Mrs Benn

I gather that Hillary Cass has gone to ground, exhausted by the venom unleashed on her following the publication of her review of care for gender questioning young people. Cass has transitioned from a respected paediatrician to a target in the Culture War – an advocate for trepanning, according to Kathleen Stock, and a fascist according to some very vocal elements of the trans community. Whatever we think about Cass’s Review, there can be no doubt that it was written from a position of enormous expertise, and that it placed the needs of children and young people at the centre of its considerations.

The British Medical Association (BMA) has now waded into this melee. The BBC reported that

“…members of its Council, its top decision-making body, voted in favour of a motion last month that was critical of the Cass Review and called on the union to “publicly critique” it.”

One of the problems in wartime is to dientangle information and misinformation, which often appear to blend seamlessly. In an opinion piece in the Guardian, Sonia Sodha lambasted the BMA for failing in its obligation to “first do no harm” by

“criticising a groundbreaking evidence review of healthcare for gender-questioning children…Cass published a damning final report in April, concluding that the NHS specialist gender clinic for children – now closed – put an unknown but significant number of gender-questioning children on puberty-blocking drugs and/or cross-sex hormones, undeterred by the lack of evidence of benefit and potentially very serious risks to their long-term health.”

In fact, the Cass Review provides detailed data for the period between 1/4/18 and 31/12/22 (see pp. 167-169). The number of patients referred to the Gender Identity Service (GIDS) is indeed known, and the number to whom puberty blockers were prescribed is also known; both figures are given in the review. About half those referred to GIDS were discharged after a single appointment; 3306 patients had at least two appointments before being discharged, and of these, 27% were referred to endocrinology. 54.8% of all patients referred to endocrinology were on both puberty blockers and masculinising/feminising hormones. The number of patients who ultimately detransitioned was less than 10, or less than 0.3%.

Sodha continues:

“This was despite the fact that studies suggest that gender dysphoria resolves itself naturally in many children; is often associated with other underlying factors,… and that a childhood diagnosis of gender dysphoria is not predictive of a lasting trans identity in adulthood.“

This paragraph recapitulates a popular transphobic narrative: gender dysphoria is not really a thing – it’s a phase that some children go through and will grow out of – and recognising it is tantamount to homophobia because it gets in the way of children coming out as gay. Hate groups like the LGB Alliance have characterised trans activists as homphobic for supporting transition. “If only we would allow children to be gay, there would be no need for all of this trans nonsense” is the argument they make. I am afraid to say that I have never been attracted to men – nor was I same-sex attracted as a child. But by now, one feels that its pointless trying to explain this because the same hate-filled people have been pontificating about autogynephila as the true explanation for why I am the way I am – something that I don’t have either. It strikes me as contradictory to claim on the one hand that I’m really gay, and on the other that I’m really aroused by the thought of myself as a woman. But of course, this has nothing to do with rationality and everything to do with hate. It strikes me as fascistic that people who I have never met and who know nothing about me feel able to make pronouncements about the inner workings of my mind on the basis of no knowledge other than their own prejudices.

Sonia Sodha’s assertions are not conclusions that one will find in the pages of the Cass Review, and the low rate of detransitioning reported in the GIDS data is striking. Cass is a clinician who is interested in the outcomes the NHS can deliver for children. She doesn’t start with an ideological perspective, but she does start from the premise that care in the NHS should be led by evidence. She accepts that detransition will happen, that treatment of “comorbidities” may lead to”resolution” of gender-questioning, but Sodha goes far beyond that – she believes that activists are “making” people trans.

In relation to Sodha’s most substantial point – “first do no harm” – the answers are more complex than she suggests. Because the real problem with the previous government’s approach to the Cass report, confirmed by incoming Health Secretary Wes Streeting, the decision to stop treatment immediately for all patients being prescribed puberty blockers, rather than its acceptance of Cass’s recommendation that in future they should only be prescribed as part of a clinical trial. [Cass talks a lot about ‘randomised control trials’ but these have no meaning when the medication is a puberty blocker and the patient knows fine well whether they are taking the drug or the placebo; the construction of a clinical trial for puberty blockers is fraught with difficulty.]

Also writing in the Guardian, clinical psychiatrist Dr Aiden kelly writes

“Making the ban permanent is misguided, cruel and likely to make hundreds of young people less safe. It will mean that those young people who have started treatment will be forced to recommence a puberty that they previously found distressing and which was, in many cases, detrimental to their mental health.”

The decision to end treatment abruptly as an act in the culture war rather than as an agreed best course of action in a clinical context throws any consideration of harm reduction out of the window. Kelly makes the following sobering observation:

“In this area of healthcare, like no other I know of, the professionals with the requisite expertise are positioned by their critics as having been “captured by ideology” and therefore lacking in credibility. Meanwhile, those without the expertise are positioned as “independent”, which critics argue makes them better able to evaluate the evidence – despite having never worked in the field and having no understanding of its complexities.”

And what of the BMA’s decision to “critique” the Cass Review? The BMA web site quotes its Chair of Council, Professor Philip Banfield as follows:

“It is vitally important we take time and care to get this work right. This is a highly specialised area of healthcare for children and young adults with complex needs, and as doctors we want to be sure they get the most appropriate care and the support they need. The task and finish group will make recommendations to improve the healthcare system that has, for too long, failed transgender patients. It will work with patients to ensure the evaluation invokes the old adage in medicine of ‘no decision about me without me’. It is time that we truly listen to this group of important, valued, and unfortunately often victimised people and, together, build a system in which they are finally provided with the care they deserve.”

It is important to understand that to develop a scientific understanding of medicine, it is neccessary to apply the scientific method: conjecture and refutation. The essence of science is the testing of hypotheses (statements about the way the world is). Scientists test and retest and where a hypothesis is falsified, they replace or improve it and expand our understanding. Sonia Sodha is so blinded by transphobia that having grasped in Cass a stick to beat trans activists with, she now asks the BMA to stop thinking, stop testing and become more sheeplike.

Again I quote from Aiden Kelly, a clinician at the coalface:

“The Cass review pointed to the forthcoming NHS England puberty-blocker trial as the start of a “programme of research” to establish a firmer evidence base. But the NHSE research oversight board for the trial contains a distinct lack of notable clinical experience in the field. Cass, who does sit on the board, acquired her own knowledge by virtue of carrying out the NHSE review into gender services, which she was commissioned to conduct despite, at that time, having no direct experience of working in these services herself. The Cass review was concluded two years later than planned (in 2024 instead of 2022) and I fear the NIHR research trial will face similar delays owing to the lack of familiarity with the field.”

None of this is easy, and anybody who claims there is nothing to critique here is being delusory. Cass is a leading paediatrician, and her report is detailed, thoughtful and constructive. But it is a stepping stone along the way, not a tablet of stone handed down on Mount Sinai.