England’s trans teens, lost in limbo, face mounting barriers to care

An overhaul of medical care for transgender minors is exacerbating bottlenecks in England, Reuters found, leaving thousands of patients in limbo and adding to years-long treatment delays. The crisis comes amid a broader debate on appropriate care for rising numbers of teens seeking help in Europe and the United States.

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DOVER, England

On an October morning in the living room of a modest family home in this coastal town, Miles Pitcher, 17, received a message that would change his life.

It came from GenderGP, a private online health service that treats people suffering from gender dysphoria – the distress of identifying as a gender different from the one assigned at birth. The doctors had reviewed his case, the message said, and would prescribe the testosterone that would help Miles develop the facial hair, deeper voice, broader physique and other characteristics aligned with his gender identity. It would put an end to the menstrual periods he dreaded.

Miles gestured at his phone, speechless. He shook his head, and, beaming, showed the message to his mother as their pet dog Moose bounded around the room.

“Finally,” he said. “Something being done.”

Miles, assigned female at birth, has identified as male since he was 14. Yet until he got that message, he was stuck in limbo for three years, one of at least 8,000 young people in England and Wales waiting to receive gender care from the state-funded National Health Service (NHS) as of October, a Reuters review of NHS documents shows.

The UK government has promised to overhaul the youth gender care system, after it was deemed inadequate by England’s regulator of health and social care. Some clinicians had complained that England’s only state-run youth gender clinic was too quick to offer medical treatments to young people. And many families protested over the distressingly long wait for a first appointment – an average of nearly three years, a Reuters analysis of the clinic’s records found.

In July, the NHS said it would close the sole clinic, known as the Tavistock, next year and replace it by spring 2023 with regional centers to better accommodate a fast-growing patient population. Its plan calls for the centers to operate under new treatment guidelines, informed by the best available medical evidence for treating transgender adolescents and the most in-depth review of care conducted by any country.

But the reality is already falling short of those ambitions, creating new delays and uncertainties, according to Reuters interviews with transgender teens and their families as well as physicians and government officials involved. They described a deeply flawed system that is now hobbled by a toxic political climate around gender care.

Young people like Miles say their only option is to turn to private providers such as GenderGP, which is registered in Singapore and thus operates beyond the supervision of the NHS. The company says under-18-year-olds make up a growing portion of its UK patient population, with about 800 youth currently on its books.

“I wish we didn’t have to exist,” said Dr Helen Webberley, who founded GenderGP with her husband. Both once worked for the NHS. “But we are years away from the NHS pulling themselves together on this.”

The NHS’s proposed new treatment guidelines were altered after they were reviewed earlier this year by a Conservative government wary of medical interventions for transgender adolescents, Reuters found. Gender clinicians say the proposals now depart from international treatment protocols, which support gender-affirming care. Pioneered more than 20 years ago in the Netherlands, such care can include everything from supporting a social transition – using a person’s preferred pronouns and name – to counseling and medical interventions, including drugs that pause puberty.

The Tavistock, based in London, continues to see existing patients. But first appointments for people who have been on its waiting list since 2019 have slowed to a trickle as staffing and morale drop ahead of the closure, according to NHS data and four people involved in the reorganization. More than 1,500 young people recently referred with gender dysphoria are being kept on a separate list for the future regional centers, with no clarity on when or how they will be treated, three NHS sources told Reuters.

Once assigned to a waiting list, young people have been effectively locked out of state-provided mental health counseling and other specialist support related to their gender dysphoria, because those services were offered only through the gender care system they are waiting to join. Delaying medical treatment also means young people mature in bodies that don’t align with their gender identity – changing that in later life is more difficult.

The NHS said in a statement to Reuters it is expanding healthcare services for young people with gender dysphoria in line with recommendations from the review, and working on better supporting those on the waiting list. It has previously said it “strongly discouraged” families from turning to private or unregulated providers.

“These have been an exceptionally challenging couple of years for our patients and their families, with a lot of toxicity in discussions around their care and chronic uncertainty about its future,” Dr Polly Carmichael, director of the youth gender clinic at the Tavistock, said in a statement to Reuters.

The Department of Health and the Prime Minister’s office declined to comment for this story.

