The Cass report has established that, in the field of gender healthcare, medicine has for some time been running ahead of the evidence base. For some time now, NHS England has stopped prescribing puberty blockers to children and young people who are new to its gender clinic services. We are glad to see that the Sandyford Clinic has come to the same decision, albeit somewhat late in the day.
We are glad about the Sandyford's decision, not because we want to stand in the way of gender-dysphoric and trans-identifying young people leading their best lives, but because we want to see a careful, rigourous examination of the pros and cons of puberty blockers before they ever again become a routine part of health interventions for these patients. In that respect it was disappointing that adult gender clinics in England failed to provide information on their patients that might have allowed Cass to come to a conclusion about the long-term benefits of puberty blockers in this patient group.
But it's not just puberty blockers that are the issue. We hold that gender dysphoria - meaning, simply, unhappiness with one's male or female body - is primarily a psychological experience. It follows that the first line of treatment should be one that addresses the psychological experience of the gender-dysphoric child. Psychotherapy seems the obvious default approach. Medical approaches involving hormonal treatment and in some cases irreversible surgical treatment would seem at best a last resort, and at worst a potentially terrible error, given that health professionals do not usually invite healthy people to take body-altering drugs or undergo medically unnecessary surgery. The ethics of this are especially questionable when we consider the vulnerabilities that come with being a child, and the additional vulnerabilities that many of these children come with.
Our education system is an important factor in the mix as well. We have a witnessed a perfect storm of children and adolescents being influenced on the one hand by social media which has then been compounded by many of our schools which have become captured by gender ideology. In Scotland there are basically three influential strands which have not served gender questioning children well. One strand has been the existence of the Scottish Government’s guidance, Supporting Transgender Pupils in Schools which has been available to all schools since August 2021. The guidance was not written by child development experts but by the activist organization LGBT Youth Scotland. The guidance amongst various concerns, refers to pseudoscientific research as justification for promoting ‘trans’ as an identity that children can have, and favors social transitioning in schools. The second concern in the education system is the fact that ‘trans’ ideology’ is woven throughout the social education curricular resource Relationships, Sexual Health and Parenthood (RSHP). This ‘product placement’ of ‘trans’ ideology in our schools, even in our primary schools, is not only unnecessary, it is unwelcome given the potential to confuse and psychologically harm children by misleading them down a path where a child thinks that they can change sex. The third strand of concern in our education system is the activities of some third sector activist organisations who have promoted gender ideologies in schools, trained teachers and demanded that schools follow and teach gender ideological ideas which have no factual basis whatsoever. We are aware that a number of children have been socially transitioned behind parents’ backs and others who have gone on to pursue medical interventions such as puberty blockers and cross sex hormones.
Unsurprisingly, we are now seeing some pushback against Hilary Cass's report, described rather colourfully by the Scottish Green Party as a "social murder charter". And this brings us to the issue of trans rights and science. Some people seem to take the view that these two are in some way irreconcilable, but this is simply not the case. Mainstream medicine has never proceeded on the basis that patients have unfettered rights to medical treatments. It has never been the case that a patient can simply elect to undergo medical interventions in the way that a person might, for example, decide to buy a new pair of shoes. Doctors need to consider not only the wishes of their patients, but also the likely costs and benefits of a particular medical intervention. As Cass has shown, we don't currently have a sufficiently high-quality evidence base to enable doctors to know about likely costs and benefits of medical transition procedures. (Ideology, along with shoddy research, has filled that gap up until now. ) What is urgently needed now is high quality long-term research, conducted in a medical context that is more cautious than it has hitherto been: "first, do not harm!"
Once the science is more established, rights to appropriate healthcare treatment will follow. Gender dysphoria, like any other 'dysphoria', is a condition that deserves to be taken seriously. Services to help individuals with these problems will need to be properly resourced, both in a material sense (staff, buildings) and in an intellectual sense (evidence, coherent understandings of the issue). Gender dysphoric and trans-identifying people have a right to these kinds of services, and in our view have been let down by the lack of sufficient 'intellectual resourcing' to date. Cass may not be popular with many trans-identifying individuals right now, especially those activists who still cling to gender ideological positions and the affirmative medical model. But it may just be that her recommendations will usher in a much-needed transformation of existing gender services, both in England and in Scotland. In our view, that can only be a good thing for gender-dysphoric and trans-identifying young people.
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