David Pilgrim posts….
The final version of the Cass Review appeared yesterday (10th April 2024), containing few surprises for those pleased or displeased. We now enter a phase of observing how leaders in public, private and third sector organisations adapt and shape their interests in response. The hegemony of the Stonewall era, which installed trans-activism readily across British society, with its neoliberal confluence of consumerism and identity politics, is finally breaking down. The second version of the Memorandum of Understanding on Conversion Therapy (MOU) is no longer a virtue signalling box to tick, but a source of embarrassment. Recently the UKCP made this statement, with Cass in the offing:
“UKCP’s withdrawal from the MoU and the Coalition Against Conversion Therapy takes immediate effect. While we work to update our Code of Ethics and Professional Practice to reflect UKCP’s withdrawal, members are advised to discount the MoU as a published policy of UKCP (as referenced in point 36 of the Code) from today, 5 April 2024”.
It would be a massive step if the BPS were to follow suit. After all, that ideologically-captured second version of the MOU was driven by trans-activists inside the Society. For a while, it was even the official administrative home for the campaign for the Coalition. At no time during that period did the BPS incorporate or seek to represent dissenting voices. Those from Thoughtful Therapists and the Clinical Advisory Group on Sex and Gender, which included many psychologists, concurred with Cass that a whole generation of children had been exposed incautiously to iatrogenic damage.
An indication of the trans-captured position of the BPS was that The Psychologist had actively promoted an affirmative stance and it marginalized or blocked any alternative position. The latter could be packaged away as simply being ‘transphobic’ or ‘anti-trans’. The gender guidelines were also under the control of trans-activists (British Psychological Society, 2019). Its Chair, Dr Christina Richards, argued that there was to be ‘no debate’ because the debate was ‘over’ – evidence clearly supported affirmative care, end of story. Legitimate complaints to the BPS about the lack of evidence for this arrogant and unfounded dismissal from Richards failed. Affirmative care, with its conveyer belt of puberty blockers, cross-sex hormones and irreversible surgeries, was the way to a bright new future to liberate children who, quite evidently, had been born in the wrong body. Pre-Cass, all the BPS worthies smugly agreed. No debate, no philosophical arguments about sex and gender and certainly no need for evidence. But then Cass came along…..
Defy or comply?
Now the Cass Review has been published those defending affirmative care, from The Psychologist to the Sexualities Section of the BPS, as well of course the authors of the still unrevised trans-captured gender guideline, are in a tricky position. Defiance was the immediate answer from Dr Rob Agnew on twitter/X. The strident anti-anti-trans Chair of the BPS Sexualities Section dismissed Cass for being ‘cis and het’. How dare a (real) woman trained in paediatrics have a view about children?
Moving on from his misogyny, Agnew reverted to a semblance of standard academic reasoning, going on to tell us that her review of the evidence was simply wrong and that he and ‘other clinicians’ will soon prove that point. At the time of writing, the world waits with bated breath to see if the Cass Review will need to be removed as policy guidance in England and Wales. Dr Agnew and his colleagues intend to provide evidence that will correct the scholarly incompetence of Cass and her team; watch this space.
Agnew may represent the trans-captured old guard in the Society but new pragmatic leaders are now required in response to Cass. At this point step in Dr Roman Raczka, recently Chair of the Division of Clinical Psychology and now President-Elect of the BPS. This is his view from the upper echelons of the Society speaking, as those at the top do, using the royal plural (though it might also signal the hand of the ubiquitous ‘Comms Team’):
“We want to commend Dr Hilary Cass for her thorough and sensitive review into an area that is highly complex and controversial to many. All too often, the way this controversy has played out in public has been damaging to the very children, young people and families desperately seeking help. We wholeheartedly join Dr Cass’s call for an end to the deeply concerning, public bullying and vilification of professionals working in this challenging area. The prescribing of puberty blockers has received a great deal of focus both in wider discussions about gender, and within the report itself. We agree with Dr Cass that the controversy around this issue has sometimes taken focus away from the important role of psychological interventions in gender services to support young people and their families. We agree that it’s vital to create a sound evidence base and better understanding of the long-term effects of puberty blockers and the need for more data in this area to help young people make informed decisions about their treatment and to support the clinicians providing care and treatment. Dr Cass and her team have produced a thought-provoking, detailed and wide-ranging list of recommendations, which will have implications for all professionals working with gender-questioning children and young people. It will take time to carefully review and respond to the whole report, but I am sure that psychology, as a profession, will reflect and learn lessons from the review, its findings and recommendations. We warmly welcome the recommendation to establish a consortium of relevant professional bodies to identify gaps in professional training and develop training materials to upskill the workforce. As the body that accredits professional training courses for psychologists and the wider psychological workforce in the UK, the BPS looks forward to contributing to this important work as it develops. Recognising the importance of supporting professionals working with children and young people around gender issues, the BPS recently launched recruitment for a Children, Young People and Gender workstream to ensure that a strong evidence base is at the heart of these conversations.”
