The British Medical Association (BMA) as the trade union and professional organisation for doctors and medical students in UK, recently made a controversial decision to challenge the recommendations of the Cass Review (CR). Whilst BMA Scotland may claim to represent medical voices, we wonder if they are aware that many GPs in Scotland are beginning to speak out about the professional conflicts they experience in the controversial field of the ambiguously-named 'gender medicine'?
At ScotPAG we are privileged to have gained access to a letter sent to the BMA from a GP who comprehensively takes apart spurious arguments about affirmative care, the administration of dangerous drugs, and surgical interventions. An important question is posed, 'If gender reassignment is personal or social, not medical, then how much should medical practitioners be expected to be involved?
The following letter clearly illustrates the views we hold as ScotPAG professionals, not only in Healthcare, but also in Education and Social Work, where it is increasingly obvious that what we are witnessing is a social phenomenon that co-opts medicine into practices that are not evidence-based. We welcome the public declarations of those courageous doctors who are challenging their professional bodies.
Letter to the British Medical Association from a Scottish GP:
I am writing to you, to warn of my resignation from the BMA, after faithful membership since I was a student. I feel unrepresented, unheeded, not consulted and totally unsupported in my concerns regarding trans medicine.
Having been brought up in an era of evidence-based medicine, which supposedly harnesses the best science we can muster at any given moment, I am dismayed that science has been trumped by the ‘beliefs’ of a minority ideology. I and many of my peers do not adhere to gender ideology, in that the body is part and parcel of that person, not a separate entity. The aetiology, by this logic, is not that the person is in the “wrong body”, but is dysphoric about their body. Hormone treatment in this framework, is not the correct treatment, but treatment would be more aptly directed at the dysphoria.
The new language gives some credence to their persuasions, but the fluidity of their definitions, including disagreements between the various groups, reveals the lack of science. The ideology promotes the separation of the definitions of ‘gender’ as a social construct, from the ‘biological reality’ of sexual identity.
I note that errors of definition were made in official documents, stemming from the inaccurate definition in the Equality Act of 2010 [1], which refers to patients who are “reassigning their sex by changing physiological or other attributes of sex” .The Gender Reassignment Policy for NHS Greater Glasgow and Clyde 2018 [2], for example directly quoted this, but by 2021 revised the text ‘you do not need to have undergone any specific treatment or surgery to change from your birth sex to your preferred gender’ , as they realised that no-one can change sex.
The reviewed version of 2021[3], however still quotes the error of the Equality Act, 2010 (Section 3 page 4). The Act defines gender reassignment as: ‘where a person has proposed, started or completed a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex’.
Interestingly the 2021 version goes on to explain the change: ‘This is because changing your physiological or other gender attributes is a personal process rather than a medical one.’
This latter point is valuable; If gender reassignment is personal or social, not medical, then how much should medical practitioners be expected to be involved? Our help is requested when the patient wants to disguise their sex to a greater degree, to satisfy their preferred gender.
NICE already looked at puberty blockers as far back as 2021[4], and advised then about insufficient evidence. The Cass Review [5] discussed the trend of an increase of gender dysphoria in young female patients, with other psychological problems including autism, rendering historic data from male transitioners not applicable to this population.
A similar review was conducted by NICE on Gender affirming hormones, with similar conclusions [6], but this was beyond the remit of Hilary Cass to study. It may be only a matter of time before the whole area of medical affirmation and surgical transitions are brought into question, not only due to lack of evidence of benefit, but due to evidence of harm. A study of retrospective data from the United States showed a 12-fold increase in the risk of suicide or self-harm associated with gender affirmation procedures [7].
We were relieved at our Practice to read that the latest RCGP guidance makes it clear that anyone who prescribes takes on a responsibility. This means that there is no obligation to be involved [8].
This is all the more important if the medication is ‘off licence’ and has no evidence base. GPs could conscientiously object for that reason. This is backed up by the BMA guidance, in relation to private medicines, which notes that if the medication is specialised in nature and is not something GPs would generally prescribe, it is for the individual GP to decide whether to accept clinical responsibility for the prescribing decision recommended by another doctor. This is especially relevant where there is no specialist follow up, and GPs are expected to order tests, and interpret the results, in an area where they have no expertise [9].
I am seeking that you, the BMA support GPs not taking part in shared care due to lack of expertise and workload. In summary, I see three main reasons:
1. The medical practitioner objects to providing treatment, which could be interpreted by the GMC as on the grounds of not ‘believing’ in the theory behind it.
2. The clinician in studying the evidence informing the proposed treatment, may find a distinct lack of medical research, or indeed, even suspect evidence of harm, and therefore consider it against his/her conscience to prescribe.
3. Fear of future litigation from de-transitioners [10].
References
[1] The Equality Act of 2010 https://www.legislation.gov.uk/ukpga/2010/15/body/data.pdf
[2] The Gender Reassignment Policy for NHS Greater Glasgow and Clyde 2018 (available on request).
[3] The Gender Reassignment Policy for NHS Greater Glasgow and Clyde 2021 revised Section 1, Introduction, page 2. https://www.nhsggc.org.uk/media/266027/gender-reassignment-policy-review-2021-revised.pdf
[4] Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria. This document will help inform Dr Hilary Cass’ independent review. The document was prepared by NICE in October 2020. p.50
[5] The Cass Review - Final Report https://cass.independent-review.uk/home/publications/final-report/
[6] Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. The document was prepared by NICE in October 2020. P.46
[7] Straub JJ, Paul KK, Bothwell LG, Deshazo SJ, Golovko G, Miller MS, Jehle DV. Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Cureus. 2024 Apr 2;16(4):e57472. doi: 10.7759/cureus.57472. PMID: 38699117; PMCID: PMC11063965. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11063965/
[8] The role of the GP in transgender care, RCGP position statement, 2024 update.
[9] General practice responsibility in responding to private healthcare (bma.org.uk) https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/general-practice-responsibility-in-responding-to-private-healthcare
[10] The judgment in Keira Bell’s case upsets trans groups
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