Dr Cass puts a spotlight on the scandal of a “magical” medical service
A damning letter from Dr Hilary Cass about adult gender clinics was sent to NHS England in May and published on 7th August (together with a reply from NHSE). The letter draws into question the basis of “gender medicine”.
Although Dr Cass’s mandate was to review services for children, she found herself approached by concerned clinicians who treat adults, both in specialist gender clinics and as GPs. They described a medical and administrative system in disarray, causing the mistreatment of a growing cohort of patients with complex mental-health histories including trauma, abuse, self-harm, criminality, mental illness and learning difficulties.
Services, they said, are ideologically driven and clinicians are put under pressure to prescribe quickly , ignoring these distinctions. Often individuals are first seen by a non-medical practitioner and then on their second visit expect a prescription for cross-sex hormones.
“Clinicians described a philosophy that it was up to patients to make their own mistakes.”
Patients receive only limited explanation of risks such as vaginal atrophy and osteoporosis, and their wider mental-health issues are not addressed. Doctors face complaints if they don’t act as ready dispensers of testosterone and oestrogen. Training is inadequate and asking questions is discouraged.
Dr Cass heard of a psychiatrist providing boilerplate letters to support surgery which did not reliably reflect the individual patients under consideration.
There is weak follow-up, and no system for tracking and learning lessons from adverse outcomes, even for suicide.
This is a medical scandal
What Dr Cass describes is nothing like the professional evidence-based care that is recognisable as the practice of medicine.
While the child gender clinic at the Tavistock sought to make “time to think” and made some effort to engage in exploration of the reasons for a child’s dysphoria, Dr Cass description of the treatment given to those over 18 seeking to make life-changing decisions implies that those services are simply pharmaceutical mills.
The NHS has appointed Dr David Levy, Medical Director of Lancashire and South Cumbria Integrated Care Board, to conduct a review. But he has been given a short timeframe, and NHS England’s response to Dr Cass does not suggest that it recognises the depth of the problem she is describing, referring blandly to “broader concerns and issues with adult services”.
Dr Levy will be supported by “a panel of expert clinicians, patients and other key stakeholders, including representatives from the CQC, Royal Colleges and professional bodies”. But these bodies have not been doing their job. The Care Quality Commission and the General Medical Council should both have raised the alarm about the fact that patients are receiving scandalously substandard care. Instead, concerned clinicians saw no other way to raise concerns than to buttonhole Dr Cass when she was conducting her review of child services.
NHS England says “we appreciate the courage it took” for clinicians to speak to Dr Cass. But it is appointing the bodies that have enabled the medical scandal, and the culture of fear around it, onto the panel that will investigate it. Both the CQC and the GMC have been Stonewall Diversity Champions, adopting an internal culture that makes gender ideology the enforced norm.
At the same time as all this the government is committed to bringing in a “ban on conversion therapy” which would make it even harder for doctors to say no to patients seeking pills and surgery.
Magical thinking across the medical system
Dr Cass says clinicians described patients as being in the grip of “magical thinking”:
“Several described ‘magical thinking’ (i.e. unrealistic beliefs about what could be achieved through medical transition) which was not corrected or challenged. Sometimes this seemed to be related to watching social media videos, and not having the cognitive ability to appreciate the limitations of hormones and surgery.”
Magical thinking is when a person believes that specific words, thoughts, emotions, or rituals can influence the external world. It is associated with obsessive and compulsive disorder (OCD) and anxiety. A related concept is the “overvalued idea” – an unreasonable and sustained belief, as seen in disorders such as anorexia and body dysmorphia.
But the very idea that a person can change from male to female or vice versa, by changing their name, clothing or hairstyle, taking hormones, having cosmetic surgery or genital remodelling, or getting a government certificate, is in itself a form of magical or unreasonable thinking, which doctors, legislators and the full apparatus of the state have engaged in.
Dr Cass says that no patient is able to give informed consent for the physical treatments they receive if they do not understand the impacts on their body. But she does not fully engage with the question of whether patients are able to give informed consent if they have the unrealistic belief that other people will see them as the opposite sex, or can be forced to pretend that they do.
As with the question of “social transition” in school, doctors do not consider other people’s human rights when encouraging their patients to use opposite-sex facilities, to compete in opposite-sex sports or to take offence if other people “misgender” them (by referring to their sex).
Is it ethical to castrate a man who believes that other people see him (or must see him) as a woman? When doctors step into the patient’s fictional world, they are unable to present the facts needed for informed consent.
David Levy needs to consider the big picture
The problem, of course, is no longer just one of medical judgement. The magical thinking has been put into law.
In 2002 the European Court of Human Rights found that the UK was in breach of a post-operative transsexual’s human rights by not allowing changes to the sex recorded on their birth certificate. It came to this view on the basis that the UK Parliament’s interdepartmental working group on transexual people had undertaken “a careful and comprehensive review of the medical condition” and that “no concrete or substantial hardship or detriment to the public interest has indeed been demonstrated” from allowing legal sex change.
So since 2004 doctors have been involved in testifying that patients have the medical condition of gender dysphoria in order for them to get a legal certificate that changes their sex for some legal purposes.
Dr Levy’s review is being asked to consider the effectiveness, safety, and patient experience that these doctors provide, and whether the existing service model is still appropriate for the patients. His findings may not agree with the uncritical findings of the interdepartmental working group.
Dr Levy is likely to face the same pressures, threats and abuse as Dr Cass if he challenges the magical thinking of gender medicine in his review, or engages with gender sceptics. But he must take into account other people’s human rights under Articles 9 and 10 (freedom of belief and freedom of expression), as well as Article 8 (private life).
“Trans women” are not women, and “trans men” are not men – either biologically or in the eyes of many people, who have a right to their own perceptions and to be protected from discrimination, not forced into compelled speech or humiliating or degrading situations.
The CQC, the GMC, the clinics and hospitals all give lip service to the idea of equality and human rights, solemnly repeating (sometimes incorrectly) the protected characteristics in the Equality Act. But none show any sign of joining the dots. A patient who wants to force, trick, coerce or cajole other people to treat them as the opposite sex is on a collision course with reality – and with other people’s rights. If the medical professionals who are being asked to support procedures to make irreversible changes to their body forget this, then they are at risk of subjecting that patient to “inhuman or degrading treatment” (in breach of Article 3).
The ultimate question that Dr Levy will have to answer is whether it is ethical for the state to give, or to regulate professionals to give, “medical treatments” that can sterilise patients, impair sexual function and cause other negative health impacts, on the basis of their mistaken belief that other people will accept them as the opposite sex.