Any student of the sociology of professions will recognize some key elements in the Raczka statement, in relation to ‘interest work’ in healthcare policy (Williamson, 2008). First, there is pragmatism, i.e. those pushing for collective professional advancement must work with the world as it is, not as they would like it to be, in order to milk it for any opportunities available. Second, and following from this, they must ignore any past stance, which inconveniently might be out of step with the politically contingent present. On the first point, notice how Raczka at the end of his statement, with its rhetorical flourish, focuses on an expanded psychological workforce and makes the standard claim that clinical psychology is an evidence-based project, working in the public interest. On the second point it is what is not said that matters. Here the role of an omissive critique is important (Pilgrim, 2020).
Raczka fails to mention the following. The DCP in recent years has not condemned the extant gender guidelines that celebrate ‘affirmative care’ (cf. Harvey, 2023). The DCP in recent years has not objected to the MOU campaign against conversion therapy or it being housed officially inside the BPS or its misleading conflation of aversion therapy with adults from the past and exploratory psychological therapy with children today (cf. Pilgrim, 2023a). The DCP in recent years has not drawn attention to the serious iatrogenic consequences of puberty blockers, cross-sex hormones and irreversible surgeries. Letters of dissenting voice about GIDS and puberty blockers were certainly sent to the CEO and were predictably ignored. Thus, not all clinical psychologists were happy about inaction from officialdom but their protests to their professional leaders proved to be in vain. A contempt for ordinary members by BPS leaders has been pointed up repeatedly on this blog.
Despite Raczka’s focus on the benign public service of a new and expanded psychological workforce, he fails to mention an elephant in the room: the now discredited GIDS approach was psychology-led. Moreover, it promoted a form of biological reductionism akin to the very worst aspects of biological psychiatry in the past (Valenstein, 1986). Where did this bizarre radical bio-reductionism come from in psychology, in collusion with endocrinology? The answer more generally can be traced to Third Wave feminism and the policy chaos created by postmodernism and its legacy of identity politics. Specifically, this was expressed in the ‘Dutch model’, subsequently rolled out at the Tavistock Clinic on the basis of no evidence and under the leadership (both in the Netherlands and the UK) of clinical psychologists (de Vries and Cohen-Kettenis 2012).
Surely what is now required, before zealous opportunism kicks in, is a needed reckoning. British clinical psychology should now admit its role in promoting an approach to care that was scandalous and resembles others recently discussed with concern in the public domain (BMJ, 2020). For now Agnew denies that there was a scandal at all and that cis, het, transphobic critics should butt out and leave the matter of ‘gender healthcare’ to him and those agreeing with him. Raczka is seemingly friendlier to Cass, but he ignores the blatant need for a reckoning in the profession, which he recently has led and which has largely looked on passively, as the car crash at GIDS unfolded in slow-mo. Both Agnew and Raczka claim to take both values and evidence seriously, so I finish on this point.
Getting serious about values and evidence
Any look back from the DCP about what went wrong at GIDS should start with two questions. First, did psychologists operate with an ethical principle of ‘do no harm’ or non-maleficence? Second, did psychologists use evidence to guide their service philosophy?
