April 12, 2024   8 mins

Pity poor Dr Hilary Cass, the eminent paediatrician charged with managing an independent review of NHS gender services for young people, whose final report was published this week. Given the hair-trigger sensibilities of interested parties, she seems to have been unable to state unambiguously that now-popular treatments for young people confused or distressed by their sexed bodies are blatant quackery: keeping pre-pubescent kids in suspended chemical animation on the basis of a single, discredited study; dosing teenagers liberally with opposite-sex hormones; or — when a child reaches the tender age of 18, though even earlier in other countries — empowering her to have major body parts cut off.

Instead, time and again in Cass’s report she is forced back into the conceit that the most pressing problem for contemporary gender medicine is the lack of good evidence for such interventions either way. It is as if a modern-day medic had been tasked with reviewing the efficacy of trepanning, and then ordered to defend her findings in front of fanatical fifth-century devotees. “It’s not that drilling a hole in a child’s skull to release demons is necessarily harmful, you understand — indeed, it may be the best outcome in some cases. The main issue is the lack of long-term follow up.”

Alongside Cass’s cumulatively devastating account of reckless decision-making, poor evidential standards, and patchy record-keeping at Gids and elsewhere, a whole section of the report gently attempts to educate its readership about “the components of evidence-based medicine” — complete with basic explainers about randomised controlled trials, blinding processes, and the possibility of bias. She might as well be addressing an archaic people who have just emerged blinking from a time capsule, still convinced that disease is God’s punishment for insufficient acts of propitiation.

In a sense, though, this is indeed very like one group to whom the report is addressed: those clinicians, parents and patients immersed in bubbles of identity affirmation, and cognitively isolated from any reasoning or evidence that would confound their worldview. Perhaps unusually for a medical review, it is clear from Cass’s overtly respectful tone and at times still-euphemistic language that her aim is not just to inform these readers but also to deprogram them.

The very first sentence of her report begins with a weary disavowal of Stonewall-endorsed paranoias (“This Review is not about
 undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare”). Somewhat nonsensically, references to “birth-registered females” are scattered throughout the text, as if the author were somehow only concerned with those with birth certificates — presumably an attempt to build bridges with child-like souls still convinced sex is something coercively assigned to neonates at random. Generally, there is a sense of gingerly addressing a group of emotionally labile people who are not quite ready to face the whole truth.

And no wonder: nearly every indicator of cult membership is present among so-called affirmative clinicians and their hapless patients. Among the most telling signs are a fervent belief in a transcendent new way of life; induction into a mystical world of occult symbols, flags and lanyards; the love-bombing of new recruits with affirmative language and talk of “queer joy”; and the replacement of traditional support systems (one Pride post on the South London and Maudsley NHS Trust  website  — a hospital involved in creating the new youth gender services to replace Gids  — talks about “the fight for LGBT rights” as something “to be won against your family or your neighbours or whoever is directly around you”).

“Nearly every indicator of cult membership is present among so-called affirmative clinicians and their hapless patients.”

Relatedly, there is a lot of what cult specialists call “hate-bonding” — that is, framing critical voices as evil enemies to be automatically discredited, a process which neatly shuts down intellectual curiosity while solidifying group cohesion at one fell swoop. A recent example of such attitudes was the intensely hostile protest last month at a clinician-organised conference critical of child transition, purportedly led by an NHS doctor. When considered alongside other obvious signs of religious commitment — the mantras and incantations, sacred texts, citations of high priests, annual holy weeks, and so on — it is not hard to conclude that, for many in the medical profession, transactivism is based on faith not reason. Consider, for instance, the astonishing levels of religiosity in this 2023 publication from the NHS Confederation, at one point encouraging “allies” to “recognise the privilege afforded to them as a cisgender person and uses this to uplift the voices of trans and non-binary colleagues”.

Cults are not unusual, as human phenomena go; the unusual point is that one came to control parts of the NHS. As Cass relates, again euphemistically, “for this group of young people expertise has been concentrated in a small group of people, which has served to gatekeep the knowledge”. Suitably translated, so that “expertise” means “power” and “gatekeep the knowledge” means “deflect real scrutiny”, she is effectively pointing to the fact that much damage can be done in an institution by only a few zealots, as long as they are the ones presumed in charge of things by others.

There is no better evidence of this than the fact, also highlighted in the report, that according to current NHS guidelines, a newly socially transitioned young person can be given a different NHS number in alignment with their preferred identity. As well as affecting the provision of sex-appropriate screening and other kinds of differentiated care, this change alone has made it very difficult to track long-term outcomes of gender treatment. When first mooted, it would not have been hard to anticipate problems; but such petty worries obviously paled in comparison to the thrill of achieving metamorphosis-by-bureaucracy.

Another clue to the level of ideological capture emerges when Cass describes a proposed data linkage study, originally envisaged as culling information about 9,000 patients from “Gids, hospital wards, outpatient clinics, emergency departments and adult gender dysphoria clinics”, and so providing “a population-level evidence base of the different pathways people take and the outcomes”. In the end, the much-needed study didn’t happen because clinicians in existing gender services nearly all refused to cooperate. (An inquiry into adult clinics has since been announced.)

