Clinical standards and negligence in gender identity services
Dear Editor
The Clinical Advisory Network on Sex and Gender (CAN-SG) (1), a group of UK and Ireland based clinicians calling for greater understanding of the effects of sex and gender in healthcare, welcomes Dr Hilary Cass’s interim report and recommendations (2). Serious concerns about the Tavistock Gender Identity Development Service (GIDS) were raised by parents, staff and governors, an initial Judicial Review judgement (3), the Care Quality Commission (4) and an Employment Tribunal involving the Trust’s Lead for Child Protection (5).
The origin of poor governance and lack of data collection needs to be openly addressed as GIDS is not unique. Globally, there are significant difficulties in discussing, let alone challenging, the practice of gender clinics, due to the belief systems of those who adhere to gender identity theory – a non-clinical ideological perspective for which there is little to no empirical support. This position requires clinicians to believe that everyone has an innate, subjective gender identity and that individuals whose bodies do not match this should be provided with ‘gender-affirming’ medical interventions regardless of the harms and lack of evidence of benefit (6,7,8). However, a child or adolescent’s sense of gender is part of a complex inner sense of self that can change during the process of development. Medicalising young people on the basis of unsubstantiated theory is unethical: there are many reasons why they might feel dysphoria, disgust, dissociated or ‘cut off’ from their physical bodies, including internalised homophobia, histories of trauma, cognitive difficulties and mental health problems. Each person suffering from such distress requires space and time to understand their feelings.
Offering puberty blockers, cross-sex hormones and radical surgery with the implicit promise of almost magical transformation may cause, and has caused, serious harms. With inadequate follow up by GIDS, no comprehensive long-term observational studies, and no reliable clinical trial data, there is simply no evidence on which to base these interventions (2,6,7,8). It is unsurprising that ‘detransitioners’ (disillusioned people who wish to reverse the effects of ‘treatments’) are coming forward; some may want legal redress and plaintiffs’ firms are seeking them out (9). Without outcome information - let alone understanding how any pre-pubertal child could make a decision to alienate adult functions they cannot understand (like sexual pleasure) - patients and their parents were never in a position to give properly informed consent to uncontrolled experimental interventions (6) clinicians failed to properly describe. These initial cases may herald more as increasing numbers of patients, parents and clinicians question the so-called ‘affirmative model’.
We would advise that the NHS proactively set up clinical services to support detransitioners, and that the NHS Litigation Authority and Medical Defence Organisations prepare. The government should look closely at materials provided by advocacy groups (such as Stonewall, Mermaids, Gendered Intelligence, and others) that teach children and clinicians (e.g. GPs, nurses, medical students and mental health professionals) gender identity theory as if it is fact, without referencing the concerns and uncertainties in the evidence. Until this is addressed young people will be at increased risk of misinterpreting their complex difficulties as proof they are ‘trans’ and believing there are simple and medical solutions to their distress.
Dr Louise Irvine, General Practitioner; Dr Juliet Singer, Child and Adolescent Psychiatrist; Dr Aileen O'Brien, Consultant Psychiatrist; Dr Seth Bhunnoo, Consultant Psychiatrist; Dr Tessa Katz, General Practitioner; Dr Jane Martin, retired Consultant Psychiatrist; Stella O’Malley, Psychotherapist; Dr David Bell, retired Consultant Psychiatrist, former President British Psychoanalytic Society; Dr Bob Withers, Jungian Analyst; Dr Antony Latham, General Practitioner, Chair of Scottish Council on Human Bioethics; Dr Angela Dixon, General Practitioner; Dr Sinead Helyar, Registered Nurse; Dr Robin Ion, Registered Nurse; Dr Az Hakeem, Consultant Psychiatrist.
Competing interests:
Dr Louise Irvine, Co-chair of CAN-SG, and Stella O’Malley, CEO of Genspect.
30 August 2022
Louise Irvine
General Practitioner
Dr Juliet Singer, Child and Adolescent Psychiatrist; Dr Aileen O'Brien, Consultant Psychiatrist; Dr Seth Bhunnoo, Consultant Psychiatrist; Dr Tessa Katz, General Practitioner; Dr Jane Martin, retired Consultant Psychiatrist; Stella O’Malley, Psychotherapist; Dr David Bell, retired Consultant Psychiatrist, former President British Psychoanalytic Society; Dr Bob Withers, Jungian Analyst; Dr Antony Latham, General Practitioner, Chair of Scottish Council on Human Bioethics; Dr Angela Dixon, General Practitioner; Dr Sinead Helyar, Registered Nurse; Dr Robin Ion, Registered Nurse
Co-chair Clinical Advisory Network on Sex and Gender (www.can-sg.org)
Rapid Response:
Clinical standards and negligence in gender identity services
Dear Editor
The Clinical Advisory Network on Sex and Gender (CAN-SG) (1), a group of UK and Ireland based clinicians calling for greater understanding of the effects of sex and gender in healthcare, welcomes Dr Hilary Cass’s interim report and recommendations (2). Serious concerns about the Tavistock Gender Identity Development Service (GIDS) were raised by parents, staff and governors, an initial Judicial Review judgement (3), the Care Quality Commission (4) and an Employment Tribunal involving the Trust’s Lead for Child Protection (5).
