Critical Therapy Antidote

The dire state of UK NHS provision for gender questioning children first burst into wider public awareness via the legal review of the Tavistock in 2020. This was a judicial review brought by Keira Bell, a detransitioner, and others, against the Tavistock’s Gender Identity Development Service (GIDS). The review was wide-ranging, and revealed the crisis in the GIDS in ruthless, forensic detail. The Tavistock clinic was overwhelmed by sharply increasing numbers of young patients, coupled with systemic failures in clinical governance and audit, within a service apparently captured by a gender-affirming model of care, and lacking any robust evidence base (Barnes, 2023).

The GIDS was then deemed ‘inadequate’ by an inspection agency. An independent review was also commissioned by Dr Hilary Cass, a leading paediatrician. This was tasked with reviewing pathways of care into local and specialist gender identity services, the use of puberty blockers, relevant models of care, and on audit and research priorities, via extensive engagement with stakeholders and a thorough review of research. Hilary Cass’s final review report has received bipartisan support from both the outgoing Conservative and incoming Labour governments.

Changing political and cultural context

However, the political and cultural context for the review has become much more sharply polarised since the review’s original commissioning four years ago. Government proposals to implement a legal ban on conversion therapy have come and gone during this period. These proposals are now finally back on the table for the new, reforming Labour Government. Major employers of therapists and health professionals, such as NHS England, are fully signed up to an inter-professional policy, which implacably opposes conversion therapy, i.e. the Memorandum of Understanding on Conversion Therapy (MOU). Almost all professional therapy and medical associations also endorse the MOU. However, some (such as the British Association for Counselling and Psychotherapy) still resolutely ignore the Cass Review as somehow not relevant to their members’ immediate concerns.

In some respects, the Cass Review is already having a substantial impact on the provision of gender identity services for children and young people. The Tavistock GIDS is closed down, to be replaced by a series of regional hubs in London, Manchester, Bristol and elsewhere. Pervasive doubts about the weak evidence base for puberty blockers are to be resolved by a carefully designed and rigorous randomised controlled trial. In the meantime, patient access to these controversial puberty blockers, originally based on the so-called ‘Dutch protocol’, is already heavily restricted. The gender affirmative model, devoutly espoused by senior staff at the GIDS, is to be replaced by a more cautious, holistic and multi-professional model of care, based on revamped recruitment and training. 

Fallout from Cass: BMA and UKCP

The Cass reforms have, nevertheless, been bitterly opposed by activist organisations and their allies. The British Medical Association (BMA), a trade union, rather than a clinical body, initially strongly opposed the Cass Review. This stance was then challenged by a wide range of BMA members, leading to a standoff, whereby the BMA will now carry out its own mini-review. Quite how the BMA expects to either replicate, or completely overturn, the four-year Cass Review, within its own chosen time frame of a mere four months, will be one of the more interesting surprises of 2025 (CAN-SG, 2024).

One of the major psychotherapy associations, the United Kingdom Council on Psychotherapy (UKCP) has also seen the longer-term writing on the wall with Cass. This has been specifically in terms of its own need to distance itself from the MOU over the twin issues of child safeguarding and the crucial need to protect exploratory therapy. The UKCP left the MOU, one of the first major therapy organisations to do so, and still remains outside it for the present. An earlier, detailed critique of the MOU’s ambiguous stance on working with children was apparently ‘instrumental’ in informing the Board’s final decision on this issue (Jenkins, 2021).

Yale paper and battle lines over Cass

So the battle lines over Cass are gradually taking shape. One of the major points of reference in the attempt to overturn the Cass Review has been via an influential academic and activist critique from the US, mislabelled the ‘Yale Report’. This is a non-peer reviewed online paper, hosted by the Yale Law Centre, but not officially endorsed by Yale University as an institution (McNamara et al, 2024). This paper has been central to the BMA’s attempted rejection of the Cass Review, so perhaps needs some careful unpicking.

