• Adolescent Health
• Child Health Services
• Mental health
• Paediatrics

When I stepped into the presidency of the Royal College of Paediatrics and Child Health (RCPCH) in May 2021, I was aware that my friend and colleague, Dr Hilary Cass, was undertaking an independent review of Gender Identity Services for children and young people, commissioned by National Health Service (NHS) England. As a neonatologist, I realised that this was not an area where I had any clinical expertise, but I recognised that it was going to be crucial for me to develop my knowledge and understanding of gender questioning children and young people. In the last three years, I have learnt a huge amount about this topic, and while I cannot pretend to be an expert, I have come to realise why we collectively need to understand the needs of these children and young people better and work together to support their health and well-being, as we would with any of our patients.

I will be honest and say I set about improving my knowledge of gender identity with some amount of fear and trepidation. We all know what a divisive topic this has become. As someone who is committed to ensuring equity of access to healthcare for all children and young people, and having made a priority of addressing diversity and inclusion one of my primary goals as college president, I recognised that I needed to conquer my fears and learn from the experts around me. I was helped hugely by my own young adult daughters who simply could not understand why I was as anxious as I seemed to be. A very helpful conversation over the dinner table two years ago made me realise that the younger generations are far less preoccupied with their friends’ gender identities than my generation is, and there is a much greater sense of comfort about the topic and acceptance of gender fluidity. That conversation galvanised me to set about addressing the big gaps in my knowledge and understanding.

I have been worried for some time about the significant waiting times for children and young people with gender-related distress. It has become clear to me that NHS services have struggled to keep up with the increasing demand for holistic care, in the context of changes in the epidemiology of children and young people seeking help for their gender incongruence. We know that many children and young people have waited years to access any support. This means that this group of children and young people are particularly vulnerable because their health and well-being needs are simply not being met. We have an overarching holistic approach to the care of babies, children and young people centred on their needs, which until now, has not percolated through to gender service provision. We now have an important opportunity to make up for lost time. This is not simply about responding to gender needs—as with all of our patients, these children and young people may also present with mental health needs, neurodiversity, school attendance issues and so on.

The more I dug into this subject, the more I was reminded of how we all collectively viewed children’s safeguarding over 20 years ago. I can so clearly remember how fearful we all felt and how a few examples of colleagues who had found themselves in trouble over complex safeguarding cases disproportionately impacted us all, to such an extent that many paediatricians tried to avoid child protection if at all possible. Now, of course, we have an excellent structure in place whereby every child health practitioner knows exactly who can support them and where they can escalate concerns and questions. We also have a very robust set of educational resources and training that is mandated for anyone who has contact with children professionally. I doubt any paediatrician in the UK would say they feared safeguarding now.

There is a further analogy here—when I stepped into the RCPCH presidency in 2021, the exponential rise in children and young people’s mental health problems was overwhelming. I can well remember paediatricians telling me that they could not manage mental ill-health and some even said they saw themselves as ‘physical health’ doctors. Just three years on, the change in stance and the way the new approach has been embraced are remarkable. The speed at which paediatricians have developed their mental health literacy and adapted is a credit to you all.

I am convinced that we can collectively approach the health and well-being needs of children and young people with gender incongruence in the same way. These young people simply need the patient-centred holistic care that we are all trained to deliver and are very good at doing. This work is crying out for multidisciplinary working which most of us love doing, as well as shared decision-making which is exactly how complex healthcare should be delivered. Comprehensive adolescent services in the UK are sadly lacking and I think we should all have a collective vision of seeing gender services being part of a suite of services offered to children and young people in regional adolescent services. A holistic approach like that would mean that our patients would get the full range of physical and mental health needs addressed in one place, and staff working in these services would find collective support from the wider multiprofessional team.

I have been very fortunate in my college role to meet parents of trans young people. As a parent myself, I have quickly realised that this group of children and young people have just the same challenges, aspirations and needs as any other that we care for. Anxiety about moving from school to university education, preparation for leaving home, establishing friendship groups and forming relationships—these are topics which pretty much all young people and their parents are preoccupied with. Children and young people who are gender questioning face just the same challenges and have all the same hopes and dreams, but they face immeasurably more hurdles along the way. Helping them on the journey from childhood to adulthood can be a very rewarding and satisfying area of work.

As I hand over the college presidency to Professor Steve Turner, I am excited by the prospect of the new services being launched by NHS England for children and young people who have gender incongruence. I believe we are on the cusp of seeing real progress in the care of this patient group. The opportunity that this new service gives us to understand the needs of children and young people better is fundamental, and the determination to undertake well-structured long-term follow-up in well-designed research studies must be central to whatever the new service develops into. This edition of Archives of Disease in Childhood includes the latest evidence review of everything that has been published on this topic and gives us the important foundation on which to build our collective expertise and confidence as we set up the new services to take care of these children and young people.