The Levy Review of adult gender services
NHS England has published the Levy Review of NHS adult gender dysphoria clinics in England. This was an operational and delivery review that did not consider the effectiveness of the treatment, just whether patients are moving through the system in a timely manner, with clinicians ticking the prescribed boxes along the way.
NHS England Specialised Commissioning’s national director, John Stewart, and medical director, Professor James Palmer, welcomed the report as offering “a clear framework from which a comprehensive plan of action can be taken forward”. NHS England, in partnership with the Department of Health and Social Care, says it will now establish a National Portfolio Board and National Quality Improvement Network with “challenging but achievable productivity goals”.
Professor Levy has been given the role of independent chair of a newly formed National Provider Collaborative for Adult Gender Services. The treatment pathway is being redesigned so that patients are more quickly assessed and discharged from the service, put on hormones under the care of GPs and then referred to wait for surgery if they wish.
The Levy Review catalogues the many gross failings of adult gender clinics, including the lack of any data on outcomes. Benefits, harms, regret and detransition are not systematically tracked. Yet inexplicably Levy goes on to recommend that the process of assessment and treatment be standardised and accelerated.
Levy’s mandate meant that he did not ask questions about the efficacy of the treatment model. The review provides no evidence that the treatment offered is effective in any medical sense. The clinics are described as having “no culture of quality improvement through data collection, local or national audits or research”. What they are doing, in other words, cannot reasonably be described as medicine at all.
The Levy Review documents the rapidly rising number of young people coming into clinics, including a significant proportion with autism, attention deficit hyperactivity disorder and other mental health conditions as well as histories of trauma or abuse during childhood. Yet despite the fast-changing patient profile there is no suggestion of a rethink and no recognition that what is needed is a totally different approach.
This review failed to consider whether treatment goals are realistic. It is a wasted opportunity to rethink a failed treatment model. Any treatment given by the NHS should be grounded in the principles of evidence-based medicine and above all to “first do no harm”.
Having presided over the review that waved away concerns about whether offering treatment to sterilise and medicalise these vulnerable young people is medically ethical or in any way effective, Professor Levy now steps into the role of “independent” chair of a newly formed “National Provider Collaborative for Adult Gender Services”.
NHS England’s response is focused on what it considers to be productivity and efficiency. Given that historically 80–90% of this patient group was same-sex attracted, some will see this as simply speeding up the pipeline of state-sponsored conversion therapy.