For an official medical organisation to even consider rejecting one of the most in-depth, evidence-based reviews of an area of healthcare ever undertaken – by one of the most respected and experienced doctors in the country – might seem extraordinary. But this is gender medicine. And the question is how best to care for often deeply distressed, gender-questioning children and young people. The normal rules don’t apply. The New Statesman can reveal that tomorrow (Wednesday July 17) the governing body of the British Medical Association (BMA) – the doctors’ trade union – will vote on whether or not to “disavow” the Cass review.
The motion, first drafted as an emergency measure in June, was not discussed at the BMA’s Annual Representative Meeting (ARM) last month. BMA rules would suggest that for it now to be going to the union’s governing body, the proposal has gained the support of at least 10 members – about one in six – of the BMA’s Council in the intervening weeks. That makes it eligible to be voted on. The motion alleges that the Cass review contains “unsubstantiated recommendations driven by unexplained study protocol deviations” and is concerned at its “exclusion of trans-affirming evidence”. It calls on the BMA to “publicly disavow the Cass Review” and to “lobby and work with other relevant organisations and stakeholders to oppose the implementation of the recommendations made by the Cass Review”. It also calls for the union to “lobby the government and NHS in all four nations to ensure continuity in provision of transgender health care for patients younger than 18 years old”.
Unlike many medical professional bodies, the BMA (which represents doctors and medical students in the UK) has not yet issued a formal response to the Cass Review, which was published in April – more than three months ago. The Royal College of GPs and the Royal College of Psychiatrists have both accepted Dr Cass’s recommendations and said that it will inform their practices going forward. So too has the Association of Clinical Psychologists. It’s understood that the BMA has not met with Dr Cass since publication of her review.
A motion passed by the BMA’s Consultants Conference in 2023, supporting Dr Cass’s interim review and calling for the “BMA to facilitate respectful discussion of the issues raised in the Interim Cass Review”, was never acted upon. And several other opportunities to discuss the Cass Review have also not been taken. The Consultants Conference motion was put forward for debate at the BMA Annual Representative Meeting in 2023, for example, but was not chosen for debate. Commenting on the BMA vote proposed for 17 July, Dr Cass said: “It is disappointing that a professional organisation should choose to determine whether to support the findings of my report based on the votes of Council, rather than a transparent and scientific appraisal of the report.” She added that were the BMA to invite her to discuss her work with its members, she would “happily accept”.
It’s unclear, then, what would have motivated such a combative approach from those proposing the motion. Initial attempts to besmirch Dr Cass’s Review were roundly discredited. A couple of more recent critiques have been published, including one, wrongly attributed to Yale, but which includes a couple of the university’s researchers among its authors. The paper is a non-peer-reviewed work, authored by some whose own research was judged as poor by the Cass Review (and who have not declared any conflict of interest). While it is only right that legitimate criticism be considered in any contested field, to rely on this over and above a four-year study, underpinned by seven systematic evidence reviews, seems odd. Odder still when there has been no attempt to speak with that study’s author and question her.
A BMA spokesperson said: “Doctors and staff at the BMA are giving extensive consideration to the Cass review, taking the appropriate time to consider the methodology, findings and recommendations. This is a lengthy process, making use of expertise within the Association, in line with the BMA’s internal policy making processes. It would be inappropriate to pre-empt our position, or to provide further public comment on those processes.”
When I interviewed Dr Cass in May, she argued that some responsibility for the mistakes of the past – where children have been prescribed powerful puberty-blocking drugs and synthetic hormones without a robust evidence base showing the benefits of these treatments – must lie with the various professional bodies. “I think that some professional organisations have ducked their responsibility in ensuring that everyone working in this field… including in secondary care, treated these young people as they would any other,” she said. After undertaking the most in-depth investigation into the care of gender-questioning children ever, Hilary Cass found that gender medicine was built on “shaky foundations”. “This is an area of remarkably weak evidence,” she wrote in her final report, “and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint.” The reality, she said, is that there is “no good evidence on the long-term outcomes of interventions to manage gender-related distress”.
Yet for people like me, who hoped that the Dr Hilary Cass’s painstaking work would lead to calmer, more nuanced discussion – and to an agreement that the previous model of care has diverged far from ethical medical practice – the past couple of weeks have proved otherwise. Not just the revelation that the body that represents the UK’s doctors would consider rejecting it, but also the response to the new Labour health secretary Wes Streeting’s indication that he intends to make a ban on the private prescription of puberty blockers permanent. Streeting has faced abuse and name-calling, being accused by former Mermaids boss Susie Green of having “blood on his hands”, and by lawyer Jolyon Maugham of killing trans children.
Claims put forward by Maugham that more than a dozen suicides of trans people can be attributed to a six-month pause in puberty blocker prescriptions at the beginning of 2021, have been strongly critiqued by US journalist Ben Ryan. British journalists, perhaps keen not to amplify these – and aware of guidelines to never suggest motive for such awful occurrences – have steered clear. More generally, systematic evidence reviews carried out by the University of York that helped inform the Cass Review found there was no evidence that either puberty blockers or hormones helped reduced suicidality in young people.
Labour MPs have criticised Streeting too. Nadia Whittome and Zarah Sultana have both indicated they would oppose a ban on puberty blockers, as has Stella Creasy, who said the Cass Review “recommended caution, not exclusion, for any treatment”. Ms Creasy is correct in the narrow sense, but it is difficult to believe that any of these MPs have read Dr Cass’s review in any detail, or indeed the comments she has made since. Dr Cass did not call for a ban in her final report, but said rather that puberty blockers should only be prescribed on the NHS for the purposes of treating gender-related distress if they are done so as part of a clinical research trial, where the results can be closely monitored. This is because not enough is known about their potential benefits and harms. It takes an enormous intellectual leap for anyone to argue that, while she only advocates prescribing under controlled research conditions in the NHS, that Dr Cass would tolerate the approach that was taking place in the private sector prior to the interim ban put in place by Victoria Atkins just before the election.
Indeed, Dr Cass has stated her concern about what was taking place in the private sector on numerous occasions. Her final report said it shared the concerns of GPs “about the use of unregulated medications and of providers that are not regulated within the UK” and recommended that the Government “consider other statutory solutions that would prevent inappropriate overseas prescribing”. Hilary Cass told the BBC’s Today programme that she had “concerns about private provision which is not providing the level of assessment that I’m recommending in the NHS”, and later told The Times that GenderGP, a Singapore-based firm founded by British medic Dr Helen Webberley, offered care that “certainly doesn’t come anywhere near anything one would recognise as adequate in terms of a proper assessment and exploration”.
However BMA Council members vote tomorrow, that a motion to reject the Cass Review without any meaningful scientific appraisal has even got so far, is noteworthy. That British doctors – who should be well-schooled in evidence-based medicine – are considering rejecting the call for a cautious evidence-based approach for some of society’s most vulnerable confirms that we are a long way from consensus. One can only hope that those doctors who have responsibility for the decision are better acquainted with the details of Dr Cass’s review than either those proposing the measure, or a number of Labour MPs who have seemingly misunderstood its core message.
Note: This article was amended on 25 July 2024 to remove an assertion that the BMA had not met with Hilary Cass during the review process; representatives from the BMA had met with Dr Cass and members of her team on several occasions between 2021 and 2023.
Update: The BMA meeting that was held on 17 July 2024 ultimately voted on an amended motion relating to the Cass Review and not to “disavow” it. This article’s headline has been amended to reflect this development.
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