The origin of poor governance and lack of data collection needs to be openly addressed as GIDS is not unique. Globally, there are significant difficulties in discussing, let alone challenging, the practice of gender clinics, due to the belief systems of those who adhere to gender identity theory – a non-clinical ideological perspective for which there is little to no empirical support. This position requires clinicians to believe that everyone has an innate, subjective gender identity and that individuals whose bodies do not match this should be provided with ‘gender-affirming’ medical interventions regardless of the harms and lack of evidence of benefit (6,7,8). However, a child or adolescent’s sense of gender is part of a complex inner sense of self that can change during the process of development. Medicalising young people on the basis of unsubstantiated theory is unethical: there are many reasons why they might feel dysphoria, disgust, dissociated or ‘cut off’ from their physical bodies, including internalised homophobia, histories of trauma, cognitive difficulties and mental health problems. Each person suffering from such distress requires space and time to understand their feelings.
Offering puberty blockers, cross-sex hormones and radical surgery with the implicit promise of almost magical transformation may cause, and has caused, serious harms. With inadequate follow up by GIDS, no comprehensive long-term observational studies, and no reliable clinical trial data, there is simply no evidence on which to base these interventions (2,6,7,8). It is unsurprising that ‘detransitioners’ (disillusioned people who wish to reverse the effects of ‘treatments’) are coming forward; some may want legal redress and plaintiffs’ firms are seeking them out (9). Without outcome information - let alone understanding how any pre-pubertal child could make a decision to alienate adult functions they cannot understand (like sexual pleasure) - patients and their parents were never in a position to give properly informed consent to uncontrolled experimental interventions (6) clinicians failed to properly describe. These initial cases may herald more as increasing numbers of patients, parents and clinicians question the so-called ‘affirmative model’.
We would advise that the NHS proactively set up clinical services to support detransitioners, and that the NHS Litigation Authority and Medical Defence Organisations prepare. The government should look closely at materials provided by advocacy groups (such as Stonewall, Mermaids, Gendered Intelligence, and others) that teach children and clinicians (e.g. GPs, nurses, medical students and mental health professionals) gender identity theory as if it is fact, without referencing the concerns and uncertainties in the evidence. Until this is addressed young people will be at increased risk of misinterpreting their complex difficulties as proof they are ‘trans’ and believing there are simple and medical solutions to their distress.
Dr Louise Irvine, General Practitioner; Dr Juliet Singer, Child and Adolescent Psychiatrist; Dr Aileen O'Brien, Consultant Psychiatrist; Dr Seth Bhunnoo, Consultant Psychiatrist; Dr Tessa Katz, General Practitioner; Dr Jane Martin, retired Consultant Psychiatrist; Stella O’Malley, Psychotherapist; Dr David Bell, retired Consultant Psychiatrist, former President British Psychoanalytic Society; Dr Bob Withers, Jungian Analyst; Dr Antony Latham, General Practitioner, Chair of Scottish Council on Human Bioethics; Dr Angela Dixon, General Practitioner; Dr Sinead Helyar, Registered Nurse; Dr Robin Ion, Registered Nurse; Dr Az Hakeem, Consultant Psychiatrist.
On behalf of CAN-SG
References
1) Clinical Advisory Network on Sex and Gender (CAN-SG) www.can-sg.org (accessed 28 August 2022)
2) The Cass Review. Independent Review of Gender Identity Services for Children and Young People: Interim Report. February 2022 https://cass.independent-review.uk/publications/interim-report/ (accessed 28 August 2022)
3) Bell & Another v The Tavistock And Portman NHS Foundation Trust [2020] EWHC 3274 (Admin) 1 December 2020 https://www.bailii.org/ew/cases/EWHC/Admin/2020/3274.html (accessed 28 August 2022)
4) Care Quality Commission. Tavistock and Portman NHS Foundation Trust Gender identity services Inspection report. 20 January 2021 https://api.cqc.org.uk/public/v1/reports/7ecf93b7-2b14-45ea-a317-53b6f48... (accessed 28 August 2022)
5) Employment Tribunal Decisions. Mrs S Appleby v The Tavistock and Portman NHS Foundation Trust: 2204772/201917 September 2020 https://www.gov.uk/employment-tribunal-decisions/mrs-s-appleby-v-the-tav... (accessed 28 August 2022)
6) Henegan C. Jefferson T. Gender-affirming hormone in children and adolescents. BMJ EBM Spotlight 2019 https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormon...
7) NICE Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria. October 2020 https://segm.org/sites/default/files/20210323_Evidence%2Breview_Gender-a... (accessed 28 August 2022)
8) NICE Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. October 2020 https://segm.org/sites/default/files/20210323_Evidence%2Breview_Gender-a... (accessed 28 August 2022)
9) Dyer C. Tavistock to face possible clinical negligence claims over gender identity service. BMJ 2022; 378:o2016 (12 August 2022)
Competing interests: Dr Louise Irvine, Co-chair of CAN-SG, and Stella O’Malley, CEO of Genspect.