Thanks to Cass, evidence, not ideology, will be used to guide children seeking gender advice | Sonia Sodha

‘Ffirst, do no harm” is the sacred principle that should underlie modern medicine. But history is littered with examples of physicians violating this doctrine. Last week the publication of Hilary Cass’s final report on health care for gender-questioning children has exposed the devastating scale of NHS failure for a vulnerable group of children and young people, supported by adult activists who bully anyone who dares to challenge a treatment model so clearly based on ideology in rather than on evidence.

Cass is a renowned pediatrician and her painstakingly thorough assessment was four years in the making. She explains how the now closed NHS specialist gender clinic for children left evidence-based medicine for a wing and a prayer. Significant numbers of children who asked gender questions – it’s impossible to know exactly how many because the clinic kept no records, which is a scandal in itself – were placed on an unproven medical pathway of puberty-blocking drugs and/or sex hormones, despite the risks of damage related to brain development, fertility, bone density, mental health and sexual functioning in adults.

What caused this? The medical trajectory is rooted in the belief that many, perhaps even most, children who question their gender will have a fixed trans identity in adulthood, and that it is possible to distinguish them from those for whom this is a temporary phase . But studies suggest that gender dysphoria goes away on its own in many children. It is often associated with neurodiversity, mental health issues, childhood trauma, discomfort about puberty, especially in girls, and children processing their emerging same-sex attraction; a large number of children referred to the Gender Identity Development Service (Guide) were homosexual. Placing these children on a medical pathway not only poses health risks, it can also pathologize temporary problems into something permanent. Cass is also clear that socially transitioning a child – treating them as if they were the opposite sex – is a psychological intervention with potentially lasting consequences and an insufficient evidence base, that a covert transition can be harmful, and says that for pre-pubescent children this decision should be made based on input from physicians with appropriate training.

There is a mystery at the heart of the report. Cass believes that a childhood diagnosis of gender dysphoria is not predictive of a lasting trans identity and doctors told the review that they cannot determine which children will have gender dysphoria into adulthood. If this is indeed impossible, is it ever ethical to put a young person on a life-changing medical path? If there are no objective diagnostic criteria, on what basis would a doctor make this decision other than professional suspicion?

The report recommends a complete overhaul of the NHS approach to caring for children and young people with gender questions: holistic, multidisciplinary services, grounded in mental health, that identify the root causes of those questions and take a therapeutic approach. Puberty blockers will only be prescribed as part of an NHS trial and she recommends “extreme caution” regarding cross-sex hormones for 16 to 18 year olds; one would expect this to depend on the ability to develop diagnostic criteria for gender dysphoria that will persist into adulthood.

Cass’s vision is what gender-questioning children deserve: to be treated with the same level of care as anyone else, and not as little projects for activists looking for affirmation of their own adult identity and belief system. But achieving this will be a huge challenge for the NHS, and not just because of the precarious underfunding of children’s mental health services. There will be resistance among imprisoned physicians committed to quasi-religious beliefs; It is astonishing that six out of seven adult clinics refused to take part in the evaluation of a study to shed more light on those the NHS treated as children. A senior NHS researcher at a trust told me that resistance to taking part in an uncontroversial methodology to achieve better outcomes came not from the board, but from some of the doctors in their employ, and this was unheard of in other parts of the NHS.

Cass has also commented on the intense toxicity of the debate. The fact that she believes medical professionals would fear being called transphobic, or accused of practicing conversion therapy, if they were to proceed more cautiously in a climate where activists and charities like Stonewall quick to make accusations of intolerance towards people raising concerns, and that NHS whistleblowers were vilified by their employers, has not only prolonged the avoidable harm that will have been caused to some young people, but will also make it difficult to recruit doctors to the new service. Cass has warned ministers of the risks of the criminal ban on conversion therapy that activists are pushing for; the definitional problems threaten to criminalize exploratory therapy and may further increase fear among physicians. The former CEO of Stonewall has already endorsed the view that the The Cass model is itself conversion therapy.

Given what it says about social transition, the implications of the Cass Review extend beyond the NHS to schools and children’s services, where similar sites of ideological slant exist. As we report today, the parents of one child whose school facilitated their social transition without their knowledge have given Brighton City Council two weeks to withdraw the trans toolkit it has approved for use in all its schools or face legal action in light of legal advice from the country’s leading equality and human rights lawyer, Karon Monaghan KC, that the toolkit itself is illegal and advises schools to act illegally.

She explains how the law is devastatingly flawed in several areas, including in protecting the welfare of children who are questioning gender and seeking to make social transitions. In the areas of single-sex spaces and sports, the report incorrectly recommends that the child’s chosen gender identity should transcend gender, which is likely to lead to unlawful discrimination against other students, especially girls. This influential toolkit is used by schools in at least some other local authorities; the parents have published the advice in full, so that other parents can address schools about its unlawfulness.

The Cass review is a huge achievement; it has taken the pressure off one of the most contentious areas of modern medicine and restored the role of evidence to its rightful place. But there is still a long way to go to unravel the influence of a contested and controversial – but in some cases deeply entrenched – adult ideology about gender in the way children are supported by the NHS, children’s services and schools.

Sonia Sodha is an Observer columnist

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