Both sides in the polarized debate are turning to the courts: patients who say they’ve waited too long, and others who say the NHS moved too fast. At the end of November, transgender rights advocates challenged NHS England in the High Court over long wait times for both youths and adults seeking treatment. In 2020, a young woman who had detransitioned from being a transgender man challenged the Tavistock’s use of puberty blockers in the same court.

Long wait lists are common within the NHS, but its statistics show the three-year wait for transgender youth is extreme. Most young people with a “non-urgent” eating disorder get specialist help within three months of being referred, the figures show. On average, young people seeking mental health support wait just over a month for a first appointment, according to a government analysis of NHS England data.

One mother shared with Reuters a letter she received from the NHS in February after she followed up on her daughter’s October 2021 referral to determine when she might receive attention. The letter said a decision would be made at some point from early 2022 on whether the child “is likely to meet the access criteria” for gender care. She has heard nothing since and suspects her child isn’t even being considered for NHS help.

“We are on a waiting list for a waiting list,” said the mother, Rose, who asked to be identified by her first name only to protect her daughter’s privacy. “She basically feels suicidal every single day.” The NHS declined to comment on the case.

“Stop hurting yourself”

Miles plans to study archaeology at university and is a keen rugby player. He has felt like a boy for as long as he can remember, but recalls a moment of delight at the start of a new school year when he was around 9.

The teachers were handing out colored notebooks and lanyards based on gender: blue with wizards and astronauts for boys, pink for girls. He was given blue books – “and wizards and astronauts over everything,” he said.

“It was not like ‘I’m trans,’ but just this amazing sense of joy within myself, ‘This feels amazing, and I don’t know why.’”

By age 11, as puberty began, Miles entered an all-girls’ secondary school. He was bullied by classmates for not wearing a bra or conforming to female norms. To fit in, he tried to be ultra-feminine, wearing skirts and make-up, having his eyebrows threaded, wearing false nails.

“My mood really dropped,” he said. After about a year, “I realized, I can’t do this anymore. I hate this.” Miles was barely leaving his room. He began cutting himself, over a period of four or five months. “In my mind, it was just easier to deal with physical pain than mental pain.”

His mother, Connie Pitcher, noticed the regular, precise lines on his arms. When she asked why he was distressed, Miles said he was struggling to understand his sexuality.

“I said, ‘I don’t care if you’re gay, straight, or whatever – I just want you to stop hurting yourself,’” Connie said. The family considered seeking mental health help, but worried about long waiting lists.

“We saw him really, really dip,” she said. “We were struggling with what to do. Because there is really no support.”

VIDEO: Miles’s story.

The World Health Organization, which informs health policy worldwide, does not have detailed guidelines for this area of healthcare for youth. It says it works closely with the World Professional Association for Transgender Health (WPATH), a U.S.-based non-profit that has drawn up the most widely adopted standards of care.

These say a young person’s exploration of gender should be respected and supported, and that medical interventions for young people at or after puberty should be one option, after a comprehensive assessment.

Research from the Netherlands paved the way for that medical treatment, establishing a model requiring adolescents who sought care to be assessed for about six to 18 months. If they had persistently expressed gender dysphoria since early childhood, lived in supportive homes, and had no other complicating mental health diagnoses, they could be offered puberty suppression, followed by hormones, and later, in some cases, surgery.

Since then, the number of young people seeking gender care has surged in parts of Europe and the United States, supported by greater awareness and the availability of professional treatment. They continue to face threats of violence and discrimination, as well as political efforts in some countries to block that care.

At the same time, some gender-care professionals have questioned the lack of definitive evidence on the long-term impact of puberty blockers or hormones on minors. Puberty blockers are not licensed in the United Kingdom or United States for treating gender dysphoria and the NHS says it is not known how they may affect brain development or long-term bone health in young people. Hormones, only available for older adolescents, cause potentially irreversible changes such as a deeper voice, and can cause infertility. Other changes, including breast development, are reversible only with surgery.

Those professionals are also concerned that as the number of pediatric patients has surged, so has the number of youth whose main source of distress may not be persistent gender dysphoria. Some may have mental health problems that complicate their cases.