The first one is easy to answer: the expectation at GIDS was that the prescription of puberty blockers and the routine trajectory of cross-sex hormones and surgeries was self-evidently ethically legitimate, even though the long term iatrogenic risks were unknown. This was despite evidence from other clinical groups that those risks were very likely (including sterility, sexual dysfunction, loss of bone density and cardio-vascular events). Thus, the ‘first do no harm’ position was definitely not adopted at GIDS: instead negligently it jeopardized the long term health of children, who were relying on the good judgment of their adult carers (Jorgensen et al, 2024; Pilgrim and Entwistle, 2020). Those adults failed them.
But, turning to the question of evidence of efficacy, the main problem was that the ideology of affirmation over-rode caution. Consequently, evidence collection was neither made transparent nor did it guide service planning. Ideology justified all decisions and the normal rules of professional probity were ignored. This ‘gung-ho’ attitude displaced a wiser ‘wait and see’ approach, both at the service philosophy level and that of individual patient care. The positive evidence that mental health gain was being achieved was simply missing. The Dutch model was a pilot service, with small numbers, not a model service with clearly proven success. The inclusion criteria (about psychological stability in research patients) for that pilot service bore no resemblance to the clinical features of those on the waiting list at GIDS. Moreover, the data on outcomes at the Tavistock, which showed no improvement overall, were suppressed for years and no explanation to date has been offered about that secrecy (Biggs, 2023). Turning as a relevant aside to adult services, there is no evidence that distress and dysfunction improve post-operatively in ‘gender reassignment’ (Dhejne, et al, 2011). Given that lacklustre picture, note how as soon as the Cass report emerged it also became evident that NHS Trusts had suppressed information about adult services. If ‘gender healthcare’ is such a welcomed and effective policy innovation, then why do those responsible for it want to hide their light under a bushel so often? Slowly policy makers are waking up to this point.
The most obvious manifestation of ideology displacing evidence has been in relation to ‘diagnostic overshadowing’. That is, the complex mental health needs of existentially confused young people, who include survivors of abuse, those with mixed anxiety and depression and those with marked autistic tendencies, have been ignored in favour of reducing the patient’s problem to that of being ‘born in the wrong body’. In any general child and adolescent mental health service the complexity of each case would be formulated case by case and iteratively. A sign of how things have changed in a decade is that such a cautious, formulation-focused, approach was offered by the Canadian clinical psychologist Ken Zucker (Zucker, et al 2012). For his wisdom, his service was closed down and he was sacked, which is the inverse scenario of the fate of GIDS, except there its leaders received substantial exit payments courtesy of the British taxpayer.
This is what Cass said on the point about optimal mental health care for children and adolescents:
“Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better…..We have to start from the understanding that this group of children and young people are just that; children and young people first and foremost, not individuals solely defined by their gender incongruence or gender-related distress.” (Cass Review briefing paper, 13-15).
Those like Agnew and other activists in the BPS will draw on the authority of WPATH (World Professional Association for Transgender Health), while holding the Cass Review in contempt. However, WPATH is not like the National Institute for Health and Care Excellence, which operates sceptical equipoise about evidence and takes iatrogenic risk seriously. Instead, its approach is shaped by the demands of trans-activist members, many of whom are neither researchers nor clinicians. Here is Cass from her recent piece in the BMJ, nailing this point about biased reviewing (see also Ionnidis, 2018):
“The findings of the series of systematic reviews and guideline appraisals are disappointing. They suggest that the majority of clinical guidelines have not followed the international standards for guideline development. The World Professional Association of Transgender Healthcare (WPATH) has been highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency. Early versions of two international guidelines—the Endocrine Society 2009 and WPATH 7—influenced nearly all other guidelines, with the exception of recent Finnish and Swedish guidelines; the latter were the only guidelines to publish details of how developers reviewed and utilised the evidence base, and the decision making process behind their recommendations.” (Cass, 2024)
From the outset WPATH was formed from the ideological project of the sexologist Harry Benjamin in the 1960s, to encourage the compassionate care of adult transsexuals. Since that time, mission creep has been clearly evident to extend the bio-medicalisation of gender confusion from adults to children, who ipso facto lack the capacity of adults. This mission creep is why affirmation has been so totemic for those running those services. Post-Cass, the talisman of affirmation will still be worshiped in private clinics staffed by trans-ideologues and unrepentant ex-GIDS personnel. On the day of the release of the Cass Review, the BBC interviewed a clinical psychologist, Dr Aidan Kelly, proudly heading up such a service (GenderPlus).
