Nearly 900 doctors have written to the British Medical Association (BMA), expressing “dismay” and disappointment” at the stance being taken by the doctors’ union on puberty blockers and the Cass Review, the New Statesman can reveal.
In a press release last week, the BMA criticised the ban on new prescriptions of puberty blocker medication – restrictions introduced by the Conservative government from June in the light of Dr Hilary Cass’s four-year review of gender identity services for children and young people. Cass’s final report was published on 10 April this year. In response, the BMA has now called for a pause in the implementation of recommendations made by the Cass Review, having branded them “unsubstantiated”.
The letter, which is addressed to Philip Banfield, chair of the BMA’s UK Council, and has been seen in full exclusively by the New Statesman and the British Medical Journal, opens: “We write as doctors to say, ‘not in my name’. We are extremely disappointed that the BMA Council has passed a motion to conduct a ‘critique’ of the Cass Review and to lobby to oppose its recommendations.”
It is signed by 57 professors and 22 former or current presidents of royal medical colleges and other clinical leaders, among others. Of the 870 signatories, more than two-thirds are BMA members. “The number of signatories to this letter speaks to the level of concern among doctors about the BMA Council motion against the Cass Review,” said Dr Camilla Kingdon, a past president of the Royal College of Paediatrics and Child Health (and a signatory of the letter).
On 16 July, the New Statesman revealed a motion tabled by the BMA that called for BMA members to “lobby and work with other relevant organisations and stakeholders to oppose the implementation of the recommendations made by the Cass Review”. The BMA’s policy-forming body – the UK Council – voted the next day on a slightly amended motion: instead of voting to “disavow” the Cass Review, the council voted to “publicly critique” it. The motion also described Cass’s recommendations as having been “driven by unexplained study protocol deviations, ambiguous eligibility criteria, and exclusion of trans-affirming evidence.”
In a press release on 31 July, the BMA confirmed the result of the vote on the motion, as well as its final wording. The doctors’ letter to the BMA criticises the process that led to the organisation’s position on the Cass Review as “opaque and secretive” and “does not reflect the views of the wider membership, whose opinion you did not seek”.
We do not know how many of the BMA’s 69 Council members voted in favour of the motion. The council’s rules mean that motions can pass with a simple majority of votes cast – abstentions can be disregarded. BMA members who have signed the letter say the refusal to provide details of the vote amount to “a failure of accountability to members”, describing it “simply not acceptable”. Meanwhile, the details of other recent BMA votes have been published. In a written response to those who have signed the letter, Philip Banfield said that the debate and vote at council followed due process and BMA members would be given the voting results once the meeting’s minutes have been approved.
After the vote, the BMA issued a press release, criticising the government’s ban on the private prescription of puberty blockers to those aged under 18 (for the purpose of treating gender-related distress).” In March, NHS England confirmed that puberty blockers would no longer be prescribed on the NHS for the treatment of gender-related distress. There was, its statement said, “not enough evidence to support the safety or clinical effectiveness of [puberty blockers] to make the treatment routinely available at this time.” Instead, they would only be prescribed as part of clinical research. This ban was judged lawful by the High Court last month, and the Health Secretary, Wes Streeting, has indicated he supports it.
In her review Cass found that gender medicine was built on “shaky foundations”: “This is an area of remarkably weak evidence.” The reality, she wrote in her report, is that there is “no good evidence on the long-term outcomes of [hormonal] interventions to manage gender-related distress”.
Speaking exclusively to the New Statesman, Cass spoke of her “disappointment” that the BMA’s UK Council had not made contact with her to discuss their concerns in the four months since the review was released. “The review [team] spoke to representatives of the BMA during the course of its work, and the recommendations in the final report reflect the issues that they raised; specifically, anxieties about lack of adequate training in this area, and the pressures put on GPs by private providers to prescribe in an area which many feel is outside their competence.”
The letter – which strongly supports Cass – has accused the union of failing to follow an evidence-based approach to medicine. The letter says: “The Cass Review has got it right when it says that because there is so little evidence about [puberty blockers’] safety and efficacy, they should only be prescribed under research conditions.” The letter also notes: “By lobbying against the best evidence we have, the BMA is going against the principles of evidence-based medicine and against ethical practice.”
The questioning of the ban on the prescription of puberty blockers was not explicitly voted upon by the council. Following the BMA’s announcement, NHS England said: “Dr Cass spent four years gathering evidence for the most comprehensive report of its kind, and her expertise and advice has been invaluable in supporting the NHS to create a fundamentally better and safer service for children and young people.” It had “full confidence” in her report and was “committed to taking forward its recommendations”.