Reasons for refusal included that the Cass Review would be politically biased; and that “[t]aking part in a study of this kind could bring into question the integrity of clinic staff and the relationships they have with patients”. It is hard to imagine such a self-serving affront to patient safeguarding being considered acceptable in any other healthcare context. Another reason offered, also with an apparently straight face, was that “the study outcomes focus on adverse health events, for which the clinics do not feel primarily responsible”. Once you have fixed the problems with a young person’s soul, apparently what happens to their body afterwards is not your concern.

One could be forgiven for thinking that medical culture should easily be able to condemn bizarre physical interventions performed upon children in the name of religion, without having to undertake a four-year clinical review first. Indeed, lawmakers have previously criminalised practices such as FGM without requiring any such tests. But one instructive thing we can learn from the wreckage of gender medicine is that, with the right kind of institutional and rhetorical scaffolding, doctors can become unsure about what their goals are supposed to be. It’s no good telling them to first do no harm, when they can’t work out how to reliably detect it.

“It’s no good telling them to first do no harm, when they can’t work out how to reliably detect it.”

A superficial reason for this confusion is that the harms taken to fall squarely under the medical profession’s remit include negative psychological impacts as well as physical ones. And indeed, this looks like the right result: we can all think of obvious cases where mental suffering causes real damage to a person, and going to see a doctor is an appropriate response. But the downside is that, in a culture very picky about physical looks, or in the grip of some other body-related derangement, a person’s perceptions of her own healthy body can cause her severely negative psychological impact too; and then what is the clinician supposed to focus upon first? Cass herself talks about the rise among teenage girls in “Body Dysmorphic Disorder”, an obsessive preoccupation “with body image and with compulsive revisiting or avoidance of thoughts to manage distress”.

At least in theory, the doctor then has a choice: changing the mind to be better able to cope with the body, or changing the patient’s healthy body to relieve the mind. Cosmetic surgery opts for the latter strategy. Though described as “not routinely provided”, the NHS will sometimes fund implants for uneven breasts, reduction for large ones, or ear-pinning, as long as these things are causing “significant distress”. This, then, is a case where psychological feelings are taken to justify an assault, quite literally, upon physically healthy flesh.

Transactivists tend to ramp up this strategy, often baselessly suggesting that early physical interventions to change children’s bodies will avoid devastating psychological consequences and perhaps even suicide later on. Inflated figures have been disseminated by mainstream sources for years about the prevalence of suicide attempts in trans-identified young people, and weaponised in order to motivate medical “affirmation”. Dr Christine Mimnagh, clinical lead at the Merseyside adult gender service CMAGIC and a member of an influential Clinical Reference Group at NHS England for gender dysphoria services, was recently caught on camera telling listeners at Dorset Healthcare University NHS Foundation Trust that if child services “worked as they should” we would induce “menopause” in some nine-year-old girls before menarche.

But a deeper reason for medical confusion about what counts as harm these days is widespread acknowledgement that judgements of harm are often or even always value-laden — that is, that they implicitly depend on background assumptions about what sort of life is worthwhile. People can put up with all sorts of physical discomfort, on their own behalf or that of their children, when the cause is placed in a moral or religious framework making it look better than the alternative. Some Christian Scientists will avoid all medical treatment for sick children, failing to shield them from great pain in the process; some Roman Catholics will put their mortally ill children through invasive medical procedures to keep them alive a bit longer. More mundanely, many parents vaccinate their children, circumcise baby boys, or pierce girls’ ears — not because they are sadists (of course), but because they believe that benefits outweigh somewhat painful costs.

Acknowledging that judgements about physical harm are not always straightforward, and often depend upon background values, can make the use of puberty blockers, cross-sex hormones and radical surgery disappear into an ethically confusing fog; and especially when the doctor herself has no strong intuitions about the prioritisation of bodily integrity over mental wellness to call upon. Certainly, there are other adults who swear that such physically damaging treatments — for what else can we call them? — have made their lives better overall in terms of other goals: mental health, or aesthetics, or self-expression.

But there are obvious differences when it comes to children and young adults — differences that apply well beyond the age of majority, to at least one’s mid-twenties. One is that so-called affirming procedures are far more physically debilitating, for longer, than things like ear-piercing, tattoos, or even most kinds of cosmetic surgery. Another is that each of them negatively affects what a recently published journal article has argued is a child’s “right to an open future”: roughly, important freedoms or capacities that can only be exercised as autonomous adults (such as biological parenthood or a fulfilling sex life), and whose value is unlikely to be recognised by an individual until later in life. When Cass writes that “the central aim” of treatment “is to help young people to thrive and achieve their life goals”, she does not of course mean the life goals they have now, but the ones they may well have afterwards.

The liberal ideal that each adult individual should be free to pursue her own conception of a good life, as long as it doesn’t impede others from doing the same, takes a bashing these days from both Right and Left. But one thing the ideal can do — at least when properly understood, and robustly applied — is protect our children from fanatics with mad glints in their eye, wishing to imprint their religious ideals, quite literally, upon children’s healthy developing bodies. In her report, Cass encourages a much wider range of people with relevant specialties to get involved with the care of trans-identified youth, moving forward; by which she presumably means, clinicians whose personal value systems won’t have such perilous physical consequences for their young charges. We can only hope that right-minded people answer her call.

Kathleen Stock is an UnHerd columnist and a co-director of The Lesbian Project.