That intersection of ideology and evidence-production should now be the focus of a look back exercise from the BPS (Hilário, 2019). It would seem though that those like Agnew will resist it actively and those like Raczak will do so passively, by only looking forwards not backwards. That blindness to history would reflect an established normative culture in the BPS, which is an organisation without a memory (Pilgrim, 2023b). It may be that the grown up in the room trying to learn all the relevant lessons from the past will have to be the Association of Clinical Psychologists UK. The DCP’s shameful silence might encourage many to leave it in favour of joining the latter, adding to the membership woes of the BPS.
Conclusion
The appearance of the Cass report is challenging for those in charge at the BPS. Its hegemonic trans-captured culture is now exposed for its ethical and empirical inadequacies. A reckoning within the profession is required, given that British clinical psychologists led the now discredited Tavistock service. That honest look back, and all the lessons learned, may never arrive from the BPS. Instead, opportunism about more jobs for the profession may take precedence. We shall see.
References
Biggs, M. (2023) The Dutch Protocol for juvenile transsexuals: origins and evidence, Journal of Sex & Marital Therapy, 49:4, 348-368.
BMJ (2020) Editorial: Cumberlege review exposes stubborn and dangerous flaws in healthcare BMJ 370: m3099
British Psychological Society (2019) Guidelines for Psychologists Working with Gender, Sexuality and Relationship Diversity Leicester: British Psychological Society.
Cass, H. (2024) Gender medicine for children and young people is built on shaky foundations. Here is how we strengthen service. BMJ; 384:q814.
de Vries, A. and Cohen-Kettenis, P. (2012) Clinical management of gender dysphoria in children and adolescents: The Dutch approach. Journal of Homosexuality, 59 (3), 301-320.
Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A.L.V.,Långström, N. and Landén, M. (2011) Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden PloS One 6(2): e16885
Harvey, P. (2023) Policy capture at the BPS (I): The gender guidelines, In D. Pilgrim (ed) British Psychology in Crisis Oxford: Phoenix.
Hilário, A.P. (2019) (Re) Making gender in the clinical context: a look at how ideologies shape the medical construction of gender dysphoria in Portugal. Social Theory & Health 17, 463–480
Ioannidis, J.P. (2018) Professional societies should abstain from authorship of guidelines and disease definition statements. Circulation: Cardiovascular Quality and Outcomes, 11(10), p.e004889.
Jorgensen, S.C.J., Athéa, N. and Masson, C. (2024) Puberty Suppression for Pediatric Gender Dysphoria and the Child’s Right to an Open Future. Archives of Sexual Behavior (open access online)
Pilgrim D. (2023a) British mental healthcare responses to adult homosexuality and gender non-conforming children at the turn of the twenty-first century. History of Psychiatry. 34(4):434-450.
Pilgrim, D. (2023b) Organisation without a memory In D. Pilgrim (ed) British Psychology in Crisis Oxford: Phoenix.
Pilgrim, D. (2020) Critical Realism for Psychologists London: Routledge.
Pilgrim, D. and Entwistle. K. (2020) GnRHa (‘Puberty Blockers’) and cross sex hormones for children and adolescents: informed consent, personhood and freedom of expression, New Bioethics, 26:3, 224-237
Zucker, K.J. Wood, H., Singh, D. and Bradley, S. (2012) A developmental, biopsychosocial model for the treatment of children with Gender Identity Disorder Journal of Homosexuality 59:3, 369-397
Valenstein, E. S. (1986). Great and Desperate Cures: The Rise and Decline of Psychosurgery and other Radical Treatments for Mental Illness. New York: Basic Books.
Williamson C. (2008) Alford’s theoretical political framework and its application to interests in health care now. British Journal of General Practice Jul;58(552):512-6.
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