“The wrong treatment”

While not all English youths with diverse gender identities seek medical help, for those who do, a doctor or professionals including social workers or teachers are the first port of call. Any one of them can refer a youth for gender care, which so far has only come through the Tavistock – formally known as the Gender Identity Development Service, or GIDS – run by the Tavistock and Portman NHS Foundation Trust.

The clinic became a focal point for opponents of youth gender care in the UK in 2018 when an internal report compiled by Dr David Bell, a former senior psychiatrist and staff representative at the Tavistock, was leaked to national media. Bell, who did not treat young people, cited accounts from 10 unidentified colleagues who were working with transgender youth and came to him with concerns, including that some patients were “rushed through” to medical treatment without proper evaluation when they finally got an appointment.

“It was not just the wait,” Bell told Reuters. “It was also a wait for the wrong treatment.”

Bell now advocates against starting a gender transition before adulthood. He is at the fore of a group of mental health professionals who argue that accepting a child’s new gender identity without exploring other underlying issues is clinically irresponsible, and puts them on a track to potentially irreversible changes that they may later regret.

The Tavistock has consistently defended its methods of treatment. Subsequent inquiries by outside investigators into care at the clinic did not raise concerns about patients being referred too quickly to medical interventions. However, they did criticize a lack of standardized assessments, adding that “it was not possible to clearly understand from the records” why care decisions had been made, according to a 2021 report from the regulator of health and social care, the Care Quality Commission.

The report rated the clinic as “inadequate” on these grounds, on the long waiting lists, and on concerns that teams treating patients did not always include the full range of experts required.

Another major challenge came in the 2020 lawsuit. Keira Bell, a young woman who detransitioned after what she said was improper care at the Tavistock, asked the court to rule on whether youths should receive puberty blockers. She alleged that the information provided by the Tavistock was not adequate, and said youths under 18 were not able to give informed consent to treatment. The High Court effectively banned their use for under-16-year-olds, a ban that was overturned last year on appeal. Bell did not respond to a request for comment.

The Tavistock told Reuters its current protocol requires meeting patients at least three to six times over some months before any recommendation for medical treatment. The timeline would be longer in complex cases. If the clinician, parents and the young person agree, puberty blockers may be prescribed from the onset of puberty, usually after the age of 10 or 11. The clinic only introduces hormone treatments after 16. Surgery is not an option before age 18 under NHS rules.

The clinic estimates that its staff referred only between 10% and 20% of young people for medical interventions, indicating what team members have described as its cautious approach. This year to August, 125 adolescents received referrals for either puberty blockers or hormones, the clinic told Reuters.

An ongoing review commissioned by the NHS highlighted another problem. Led by Dr Hilary Cass, a prominent pediatrician, the review found that practitioners across the country might be referring patients with gender concerns to the Tavistock without first addressing mental health issues such as depression, according to an interim report released in February. Such practices may have contributed to the clinic’s fast-growing waiting list, the report said.

Annual referrals to the clinic have surged from 210 a decade ago to 5,234 in the financial year that ended in March 2022.

According to NHS documents seen by Reuters, there were 7,696 minors on the waiting list for a first appointment as of July. Just over 1,000 young people were referred to the Tavistock from April to October and are awaiting attention, the clinic says.

“I’m still your child”

In 2019, a 13-year-old Miles began exploring his relationship with his changing body, wearing baggy clothes. He cut his hair short and began sampling videos from transgender teens on YouTube.

At first, “it was denial – those guys are cool, but I’m not like them,” he said. “Then slowly, I thought, ‘what they’re talking about is exactly what I feel. So maybe I need to actually look at this.’”

He came out to his close friends, who were supportive. In February 2020, Miles left a letter on his bed for his parents, just before heading to school.

“Dear Mum and Dad,” it read. “I am transgender. I identify as male. I’m still your child.”

His mother was taken aback. “I was a little bit fearful, because I didn’t understand it,” Connie said. She texted Miles at school. “We’ll talk about this in a few days,” she wrote. “We love you.”

That November, an NHS doctor referred Miles’s case to the Tavistock. Miles was excited, hoping to receive puberty blockers but realizing that, given the long waiting list, he was likely to be too mature for them by the time he was seen.

