you say the characteristics of the people who've dransitioned you know you've got some of the same characteristics but then you make you make you you make your choice. So, it's not to stop people. It's just to tell us tell people what we know about the risks and maybe, you know, you might want to wait a bit longer or whatever. But it, you know, ultimately what we're trying to do is just is just give people better clinical advice based on better evidence, the same as we would for any other intervention where the, you know,
the outcomes are not always kind of 100% known.
Thank you. And I suppose sort of moving on from that, we've got another question which says, "What role do you see for pediatric endocrinologists in a gender service?"
Um well, I would be um great to have um uh each center having their own local endocrinologist because it's better for the patients and better for everyone and communication and so on. I hope that endocrinologists will and well and everyone for that matter will feel more encouraged to participate because they'd be doing so under the protection of a research protocol really tight decision making about who's going into the study um support from the endocrinologists who've been in this game over a um a longer period I mean I think if I was an end pediatric endocrinologist being asked to prescribe in isolation I would feel really exposed Um um although actually there is a strange dynamic between the JID service and the endocrinologists who are based at UCL where the JID services we don't put children on drugs they do and the endocrinologist said well we don't diagnose gender dysphoria they do and we just you know do what they say but now
it's a proper it's a proper um MDT um and I I kind of see it a bit like um safeguarding was in pediatrics um
you know back in the day when I was college registra and we were really worried you wouldn't be able to recruit pediatricians because you were you know it was that time when you were damned if you did that you mistaken either direction was a disaster there was very little evidence there was very little training there's very little support and then once we got you know better evidence base which was largely driven by Cardiff actually and you know clear training and clear guidelines and you know safeguarding networks and that is it then sort of became an interesting area which some people, you know, have have um done a lot of work in and I hope it'll be the same for this. This is the there are some fabulous people working in the network. One of the reasons that I've kind of carried on staying engaged is because I can still keep in touch with my old buddies, but it's just such a rich group of of of people and a very supportive network and there are different perspectives on some aspects which is really good and really healthy.
But but they you know they they try and keep the sort of key operational things um aligned. So I think people should feel that they're in a quite a safe net really.
Thank you very much. A couple going back to neurodiversity and also there's a question here around it. Did you ever find a link between increased presentations of functional neurological disorder and um gender identity?
Yeah, there are there are definitely I mean people have have written written about that actually. Um there is there is a link between people with I think tick disorders and uh gender dysphoria and I can't I think there might be um um others as well but that those links have definitely been um observed. I mean, I think I think in terms of the young people with neurodeiversity, I think um uh they would say that just because you're neurodeiverse doesn't mean you can't also be trans. But it is also important to because um it's, you know, it's quite hard for somebody who is neurodeiverse to live with uncertainty and gray and fuzzy. And so it is important to try and make sure they don't foreclose on their options
um too early. So you know I think that's you know that just requires a some really kind of you know careful thought and careful support and and and the other problem that um kids had is they didn't have experts in neurodeiversity working in the service whereas um the
the new centers do. So you know it's also the role of the speech therapist for example in the new services it is also about making sure that you know communication is appropriately adapted. It's not just about you know voice work for example you know
thank you very much and just a couple more minutes left. Um asked about um nice guidelines because clearly there aren't there isn't a lot at the moment. Is that um something that um you know sort of is is likely to be developed
over time?
Yeah, I mean I think you know and that was another misunderstanding about the report. They said I didn't follow standard guideline approaches. Well, it wasn't actually a guideline so that that's why. I think we do need nice guidelines, but I think we we're not going to be able to do them quickly because the evidence base is, you know, we'll need to we need to wait till we get a bit more ev, you know, a bit more um uh development in the research to make a, you know, a useful guideline really. But I think we absolutely should be aiming for that.
Thank you. Um I think that is the end of
the questions that that I have for you. Yeah. Oh, by the way, nice is doing something
on the service model on the, you know, on on service standards, but just not on you. Yeah.
Yeah. Good. So, just very quickly, has anyone in the last minute or so got any more
questions? It's all straightforward. There we go.
Yeah, we could put our feet up. That's no problem. In which case, can I thank you very much, Hillary, for your time today. um for your wisdom and expertise in this area and actually for taking us through what is a really complex subject and you know sort of been able to take it through and sort of make it sort of understandable for us as as you know who are sort of I'm going to say we are as an organization looking to develop a
business case as we've said you know so it's been really helpful to sort of understand on the background to that where many of the things within the business case are coming from to to sort of take through, but also for the wider sort of um you know sort of colleagues just where you've come from in in developing the report because you know we've all heard about it, we've read it, we've read the criticisms of it. It's really helpful to understand your position with it and and actually to be so open and and discuss it and discuss the limitations to it as well as the um you know the outcomes from it. So, can I thank you very much on behalf of everybody for your time today. It's been great and um look forward to seeing you another time. Well, I was going to say, you know, you if you if you if you if you make some further steps, I can come up for a visit and see my old friends up in Sheffield. We would love you to come for a visit. That would be brilliant.
Okay, take care then. Um good to everyone. Okay, cheers. Bye.
Bye. Bye. Bye.