Religion is a Mental Illness

The Cass review of gender identity services marks a return to reason and evidence – it must be defended | David Bell

Its author has had to fend off criticism and misinformation, but the report offers hope for a realistic conversation, says consultant psychi

the Guardian

As the dust settles around Hilary Cass’s report – the most extensive and thoroughgoing evidence-based review of treatment for children experiencing gender distress ever undertaken – it is clear her findings support the grave concerns I and many others have raised. Central here was the lack of an evidential base of good quality that could back claims for the effectiveness of young people being prescribed puberty blockers or proceeding on a medical pathway to transition. I and many other clinicians were concerned about the risks of long-term damaging consequences of early medical intervention. Cass has already had to speak out against misinformation being spread about her review, and a Labour MP has admitted she “may have misled” Parliament when referring to it. The review should be defended from misrepresentation.

The policy of “affirmation” – that is, speedily agreeing with a child that they are of the wrong gender – was an inappropriate clinical stance brought about by influential activist groups and some senior gender identity development service (Gids) staff, resulting in a distortion of the clinical domain. Studies indicate that a majority of children in the absence of medical intervention will desist – that is, change their minds.

The many complex problems that affect these young people were left unaddressed once they were viewed simplistically through the prism of gender. Cass helpfully calls this “diagnostic overshadowing”. Thus children suffered thrice over: through not having all their problems properly addressed; by being put on a pathway for which there is not adequate evidence and for which there is considerable risk of harm; and lastly because children not unreasonably believed that all their problems would disappear once they transitioned. It is, I think, not possible for a child in acute states of torment to be able to think through consequences of a future medical transition. Children struggle to even imagine themselves in an adult sexual body.

Some claim that low numbers of puberty blockers were prescribed. Cass quotes figures showing around 30% of Gids patients in England discharged between April 2018 and 31 December 2022 were referred to the endocrinology service, of whom around 80% were prescribed puberty blockers; the proportion was higher for older children. But these numbers are likely to be an underestimate, as 70% of children were transferred to adult services once they were 17, and their data lost, as very regrettably they were not followed up. This is one of the most serious governance problems of Gids – also specifically addressed by the judges in Keira Bell v Tavistock. Six adult gender clinics refused to cooperate and provide data to Cass. However, having come under considerable pressure, they have now relented.

It is often claimed that puberty blockers were not experimental, as there is a long history of their use. They had been used in precocious puberty (for example where a child, sometimes because of a pituitary abnormality, develops secondary sexual characteristics before the age of eight) and in the treatment of prostate cancer. But they had not been prescribed by Gids to children experiencing gender dysphoria before 2011. The lack of long-term evidence underlies the decision of the NHS to put an end to their routine prescription for children as a treatment for gender dysphoria – that is, for those whose bodies were physically healthy.

The attempts of Gids clinicians to raise concerns about safeguarding and the medical approach were ignored or worse.The then medical director heard concerns but did not act; ditto the Speak up Guardian and the Tavistock and Portman NHS foundation trust management. I was a senior consultant psychiatrist, and it was in my role as staff representative on the trust council of governors that a large number of the Gids clinicians approached me with their grave concerns. This formed the basis of the report submitted to the board in 2018. The trust then conducted a “review” of Gids, based only on interviewing staff. The CEO stated that the review did not identify any “failings in the overall approach taken by the service in responding to the needs of the young people and families who access its support”. I was threatened with disciplinary action. When the child safeguarding lead, Sonia Appleby, raised her concerns before the trust’s review, the trust threatened her with an investigation; and its response, as an employment tribunal later confirmed, damaged her professional reputation and stood in the way of her safeguarding work.

Characterising a child as “being transgender” is harmful as it forecloses the situation and also implies that this is a unitary condition for which there is unitary “treatment”. It is much more helpful to use a description: that the child suffers from distress in relation to gender/sexuality, and this needs to be carefully explored in terms of the narrative of their lives, the presence of other difficulties such as autism, depression, histories of abuse and trauma, and confusion about sexuality. As the Cass report notes, studies suggest that a high proportion of these children are same-sex attracted, and many suffer from homophobia. Concerned gay and lesbian clinicians have said they experienced homophobia in the service, and that staff worked in a “climate of fear”.

It is misleading to suggest that I and others who have raised these concerns are hostile to transgender people – we believe they should be able to live their lives free of discrimination, and we want them to have safe, evidence-based holistic healthcare. What we have opposed is the precipitate placing of children on a potentially damaging medical pathway for which there is considerable evidence of risk of harm. We emphasised the need, before taking such steps, to spend considerable time exploring this complex and multifaceted clinical presentation. Young people and clinicians routinely refer to “top surgery” and “bottom surgery”, terms that serve to seriously underplay these major surgical procedures, ie double mastectomy, removal of pelvic organs and fashioning of constructed penis or vagina. These procedures carry very serious risks such as urinary incontinence, vaginal atrophy, cardiovascular complications and many others we are only beginning to learn about. There is a very serious risk of sexual dysfunction and sterility.

There are no reliable studies (for children or adults) that could support claims of low levels of regret. The studies often quoted (eg Bustos et al 2021) have been criticised for using inadequate and erroneous data. The critical issue here is the fact that children and young people who were put on a medical pathway were not followed up. Studies suggest that the majority of detransitioners, a growing population, who are having to deal with the consequences of having been put on a medical pathway, do not return to the clinics as they are very fearful of the consequences. The fact that there are no dedicated NHS services for detransitioners is symptomatic of the NHS’s lack of concern for this group. Many live very lonely and isolated lives.

Those who say a child has been “born in the wrong body”, and who have sidelined child safeguarding, bear a very heavy responsibility. Parents have been asked “Do you want a happy little girl or a dead little boy?” Cass notes that rates of suicidality are similar to rates among non-trans identified youth referred to child and adolescent mental health services (CAMHS). Indeed, the NHS lead for suicide prevention, Prof Sir Louis Appleby, has said “invoking suicide in this debate is mistaken and potentially harmful”.

It has been suggested that the Cass report sought to “appease” various interests, with the implication that those who have promoted these potentially damaging treatments have been sidelined. But in reality, it is those of us who have raised these concerns who have been silenced by trans rights activists who have had considerable success in closing down debate, including preventing conferences going ahead. Doctors and scientists have said that they have been deterred from conducting studies in this area by a climate of fear, and faced great personal costs for speaking out, ranging from harassment to professional risks and even, as Cass has experienced, safety concerns in public.

The pendulum is already swinging towards a reassertion of rationality. Cass’s achievement is to give that pendulum a hugely increased momentum. In years to come we will look back at the damage done to children with incredulity and horror.

David Bell is a retired psychiatrist and former president of the British Psychoanalytic Society