As he waited to hear from the clinic, he began his social transition, dressing like a boy and using male pronouns. He started to wear a binder to conceal his breasts and, on occasion, padding known as a packer inside his underwear to give the look of male genitalia. He took a contraceptive pill to limit the frequency of his periods.

“No-one really knows what to do.”

Miles Pitcher

Last year, he legally changed his name – his parents paid, as a gift for his 16th birthday. Miles now studies at school in a co-educational class. He is attracted to boys.

By July this year, Miles was uneasy, having heard nothing from the Tavistock clinic. He contacted them to ask about his referral. They had no record of it.

“That was a crash and burn,” Miles said. “I’ve had two years of my life thinking it was happening, for nothing. It sounds extreme, but it feels like the NHS has failed me as a trans person. Because I’m just left in limbo. No-one really knows what to do.”

Miles’s doctor referred him a second time. But a few weeks later, when he checked with the clinic again, it still had no record of him. Neither his doctor nor the Tavistock would comment on his case.

“Incredibly distressing”

Other young people and their parents across England are also at a loss. Waiting “isn’t an option when you’ve got a child in distress,” said Rose, whose daughter has been on a waiting list since October 2021.

Her daughter’s case shows how hard life for young trans people can be -- even when they do get care.

Assigned male at birth, Rose’s daughter told her parents how unhappy she was in her changing body at age 12, two years ago. A few months later, knowing about the NHS waiting list, Rose sought help from family members to pay for private care from Dr Aidan Kelly, a clinical psychologist now in private practice who worked with youth at the Tavistock for five years.

Kelly diagnosed their daughter with gender dysphoria in August 2021, and she socially transitioned a month later. Now 14, she is taking puberty blockers prescribed overseas by a registered pediatric endocrinologist whom Kelly declined to identify. Kelly remains involved in her care.

In June this year, Rose’s daughter tried to take her own life, cutting herself and attempting to drink bleach. She had previously been referred for NHS mental health care, but did not receive attention until she tried to kill herself, Rose said. The NHS then prescribed antidepressants.

A different private practitioner has also recently diagnosed the teen as autistic. Rose declined to make her daughter available to Reuters for comment due to the teen’s distress.

“I’m just trying to do things to keep my child here,” said Rose. The treatments are helping, she said, but her daughter is still struggling.

Another mother, Liz, said her teenager has been on the Tavistock waiting list for three years after being referred by their family doctor. Assigned female at birth, the child came out as a transgender boy at school, but Liz and her husband do not use his chosen pronouns. Instead, they use a gender-neutral nickname, saying that they want to keep their child’s options open.

Liz said the child has autistic traits, depression and childhood trauma, and has experienced years of severe homophobic bullying. Liz declined to make the child available for comment.

“I’m just trying to do things to keep my child here.”

Rose, whose teenager has been waiting since October 2021

She worries that the teen, now 16, could receive gender medication without taking into account these other issues. The family has received no NHS gender care or mental health support since the referral, she said. The family is also frightened to entrust the teen to a system that is set to be replaced because it has been judged to be failing young people.

Most of all, Liz is afraid of her child making a mistake.

“If I knew this was the route” for the child to grow “into a healthy well-adjusted adult, that would be a different question,” she said. “But I don’t have that kind of information.”

In a statement to Reuters, the NHS’s Healthcare Safety Investigation Branch said the “incredibly distressing” wait for gender care “created a significant patient safety risk for young people.”

In April, the investigation branch released a report into the death of a young transgender man before his 19th birthday, outlining how he had complained of the long wait for care before committing suicide. He was first referred to the Tavistock at 16. The clinic itself referred the incident to the investigators, saying it was “vital” that services worked together to better protect vulnerable young people.

There is evidence that transgender youth face a higher risk of suicide, but whether that risk has increased for adolescents in England who are waiting for care is not well understood. The Cass report said in February that many young people’s mental health deteriorated while in a holding pattern.

“Drowning in the middle”

For young people already in the system, the NHS has said care at the Tavistock clinic would continue unchanged ahead of its closure. NHS documents reviewed by Reuters show only a few dozen appointments are available for new patients each month, down from between 75 and 120 for most of last year, despite the growing waiting list.