Speaking to the New Statesman, both Kingdon and Dame Clare Gerada (a former president of the Royal College of General Practitioners, and another signatory) echoed the letter, insisting the Cass Review is “the most comprehensive review of its type ever conducted”. “Patients – and that includes children – have a right to receive treatment based on best evidence,” Gerada added. “This is especially important when that treatment is a life-altering intervention.”
Scores of signatories to the letter added further comment below the main text. They didn’t hold back: “appalled”, “horrified”, “shocked”, “reprehensible”, “irresponsible” and “wrong”. Some claim that the move will cause direct harm to children, while one signatory claims it shows “an abysmal failure of leadership”. Another writes: “The BMA has stepped outside of its limitations in attempting to critique a large body of carefully conducted specialist research.” A number are perplexed why the BMA – a trade union for doctors – is getting involved at all, suggesting that its focus should be on pay and working conditions, rather than “challenging an evidenced based document which took four years of painstaking research to produce”. (These remarks were put to the BMA; the organisation declined to comment.) Several signatories say they have resigned their membership as a result of last week’s announcement.
Dr Peter Green, co-chair of the National Network of Designated Healthcare Professionals (NNDHP) – whose members are responsible for children’s safeguarding across the NHS – is a lifelong BMA member. He is also a signatory of the letter.
“The NNDHP has supported the Cass Review from the beginning as a means to providing answers to a conflicted clinical issue,” Green told the New Statesman. “The review was admirably rigorous in its approach and provided sober clarity in the eye of a social storm. The NNDHP are surprised at the BMA intervention and, with all due respect, urge the association, world renowned as it is, to reassess its approach and position.”
“I cannot understand what the BMA thinks they can add to this complex area of healthcare,” said Kingdon. “There is a real imperative that we start implementing the Cass Review recommendations and underpin our work with further research to answer important questions about our approach, especially with regards to the use of hormones,” she added.
Signatories are deeply concerned about the thousands of distressed children in need of help. The most recent figures suggest that more than 5,700 are on the waiting list for youth gender services.
In support of its stance, the BMA has referenced a paper critical of the Cass Review, authored by some whose own research was criticised in the evidence reviews that informed Cass’s work. “We note that the sources the BMA is relying on to cast doubt on the review are authored by groups with serious conflicts of interest and have not been through peer review,” the letter notes. The seven systematic reviews that underpin the Cass report are all peer reviewed.
The BMA now plans to embark on its own review of the Cass Review, which it hopes to have completed by the end of the year. The organisation’s “task and finish” group will, the BMA said in its press release of 31 July, “pay particular attention to the methodology used to underpin the report’s recommendations”. The letter, however, questions whether the BMA has the expertise to do this and argues that it will be “very difficult for the BMA to produce a fair critique when it has already attacked the review and voted to oppose implementation of its recommendations”.
“Whilst BMA Council elected not to consult their members,” Cass said in a statement, “the review consulted with several hundred clinical staff most closely involved in the care of children and young people with gender-related distress, many of whom are of course BMA members. We also had regular discussions with medical royal colleges and other professional bodies responsible for producing guidance and setting professional standards, and an extensive engagement programme with service users and people with lived experience.”
In a two-page reply to the letter’s signatories, shared with the New Statesman, Banfield said that while “the motion passed by the BMA’s UK Council criticises the Cass Review and the actions that have been implemented in its name”, the critique called for “must begin from a point of neutrality and any evaluation must be evidence led”. “The idea that any review, even on such a sensitive topic, should not be critiqued, is, I believe, contrary to the very principles” of scientific process, he added.
Banfield said that the ban on “the use of puberty blockers for transgender and gender-diverse young people goes further than any recommendation in the Cass Review”, which said they should be “used only under research conditions”. The impact of the government’s decision, he argued “means that right now, today, there are those who could benefit from care who are being denied that option”.
The publication of the final report of the Cass Review in April 2024 seemed – for a short while – to bring some calm, and clinical consensus, to a noisy, toxic debate about how best to care for gender-questioning children. Its findings have been accepted by both the previous Conservative government and the current Labour administration. NHS England has pledged to implement its findings in full, and yesterday issued an update on its plans to do so. A third specialist gender hub will open later this year in Bristol, with others planned in the future. As evidenced by the letter to BMA, doctors are now seriously worried this could unravel.
The letter to Philip Banfield express its signatories’ “dismay” that the BMA has chosen to critique Cass. The letter concludes: “We call on the BMA to abandon this pointless exercise and to welcome and follow the Cass Review as the Royal College of Psychiatrists, the Royal College of General Practitioners, the Royal College of Paediatrics and Child Health and the Academy of Medical Royal Colleges have done.”
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