NHS to test all ‘trans' children for autism
The NHS will test all children who believe they are transgender for autism under new plans seen by The Telegraph.
Every child referred to a gender clinic will be 'screened for neurodevelopmental conditions' such as autism and ADHD under new guidance, to be introduced in the wake of the Cass review.
The review, by paediatrician Baroness Cass, found that the mental health conditions were disproportionately common among children and young people with gender dysphoria.
Medics will also evaluate each child's mental health, their relationship with their family and their sexual development, including whether they are experiencing same-sex attraction.
As part of a proposal to incorporate Lady Cass's recommendations, the health service will move away from the 'medical model' operated by the controversial Tavistock's Gender Identity Development Service in favour of a 'holistic' approach.
The new guidance will be released for public consultation imminently before being rolled out later this year.
It will be used by established children's gender clinics in London and Manchester, and was reviewed by Lady Cass at the start of 2025.
Medics will also evaluate each child's mental health, relationship with their family and sexual development, including whether they are experiencing same-sex attraction.
However, some groups criticised a 'serious flaw' in the policy as it leaves an open door to the use of cross-sex hormones. They also condemned its absence of recognition of the wider societal issues to which children are exposed.
Policy probes eight key areas
The new NHS Children and Young People's Gender Service will explore eight key areas of a child's life.
To assess 'development', doctors will take a 'detailed history' of the child's social, cognitive and physical growth, particularly because of the 'substantial' changes that take place during puberty.
They will screen children for autism and learning disabilities and look into whether further 'cognitive assessments' are necessary.
The specification says: 'Given the high prevalence of neurodiversity identified within this population, all those attending the NHS Children and Young People's Gender Service should receive screening for neurodevelopmental conditions.'
The 'multidisciplinary team' of experts, including a consultant specialising in neurodevelopmental disorders, will create a treatment plan for each individual depending on their diagnosis.
If screening 'identifies the presence of neurodevelopmental conditions, including autism spectrum disorder (ASD), a referral should be considered to the Paediatric Neurodevelopmental Service or Paediatric ASD Service,' the guidance states.
In such cases, the team of doctors will have to determine if the child's symptoms are caused by autism or whether they also need separate treatment for gender dysphoria.
They could also be kept under review every six months while getting help for their autism or discharged from the service.
Cases of both conditions have risen sharply in recent years. Recorded rates of gender confusion in under 18s have risen from 0.14 per 10,000 people in 2011 to 4.4 per 10,000 in 2021, driven largely by girls entering adolescence.
At the same time, autism has gone from being diagnosed in about one in 2,500 children, to one in 34 children aged 10-14 as of estimates for 2018.
Prof Michael Craig, clinical lead for the NHS National Autism Unit from 2007 until 2023, previously estimated half of patients seen by the Tavistock's clinic had autism after observing sessions.
In her review, Baroness Cass linked the rise in teenage girls 'struggling with gender identity, suicidal ideation and self-harm' with cases of 'undiagnosed autism, which is often missed in adolescent girls'.
She said it was the 'common denominator' with one study finding transgender people were three to six times more likely to be autistic than those who are not.
Patients at the new service will also undergo a thorough mental health assessment because of the 'higher rates of mental health difficulties' among gender-questioning children.
The NHS guidance described a previous 'reluctance to explore or address' mental health conditions because gender dysphoria was not classified as one, but said that 'identifying and treating' any mental illness should be an 'integrated part' of their care.
It added that they should undergo a 'mental state examination' and be questioned about 'mood, anxiety, emotional regulation, beliefs around weight, potential somatic symptoms, concentration, sleep and appetite, self-harm, and suicidal thoughts and behaviours'.
'Family context'
Another key area is dubbed 'family context', with medics being tasked to paint a picture of each child's upbringing and familial relationships.
The specification noted that 'there is evidence of an increased frequency of family parental physical and/or mental ill health and other family stressors in this group'.
Under the section titled sexual development, knowledge and sexual orientation, it said 'clinicians should seek to understand the child/young person's emerging sexuality and sexual orientation'.
If this has been a previous issue, doctors should consider whether the child was exposed to 'adversity and trauma'.
They will also examine the children's physical health needs and the impact of any long-term conditions, along with their broader well-being, school relationships and educational attainment.
Medical teams will 'undertake an in-depth assessment' of how the gender dysphoria 'manifested', how it has been managed by the family, if any 'social transition' has taken place and the impact of any distress caused.
They have been told to look out for 'safeguarding issues' such as 'transphobic bullying', 'online grooming' and a 'breakdown in relationships with families'.
The Clinical Advisory Network on Sex and Gender welcomed the 'proposed holistic approach and prioritisation of psychological interventions'.
NHS wait times 'very long'
Dr Louise Irvine, a GP and the group's co-chairman, said: 'The new service recognises that many also experience mental health, neurodevelopmental and/or personal, family or social complexities in their lives.
'The challenge will be to ensure NHS services can provide prompt access to appropriate service for any identified needs as waiting lists are currently very long.'
But she went on to say a 'serious flaw' in the policy was that it 'leaves the door open for referral of children and young people under 18 for cross-sex hormones'.
She described the guidance's reference to a drug policy that is 'seriously out of date, was published before the Cass Review and does not take on board the scientific reviews which showed lack of evidence of benefit of hormones in this group' as 'irresponsible'.
A spokesman for Bayswater Support Group, which advocates for evidence-based care on behalf of 600 families with trans-identifying children, said: 'The more careful and holistic assessment by the NHS is welcome, however, there is still scant recognition of the environmental factors influencing children's understanding of gender issues.
'Schools continue to teach gender identity as fact and socially transition children without parental consent. Young social media influencers monetise content claiming the health benefits of controversial medical treatments.
'And authority figures, including politicians, cast doubt on the findings of the Cass Review and falsely associate evidence-based findings with far-Right narratives.'
They added: 'Within this context, it is very difficult indeed for professionals to make accurate diagnoses or to determine the most effective support for a patient experiencing distress.'
An NHS spokesman said: 'We will soon be going to full public consultation on this draft specification which sets out the new holistic assessment framework that was described by Dr Cass in her report.
'NHS England has recently changed the referral pathway so child patients can only access gender services that we commission if they're referred by a paediatrician or a child and adolescent mental health worker.'
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