Staffing has also dipped as several psychologists have left or, like Kelly, entered private practice. The Tavistock said in board documents that staff morale is low and told Reuters it does not have the capacity to meet demand.

The deadline for shuttering the clinic has also slipped, to late June 2023 at the earliest, two people familiar with the plans said, although the NHS is still aiming to open two new sites in spring next year, with up to seven more to follow. People who have been waiting the longest will be prioritized. The NHS is also working on a system to cope with the backlog and improve support for those on the new list, a spokesman said.

But clinicians say polarized views around gender care will make finding staff challenging.

“The people who have gender-critical views call you child abusers and monsters, and then there are a lot of angry families accusing you of gatekeeping. And you’re just drowning in the middle of it all,” said Dr Laura Charlton, a clinical psychologist who left the Tavistock in 2020 after six years and now only treats adults.

The gender-care revamp became further entangled in political upheaval after Prime Minister Boris Johnson resigned in September. Both his successors, Liz Truss and Rishi Sunak, voiced their opposition to the use of what they described as “irreversible” measures for transgender young people earlier this year.

Neither Truss nor Sunak’s office responded to a request for comment for this story. Sunak has said under-18s should be protected from “life-altering treatments.”

A few weeks into Truss’s tenure, in September, the NHS briefly posted a draft of its proposed new treatment guidelines on its website, then removed them. The guidelines were re-released on Oct. 20, the night Truss resigned.

A Reuters review of the original draft shows key passages were changed by the time they were re-released.

Both versions of the guidelines say only medical professionals may refer young people for gender care, and call for a meeting between clinicians before a child is added to the waiting list. New clinics will be led by medical doctors rather than psychologists, they say.

The guidelines also say young people who, like Miles, obtain medicines from providers that are not regulated in the UK should be referred to local authorities – such as police and social services – once the NHS takes on their case .

The NHS has said separately it would only prescribe puberty-blocking drugs for transgender teens “in the context of a formal research protocol.” It has not specified how gender-affirming hormones would be prescribed, although it also suggests enrolling young people into a clinical trial in the future.

However, the revised guidelines say adolescent patients would require a gender dysphoria diagnosis from a specialist clinician before their social transition would be supported by the NHS, rather than, as at present, relying on the statements of an adolescent.

The changes around social transition appeared after the draft was sent through government approval processes within the Department of Health and the Prime Minister’s Office, rather than the NHS or gender experts, two people involved in the process said.

For government employees to not recognize a young person’s preferred gender identity without a medical diagnosis would run counter to the way gender-affirming care has been practiced both in England and globally. The proposed requirement was not endorsed by the doctors involved in the Cass review, said people briefed on the matter. There was no such requirement around social transitioning in the original draft.

The draft plan has been criticized by medical groups specializing in transgender health around the world.

“This represents an unconscionable degree of … intrusion into … everyday matters such as clothing, name, pronouns, and school arrangements,” WPATH, along with a number of allied regional and national groups, said in a statement in late November.

“We’ve spent 20 years trying to reduce barriers to care. And now we’re seeing barriers put up.”

Dr Marci Bowers, president of WPATH

“We’ve spent 20 years trying to reduce barriers to care. And now we’re seeing barriers put up,” Dr Marci Bowers, president of WPATH and a gender surgeon in the United States, told Reuters in response to the NHS guidelines.

Spokespeople from the Health department and the Prime Minister’s office declined to comment. The government is considering public feedback on the proposals and expects to publish final guidelines early next year.

England is not the only country in Europe that is changing its approach. In Finland and Sweden, healthcare officials are limiting access to puberty blockers and hormone treatments, citing concerns that the risks may outweigh any benefit for adolescents, particularly those struggling with mental health problems.

Until 2020, adolescents expressing gender dysphoria in Finland could generally access puberty blockers and hormones, but that year its national healthcare council released guidelines for transgender care. These recommended supporting “identity exploration” and mental health treatment as the first steps to ensure that any psychological issues are addressed. The council said medical intervention for transgender minors “is still an experimental practice.”

Health officials in Sweden changed course after finding many adolescents seeking treatment had diagnoses beyond gender dysphoria.

