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.

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Sex Matters commissioned a representative survey from an independent polling company to find out what people think of the main policy pledges on sex and the law: 

• There is widespread support for clarifying the Equality Act. Overall, 57% of the population support the proposal to clarify that “male” and “female” in the Equality Act mean biological sex, with just 10% opposing. 

• There is very little support for making it easier for people to change their sex on their birth certificate. 53% of the population oppose and just 20% support.

• Non-binary recognition is more popular, though still with more opposition than support. 44% oppose and 29% support. 

Attitudes to sex and gender policies, June 2024

The poll found that 48% of those who voted Labour in the 2019 election support amending the Equality Act to protect single-sex services, while just 19% oppose it. 

Attitudes to clarifying the Equality Act, by previous voting

More Labour voters reject than support Labour’s manifesto proposal to amend the law to make it easier for people to change the sex on their birth certificates, with 40% opposing and 35% in support.

Attitudes to making it easier to change birth certificates, by previous voting

The results also revealed that Gen Z (age 18–24) are more supportive of sex-based policies than Millennials (age 25–44), suggesting that support for gender-identity ideology among young people has passed its peak.

Attitudes to clarifying the Equality Act by age group

Attitudes to making it easier to change birth certificates, by age group

Both women and men are more supportive of the proposal to clarify the Equality Act than to make it easier to change sex on birth certificates, but men are more supportive of protection for sex-based rights than women overall. 

These findings concur with the results from the National Centre for Social Research, which found that levels of support for allowing people to change the sex on their birth certificates had fallen from 58% in 2016 to just 24% in 2023. 

Support for people being able to change the sex on their birth certificates

At the same time as public support has plummeted, the rate at which gender-recognition certificates are given out has soared.

Number of gender-recognition certificates issued

Whichever party forms the next government needs to understand that the public strongly supports protections for sex-based rights, and is increasingly concerned about the legal falsification of records about people’s sex.

The survey commissioned by Sex Matters was undertaken by PeoplePolling on 26th June 2024 with a sample size of 2,146 people.  For more information on methodology, see the introduction to the poll results or contact info@peoplepolling.org. People Polling is a member of the British Polling Council. All the data is available to download from https://sex-matters.org/wp-content/uploads/2024/06/PeoplePolling-poll_29_20240627.xlsx.pdf

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The critical question that the Department for Education appears to be stumped by is whether they should tell schools that they must consider “socially transitioning” some children, in other words calling some boys “girls”, and some girls “boys”.

It is a question that is often presented in innocuous-sounding terms as “Let a child chose their own pronouns”. But this refers to words that other people use. Pronouns are words that stand in for nouns. The pronoun “he” substitutes for the noun “boy”, and the term “male child” and the pronoun “she” substitutes for “girl” and “female child”.

A child (and their parents) who believes it is their right to be called “he” will not take kindly to being referred to as a girl and female. And children who have been told that they should call a child “he” or “she” will rightly take from this that they are expected to believe they are a boy or girl respectively.

As the National Curriculum states:

“The grammar of our first language is learnt naturally and implicitly through interactions with other speakers and from reading.”

Schools form part of a system that is regulated at a national level. In England that system is the responsibility of the Secretary of State for Education.

The Department for Education’s guidance must ensure that schools do not respond to demands by children and parents who want to be referred to as the opposite sex by losing sight of reality and acting unlawfully: failing in their statutory duty to keep and use information on a child’s sex, and to communicate and enforce sex-based rules fairly and clearly. Nor should it allow schools to adopt policies which unlawfully constrain the freedom of belief and speech of others.

“Gender reassignment”

We think that the DfE may have got tangled up in a common misperception about the protected characteristic of “gender reassignment” – that it reflects an obligation on others to pretend a person has changed sex. We have published a new set of Frequently Asked Questions.

The FAQs set out who the protected characteristic of gender reassignment applies to (anyone at any stage of proposing or going through with any part of what they identify as a personal process of transition), and what it means (they shouldn’t be discriminated against, harassed or victimised).

As the legislation and case law show, the protected characteristic is wide:

• Does a person have to be under medical supervision to have the characteristic? No.
• Must they have a gender-recognition certificate or be in the process of applying for one? No.
• Does a person have to have made a firm decision to transition? No.
• Can children have the protected characteristic? Yes.

But its effects are narrow:

• Does having the protected characteristic of gender reassignment mean that a person must be treated as the opposite sex? No.
• Does the Equality Act outlaw “misgendering”? No.
• Is it harassment to “out” a person as transgender? Not necessarily.
• Can employers have policies which require people to refer to transgender people in particular situations in a particular way? Yes, but those policies must be proportionate.

The Department for Education will also be thinking about “proportionality”, which is the principle in human-rights law that the state may only restrict non-absolute rights such as the right to private and family life (Article 8), or the right to manifest a belief (Article 9), if the restriction is (1) allowed by law (2) justified and (3) proportionate. “Proportionality” is often interpreted as meaning that blanket rules can not be set or enforced. But it is a red herring here.

Schools are already required by law to record each child’s sex in their records and consider each child’s sex in safeguarding. This is a blanket rule. It follows from this that they should not misrepresent that information or compel others to misrepresent it, and it is not possible to keep it private within a school community. Not lying about a pupil’s sex or forcing others to lie about it is not an incursion into that child’s privacy which needs to be justified.

Would it be lawful for a school to have a policy that forbids, punishes or denigrates pupils who use clear words about the sex of other people (such as pronouns, but also boy/girl, male/female and so on) or that require pupils to refer to some classmates as if they were the opposite sex?

We think it would not, for four reasons:

• To do so constrains the freedom of speech of pupils in a way that is unjustified and discriminates against them on the basis of belief. 
• It is inconsistent with schools’ safeguarding duty of care, and with their record-keeping responsibilities, for staff to misrepresent the sex of pupils in their records or in introducing them to their peers. 
• In order to explain and enforce sex-based rules designed to keep children safe (such as who is allowed in which showers, toilets, dormitories or sports teams), schools must be able to use clear and unequivocal language. 
• It is not reasonable to expect that a child at school (or transferring between schools), can avoid having their sex known and and clearly acknowledged.

The Department for Education must not pass the buck down to individual schools to consider on a “case-by-case” basis whether to give into pressure to lie about a child’s sex, or to force other children and teachers to lie or dissemble. It should simply tell them that they cannot do it.

And if there needs to be a judicial review to defend this then it should be at the level of the DfE and the whole system.

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