BMA’s stance on puberty blockers defies the most important principle of medicine: first, do no harm | Sonia Sodha

We trust physicians with our health. Patients have the right to expect those physicians to make decisions based on evidence-based clinical guidelines, not fashionable fads, grounded in the principle of “first, do no harm.” That has perhaps never been more important than when it comes to life-changing medical interventions for children.

It is therefore difficult to understand a decision by the governing council of the doctors’ union, the British Medical Association, to to adopt a motion criticism of a groundbreaking study into healthcare for children with gender issues, led by leading paediatrician Hilary Cass.

It’s a highly controversial area of ​​medicine, which is why NHS England commissioned an independent investigation in 2020. Cass published a damning final report in April, finding that the NHS specialist children’s gender clinic – now closed – was prescribing puberty-blocking drugs and/or cross-sex hormones to an unknown but significant number of children with gender issues, undeterred by the lack of evidence of the benefits and the potentially very serious risks to their long-term health.

This is despite the fact that studies suggest that gender dysphoria resolves itself naturally in many children; is often associated with other underlying factors, including young people coming to terms with their own same-sex attractions, neurodiversity, childhood trauma, puberty anxiety (particularly in girls), and mental health concerns; and that a diagnosis of gender dysphoria in childhood is not predictive of enduring trans identity in adulthood. In other words, there is a real risk that placing children on a medical pathway could cement a temporary distress into something permanent.

The review recommended a complete rethink of NHS services for children with gender issues: a holistic, therapeutic approach, with puberty blockers only prescribed to new patients as part of an NHS research study. These recommendations have been followed by the NHS.

There is no doubt about it: the Cass review has brought the curtain down on the total failure of gender questioning children by the medical profession. You would think that would give pause for thought. Not at the BMA: it has just announced that its board of 69 medical professionals has passed a motion accusing the Cass review of making “unfounded recommendations” and calling on the BMA to “To publicly criticize“the review and to “lobby… to oppose the implementation of its recommendations”, including stopping the use of unproven drugs in children outside of a trial. The BMA has also, ridiculously, called on the government not to implement the Cass review while it carries out its own review. It would be one thing if the BMA had serious criticisms of the review. It doesn’t. When I asked, it couldn’t tell me which of the Cass recommendations the board considered unfounded, and said it would not pre-empt its own review. The press release points to two papers that were not peer-reviewed or published in a reputable scientific journal – and thus required to declare conflicts of interest – as evidence of sufficient concern about the review’s methodology to pause its implementation.

The Yale Law School paper cited by the BMA was written by a mix of legal and medical academics, the majority of whom are members of the World Professional Association for Transgender Health. WPATH is an American organisation whose clinical guidelines for gender questioning children were directly criticised by the Cass review for lack of developmental rigour and failure to reference its own systematic review of the evidence. Evidence has since emerged to suggest that WPATH has in fact attempted suppress systematic reviews that it commissioned Johns Hopkins University because the results undermined the preferred approach, and that it was pressured by the Biden administration to remove the minimum age for treatment from the 2022 standards of care. The Cass review also found a study by at least one of the paper’s authors to be of low quality.

The second paper that the BMA cites is a preprint that takes an ideological position that evaluating these medical interventions in relation to mental health outcomes is a misguided undertaking because it “runs counter to the depathologisation of transgenderness”. One of the authors is the lead signatory to a public letter who spreads misinformation about the methodology of the Cass study, which has since been extensively scrutinized debunked.

How on earth has the BMA found itself in a position where its doctors are calling on the NHS to reintroduce the prescribing of drugs to children without evidence, thereby Academy of Royal Medical Colleges and the Association of Clinical Psychologists to make statements in support of the evaluation? I have spoken to several members who are downright furious about the lack of consultation outside the council, which was elected on a turnout of only 7% of the 160,000 members of the BMAand the way this appears to have been arranged behind closed doors, despite the advisory committee adopting a motion last year calling on the BMA to facilitate discussion about the Cass review. A council member has openly stated that she believes that the BMA’s position out of step with its members.

It is not the first time that the BMA has embarrassed itself by intervening in crucial health policy issues that it does not fully understand. In 2021, it did the same with the Covid vaccines.

It appears that the BMA leadership has been sucked into a polarised debate, characterised by a disinformation campaign from activists and academics unhappy with what the Cass review found. That campaign included a failed judicial review of the government’s decision to ban the private prescribing of puberty blockers for gender dysphoria (the High Court ruled last week that the Cass review amounted to “strong scientific evidence in support of restrictions on the supply of puberty blockers”), and false claims about young people and suicide that the government’s adviser on suicide prevention described last month as “painful and dangerous“.

Yes, the BMA is run by doctors. But it was clinicians who were behind this scandal in the first place. The BMA’s intervention serves as a reminder of how easily some doctors can be blinded by misinformation about the reason, rationality and evidence that are crucial to the best interests of patients.

It shows that the publication of the Cass review is not enough. The many doctors who cling to the “first do no harm” must ensure that their colleagues return to the evidence regarding this group of vulnerable children who deserve so much better from the medical profession.