In February, Sweden’s National Board of Health and Welfare revised its recommendations on puberty blockers and hormone treatment for adolescents. It recommended the treatments be given within a clinical trial. Until a trial is in place, it said, the drugs should only be given to people who fit the original Dutch model of persistent gender dysphoria with no mental health issues.

“It’s not an easy decision,” Thomas Lindén, a director at the board, told Reuters. “Some people are in great need of medical attention. Others are at risk of being harmed if they are given the same treatment. We really need better precision in the diagnosis.”

Kelly, the former Tavistock clinician, said even as knowledge changes and governments review policies, clinicians must not deny young people care.

“We need to practice within an evolving evidence base – and that doesn’t mean do nothing,” he said.

“A normal teenager”

It took just one week after Miles’s first full online appointment for GenderGP to agree to prescribe testosterone. The company, which operates in more than 40 countries, says its practices are consistent with WPATH and other international care guidelines.

GenderGP has no age limits to care, or minimum time periods before recommending prescriptions, including puberty blockers, to young people, co-founder Helen Webberley told Reuters. Its usual time-frame is within four to six weeks, she said, although complex cases take more assessment. Parental consent is not always required.

Miles said he hesitated about turning to GenderGP. The Webberleys have both been sanctioned by official medical tribunals for gender care they have provided since setting up their online clinic in 2015. The General Medical Council (GMC), the national watchdog that sets standards for doctors and maintains a register of those deemed fit to practice, referred both cases to the tribunals after concerns were raised by other doctors involved in caring for the same patients as the Webberleys.

Founder Dr Michael Webberley was struck off the British medical register this year after the tribunal found he had failed several patients by not conducting proper tests or assessing them robustly enough, both before and after recommending hormones or puberty blockers. The tribunal concluded that he was working outside his specialty as a gastroenterologist.

His wife, Helen, is currently suspended from practice after a separate hearing found she did not adequately explain the potential fertility impacts of medical treatment to a patient seeking help with gender-related distress.

Both deny that they failed their patients and appealed, although Michael Webberley’s appeal was dismissed by the High Court in early December. They told Reuters that they currently do no clinical work for GenderGP.

There is little NHS or independent data available on how many young people seek care privately. GenderGP says the share of under-18-year-olds among its more than 8,000 UK patients is rising, which it attributes to the lack of care offered through the NHS.

The Webberleys transferred their ownership of GenderGP to a Hong Kong-based company, Harland International, in 2019 to avoid the controversy associated with them, they said. The company is now registered in Singapore as GenderGP PTE Ltd, with Dr Helen Webberley as a director. Harland could not be reached.

The clinic’s prescribing doctors are all based overseas and regulated within their home countries – from the United States to European Union countries. EU-based doctors can prescribe to UK patients under rules drawn up after Brexit. Some GenderGP therapeutic counselors are UK-based.

Miles’s parents say they are happy with GenderGP, but worry that the lack of NHS care will lead young people to unscrupulous online providers or even to self-medicate.

The NHS doesn’t cover the cost of Miles’s private treatment. He is paying for his care with his wages from working at a local restaurant, and can recite the company’s charges by heart. He says he had reservations about using testosterone but decided to go ahead.

“I know it can affect fertility,” he said. “And it sounds weird, but baldness, because it runs in my family.”

He applies a testosterone gel to his arms every morning, normally before heading to school. The gel dries and then cracks, like a face mask, when first applied, he said, then sinks in.

Miles has not told his co-workers that he is transgender. To them, along with his friends at an archaeology group that he digs with in Dover, he is just a young man. Yet he still plays for a girls’ rugby team, until the effects of the testosterone kick in.

“I’m going to be able to start living my life as I want to,” he said. “I want people to see that just because I’m trans, that doesn’t affect who I am. I’m still a normal teenager.”

Do you have an experience with gender-affirming care to share as a patient, family member or medical provider? Share it with Reuters.

Youth in Transition

By Jennifer Rigby, Robin Respaut and Chad Terhune

Photo editing: Simon Newman

Video: Natalie Thomas and Rosanna Philpott

Art direction: John Emerson

Edited by Michele Gershberg and Sara Ledwith