At first reading, the McNamara paper seems to present a balanced critique of the Cass Review, citing an impressive tranche of academic and research papers, which appear to contradict some of the key claims made by Cass. However, a closer scrutiny suggests some problems. The paper picks out some isolated examples where Cass has made occasional, positive reference to WPATH’s Standards of Care (“particularly high in the areas of ‘rigor of development’ and ‘editorial independence.’”) (Cass, 2024: 5), but fails to mention the negative reference to the standards’ weak “applicability” in the very same table of evidence (2024: 129). Also, the Yale paper seems to reveal strikingly different tones in its presentation, which is always a problem with multi-authored documents of this kind. On the one hand, the paper wearily takes the Cass Review to task for failing to understand and apply basic research methodology, the need to include a much wider range of relevant research findings, and to reach more humane and patient-friendly conclusions. Every so often, this academic mask drops and it launches into a tirade of emotive abuse against Cass, claiming it is: “blatantly incorrect” (20); “confidently citing pseudoscience” (23); “science or is it speculation?” (25); “misunderstanding at best, and intentional deception …at worst” (27); “rife with misapplications of the scientific method” (37), and (a personal favourite here) taking “an ideological position on care for transgender youth” (37).

Weakness of Yale critique of Cass

Defenders of Cass have pointed out that the Yale authors are appraising it by using the wrong yardstick. Hence, the Yale authors “misrepresent the Cass Review’s role and process (specifically, by mistakenly comparing the Review to clinical practice guideline development)” (Cheung et al, 2024: 1). Further, the Yale paper is itself “based on flawed and non peer-reviewed analyses intended for legal (rather than clinical) purpose” (2024: 1: emphasis added: PJ). Now, McNamara et al might be forgiven for not fully grasping the uniquely British nature and purpose of NHS independent reviews, such as Cass. However, the Cass Review really needs to be judged against whether or not it has met its own terms of reference (cited earlier), and not whether it has overlooked out this particular piece of research, or disappointed that particular patient lobby group.

There are two major weaknesses which further fatally undermine the case presented by McNamara et al. The first is the ideology of gender identity, which underpins its own reasoning at every significant point. Hence, the Yale paper claims that “It is a transgender identity that drives social transition and subsequent medical interventions” (2024: 21). Furthermore, “Gender identity has strong biological underpinnings” (24). So there we have it. The whole process of developing appropriate services for young people must be based on accepting the existence of a concept (‘gender identity’) which has no agreed or testable criteria, and no empirical status, other than self-declaration and unqualified acceptance by appropriate peers and allies.

WPATH versus Cass

The second weakness is also very deeply-seated. The Yale paper rehearses all the core WPATH claims, such as the need for wider patient autonomy (10), its calls for facilitated access to healthcare (195), the adverse role of minority stress (32), and the favoured canard of a detransition rate of less than 1% (22). So far, so WPATH. However, there is a much deeper chasm of misapprehension between the Yale/WPATH stance and Cass. This reflects their very different positions regarding the role of government regulation of healthcare. The Cass Review comes from a long-established political tradition within Western Europe, evident since the Bismarck reforms of the late nineteenth century in Germany, concerning the crucial need for government oversight and investment in public health. This political tradition is revealed in the recent pan-European move towards undertaking systematic reviews into the use of puberty blockers. This was first triggered by Sweden in 2019 (SBU, 2019), which pioneered the subsequent European-wide shift away from medicalisation and towards psychological interventions for gender questioning young people.

WPATH is, in contrast, deeply invested in a consumer-led model of patient care in the US, born of the Reagan era, which is supercharged by social media and the pharmaceutical industry, and which is instantly responsive to demographic and political pressures for change. This is evidenced by its enraged response to the Interim Cass Review’s earlier cautious approach to social transition: WPATH and its associated bodies decried “an unconscionable degree of medical and State intrusion into personal and family decision-making about simple everyday matters such as clothing, name, pronouns, and school arrangements” (WPATH, 2022. Emphasis added: PJ).

So, whatever the alleged failings of the Cass Review, the Yale paper could never accept its legitimacy, or even any of its findings, given that Cass does not openly endorse the crucial concept of gender identity. Cass is also totally committed to the key public health principles of government oversight and intervention into medical healthcare for whatever population may require this.

MOU joins the opposition to Cass

WPATH’s open hostility to Cass is, therefore, hardly a surprise to informed observers. More puzzling, however, has been the recent open letter about the Cass Review to Wes Streeting MP, Secretary of State for Health and Social Care, from a prominent activist lobby group (Transactual, 2024). Citing the BMA action and the Yale report, this rejects the commissioning process for Cass, its methodology, findings and policy recommendations, which really amounts to a total disavowal. The letter also laments the Review’s apparent lack of transparency. (This is somewhat ironic, in view of the fact that all of our Freedom of Information Act requests for details of MOU meetings with the Government Equalities Office have been consistently denied to date.) The other interesting point here is that the open letter is signed by the current chair of the MOU, Igi Moon, a longtime member of WPATH.

