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Two mothers are suing the health service over concerns that as soon as a teenager turns 17, they can transfer to adult gender clinics and be fast-tracked to surgery and sex-change drugs.
This is despite a recent crackdown on treatment for under-18s, including a ban on puberty blockers and a guarantee of assessment of underlying mental-health conditions and neurodevelopmental disorders such as autism before treatment is given for gender issues.
The mothers, who both have "vulnerable" teenage daughters seeking sex-change surgery, are now taking the case to the High Court in an attempt to force NHSE to guarantee the same protections at adult clinics.
Dr Karl Neff, a consultant endocrinologist and the head of Ireland's National Gender Service, will warn the judge that the treatment currently offered to adults in England "will not fully meet their needs or offer them adequate protection and thereby will place them at unreasonable risk of irreversible harm".
The judge will hear that in 2019, 17-year-olds made up 18 per cent of referrals to adult gender services, the largest single group by age. Since then, NHSE has written to all those of that age who were on the Tavistock waiting list telling them that instead they will go straight to the adult clinic.
In a NHS letter to an 18-year-old transferring them to the adult service, the patient was told that "not all clinics offer things like... psychological support".
'Lack of evidence-based care'
Anna Castle, one of the mothers bringing the case, said that "something needs to be done about the lack of evidence-based and multi-disciplinary care and the fact that our children and vulnerable people are being sent on a one-way pathway without having any of their other conditions considered".
Ms Castle, whose daughter suffers with ADHD, has autistic traits and decided she was a boy during lockdown, said that sex-change surgery "is the most extreme decision anyone could make about their body".
"But it has the least amount of safeguarding and preliminary investigation into whether it is actually necessary and then there is no evidence as to whether it actually helps," she added.
"All these children, all these vulnerable people, as soon as they say they think they are the opposite sex then everyone - institutions, organisations - straight away says that they have gender dysphoria.
"There is no proof of this, they haven't been assessed. It is frustrating that in any other situation people would be required to give proof of diagnosis. But instead society is playing into this assuming that people have gender dysphoria when there are so many other reasons for the troubles that they are having."
In a witness statement seen by The Telegraph, Dr Neff describes how he is working on the "front line" of transgender care and the "clinical practice in gender-related healthcare is contentious" because as it stands "evidence base is poor and often compromised by serious bias".
Dr Neff said that "a major discrepancy" between the NHSE service for adults and the model of care at his own clinic was that in England there is no "mandated specialist mental-health assessment".
'Would not seem sensible'
He will tell the court that "it would not seem sensible or prudent to proceed to hormone therapy or surgery" without this assessment as "the single most common fatal adverse event after initiating medical transition in our experience is suicide".
Adding that its absence from NHSE adult clinics "leaves people at risk of harm as a result of undiagnosed or unaddressed mental-health problems, or an unidentified risk of suicide" that would be greater among young neurodiverse people like the two involved in the case.
Dr Neff took over as the clinical lead at the Dublin adult gender clinic since 2019, which now ensures that patients are seen by a range of medical professionals after noticing "an increase in adverse events" years after transition, including suicide, social isolation and declining mental health.
He also said that it is "concerning" that NHSE allows people to self-refer to the clinics, saying that it means patients "potentially have clinical needs left unaddressed. This would place them at a greater risk of harm".
Dr Neff said that the new NHS guidelines for treating children and adolescents with gender dysphoria provide "a prescriptive, holistic, and cautious clinical approach".
But he noted that the "considered approach contrasts strongly with the adult service specifications which appear to assume that most referrals to adult gender services do not involve clinical complexity. By doing so the service specification puts those with complex presentations at an unreasonable risk of harm".
He concluded: "In light of the emerging evidence of increasing vulnerability in people attending gender services, and the limitations of the available evidence base, I am not confident that the adult NHS service specifications as written adequately safeguard vulnerable people, or provide treatment or intervention pathways that would be suitable for all."
Seeking judicial review
Ms Castle and the second mother, listed on court papers only as XYZ, will launch an appeal for permission to hold a judicial review at London's High Court on Tuesday.
An NHS spokesman said that a written application for the permission was rejected by the High Court in December last year "including because there was no arguable case".
The spokesman said: "The court accepted that NHS England's service specifications for both adult and children's gender services are aimed at securing personalised and specialised assessments that address all aspects of the patient's history and presentation, and that they are conducted by experienced clinicians."
He added: "Separately, NHS England has already described that a planned review of the service specification for adult gender services will take place this year, which will include an extensive process of engagement and public consultation."
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