Undemocratic and secretive: BMA no longer speaks for doctors trying to protect children | Jacky Davis

TThe British Medical Association is both a trade union and a professional organisation. Professional activities such as successful campaigns around seat belt legislation and smoking have added weight to the union’s position. The association is not known for drama and theatrics.

There was therefore great surprise when the governing body, the BMA Council, recently voted to adopt the recommendations of the Cass Reviewan independent inquiry into NHS gender identity services in England, which was fully accepted by the previous government and its successor.

BMA members were genuinely outraged. Letters to the BMJ accused the council of “bringing the BMA and the medical profession into disrepute”. One correspondent said they were “more shocked than I can remember in 40 years of medicine”. Some members, appalled by the fact that the BMA was pursuing such irrational policies, resigned after decades of union membership. A letter accusing the BMA of being secretive, opaque and at odds with the principles of evidence-based medicine and ethical practice quickly attracted 1,500 signatures, 1,000 of them BMA members. signatories include many well-known names in the field, people who would not normally be inclined to sign protest letters.

Opposition to the review is hard to understand because Dr Hilary Cass, who chaired the review, is clear that she wants to improve the evidence base for treating patients with gender dysphoria, which she found to be seriously lacking. She and her team spent four years looking at evidence from around the world and speaking to over 1,000 people, including children and their families, clinicians and people with lived experience. Her conclusions, supported by seven peer-reviewed systematic reviewswere met with relief by doctors and their professional bodies, who felt that children and adolescents were being subjected to potentially life-changing treatments for too long without sufficient evidence to support them.

How did the BMA become so completely out of touch with its members? In short, the union is a victim of entryism, a political strategy in which members of one organisation join a larger organisation in order to influence and change policy. Doctors in training (formerly junior doctors) were angry about the sharp drop in their salaries since 2008 and formed a group they called DoctorsVoices to campaign for full payment. Part of the group’s strategy was to get its members onto the BMA council, which they did with great success, taking almost half the voting seats in 2022.

So far, everything makes sense: the BMA is a trade union and its main task is to improve the working conditions of doctors.

But having a large and well-organised pressure group on the council has brought predictable problems. DoctorsVote is disciplined in pursuing its agenda (which has gone beyond full pay recovery and encompassed deeply held views on the transgender debate), and in voting group members onto BMA committees.

A toxic atmosphere developed in the council chamber and a climate of fear and intolerance of sincerely held beliefs made some people reluctant to express opinions that were not aligned with DoctorsVote, setting the stage for the Cass review debacle.

A motion to the council calling for the investigation to be dismissed was – after a leak to the press – amended to a motion calling for public criticism and calling on the BMA block the implementation of the evaluation recommendations.

The motion was passed, although the vote was not unanimous. Further leaked figures show that more council members abstained or voted against the crucial part of the motion than voted forThe leaks – of material that should never have been secret in the first place – led to an unpleasant witch-hunt against the leakers, when the BMA would have been far better off asking itself where it had gone wrong in the whole process. The subsequent rift between the council and its members was inevitable, and was exacerbated by a leadership in denial, more concerned with whistleblowing than facilitating open debate.

Why did the BMA, which is not a scientific body like Nicethe feeling that it could criticise and undermine the work of Cass? The BMA has put itself in a position where a vocal minority of councillors with an anti-Cass agenda have created a policy that members have not been consulted about and do not agree with. Although sincere in their beliefs, these councillors have no hard evidence to support their opposition, and good intentions are not enough to guide medical practice. They need to be supported by evidence.

The BMA now finds itself isolated in its opposition to Cass, and with its reputation and integrity damaged. The prognosis for the union is not terminal, but it must acknowledge the mess it is in and then pull back from the brink of what one critic called “its descent into madness”.

It should start with the realisation that it is unacceptable for a membership organisation to shroud its debates on important issues in secrecy and cover-ups. Members who elect their representatives on the council have a right to know who supported the motion and who voted for it. The abuse that unfortunately accompanies every debate on trans issues is no excuse for a lack of transparency. If you are not prepared to be accountable to the members who elect you, then you should not be running for public office.

The BMA must embrace democracy and consult its members, as it has done in the past on sensitive and contentious issues such as euthanasia. If it does not, you would be forced to conclude that it fears the views of its wider membership. The BMA has set up a ‘task and finish’ group to review the Cass review; the review will continue, but in the meantime the union should be neutral on the review and commit to consulting its members when the results are available. Only then can it restore confidence in the profession and ultimately our patients.

A union that does not represent the interests of its members is a union in trouble. A union leadership that ignores the concerns of its members will ultimately pay the price. And if the BMA acts in a way that damages its own reputation, then the reputation of all British doctors is under threat. That is why the medical profession is in an uproar over what has happened.