There are a number of problems which follow on from this intriguing development. The first problem here is that the MOU offers only very conditional support for exploratory therapy, as this is sometimes presented as opening the door to conversion therapy. Hilary Cass, however, has been very careful to emphasise the urgent need for exploratory therapy with young people, rather than rush to offer an affirmative approach.

Hence:

“The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve” (Cass, 2024: 150).

New policy logjam for a Labour government?

So a major policy logjam is slowly and inexorably building up here. The Labour Government is committed to implementing Cass. The Labour Government is also committed to implementing a legal ban on conversion therapy. A ban on conversion therapy will arguably impede the proper implementation of the Cass review, by constraining exploratory therapy.

NHS England is committed to implementing Cass. However, NHS England also supports the Memorandum of Understanding on Conversion Therapy (MOU). The chair of the MOU opposes Cass. So NHS England simultaneously supports both the implementation of Cass and the MOU, which now opposes Cass.

So maybe the time is right for NHS England to reconsider its unquestioning (and now heavily compromised) support for the Memorandum Of Understanding on Conversion Therapy?

References

Barnes, H. (2023) Time to think: The inside story of the collapse of the Tavistock Gender Service for children. Swift: London.

Cass, H. (2024) Independent review of gender identity services for children and young people. https://cass.independent-review.uk/home/publications/final-report/

Cheung, R. et al (2024) Gender medicine and the Cass Review: why medicine and the law make poor bedfellows. Archives of Disease in Childhood. 0: 1–5. doi:10.1136/archdischild-2024-327994

Clinical Advisory Network on Sex and Gender (CAN-SG) (2024) The Cass review and the BMA: The story of a U-turn. The Cass Review and the BMA: the story of a u-turn – Clinical Advisory Network on Sex and Gender

Jenkins, P. (2021) Through the looking glass: Making sense of the MOU Parts 1 and 2: Critical Therapy Antidote: https://criticaltherapyantidote.org/2022/03/25/through-the-looking-glass-making-sense-of-the-mou-part-1

Through the Looking Glass: Making sense of the MOU – Part 2 – Critical Therapy Antidote

McNamara, M. et al (2024) An Evidence-Based Critique of “The Cass Review” on Gender-affirming Care for Adolescent Gender Dysphoria. Yale Law Centre. https://law.yale.edu/sites/default/files/documents/integrity-project_cass-response.pdf

Statens Beredning för Medicinsk och Social Utvärdering (Swedish Agency for Health Technology Assessment and Assessment of Social Services) (SBU) (2019) Gender dysphoria in children and adolescents: An inventory of the literature. A systematic scoping review. https://www.sbu.se/en/publications/sbu-bereder/gender-dysphoria-in-children-and-adolescents-an-inventory-of-the-literature

Transactual (2024) Letter to Wes Streeting: https://transactual.org.uk/blog/2024/10/18/trans-community-letter-to-secretary-of-state-for-health-wes-streeting/

WPATH, ASIAPATH, EPATH, PATHA, and USPATH. (2022) Response to NHS England in the United Kingdom (UK): Statement regarding the Interim Service Specification for the Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) by NHS England.https://www.wpath.org/media/cms/Documents/ublic%20Policies/2022/25.11.22%20AUSPATH%20Statement%20reworked%20for%20WPATH%20Final%20ASIAPATH.EPATH.PATHA.USPATH.pdf?_t=1669428978

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By Peter Jenkins, counsellor, supervisor, trainer and researcher in the UK. He has been a member of both the BACP Professional Conduct Committee and the UKCP Ethics Committee. He has published a number of books on legal aspects of therapy, including Professional Practice in Counselling and Psychotherapy: Ethics and the Law (Sage, 2017).  https://us.sagepub.com/en-us/nam/author/peter-jenkins

Peter Jenkins is also a member of Thoughtful Therapists, whose scoping survey for the government consultation on conversion therapy can be found here: https://thoughtfultherapists.org/scoping-survey-pdf