Now that we know thousands of vulnerable children embarked on gender transition without any good evidence to justify such drastic leaps into the unknown, many people might be left wondering: how was this allowed to happen?
Who was invested in pushing this idea that adolescent bodies could be transitioned from one sex to the other through hormones and surgery — and that doing so would bring these youngsters happiness? And why?
In her exceptionally detailed report, Dr Hilary Cass warned against “the creep of unproven approaches into clinical practice”.
It is worth rewinding a decade to 2014 — the year that Cass identifies as the point at which referrals to gender identity youth services in the UK spiked in favour of teenage girls.
This was also a time of huge cultural change in the transgender rights movement. It was the year of the first gay marriages in the UK and with the battle for gay rights effectively won, Baroness Hunt of Bethnal Green announced, when she became chief executive of the charity that same year, that Stonewall’s focus would pivot to championing a new minority group: transgender rights would be the new fundraising frontier.
Advertisement
This coincided with broader global efforts to reframe being transgender as a positive identity to be celebrated, as opposed to a mental health disorder, as it was categorised by the World Health Organisation’s manual of diagnoses until 2019.
• Nine key findings from the Cass report into gender transition
The past decade also brought a mental health crisis among young people, with higher rates of anxiety and depression, particularly among teenage girls, and a rise in young people presenting with what Cass calls “other bodily manifestations of distress”, such as eating disorders, tics and body dysmorphic disorders. And yet, for some reason, young people who manifested their distress through gender were increasingly treated in isolation, as a separate group. It is this exceptionalism which Cass identifies as key in understanding why they received poorer healthcare.
From 2011 onwards, the NHS’s gender clinic for young people sent countless distressed patients to the endocrinology clinic for puberty blockers, even though the imagined benefits rested solely and precariously on a single Dutch study, whose own results were far from conclusive. Even the most optimistic interpretation of the Dutch results ignored that the original participants were screened to filter out young people who already had other conditions, such as autism. No such filter was applied to referrals from Gids, the NHS Gender Identity Development Service.
Despite this absence of evidence — or perhaps, even, because of it — an ecosystem of charities, positioning themselves as experts in gender, developed to support the growing number of young people who were becoming well-versed in the language of transgender rights.
Advertisement
These include Mermaids, the controversial charity under investigation by the Charity Commission, which began life as an internal support group for families of young people attending Gids; Gendered Intelligence, an activist organisation which runs support groups and camping trips for young people identifying as transgender; and Gires, another activist group which claims to have trained professionals on transgender issues in 200 organisations across the private and public sectors.
Dr Anna Hutchinson, a clinical psychotherapist who was among the Gids staff to raise concerns, recalls how she and colleagues began seeing patterns emerging among youngsters wishing to transition.
“A lot of the kids had chosen the same names from some of their favourite YouTubers. Some of them were coming into the consultation room with the same script. They were clearly speaking with each other in online spaces and other worlds which we were not part of, as professionals,” she said.
“The personal testimony videos on YouTube [which typically document a person’s journey as they transition] are very powerful and evocative.
“It’s a very powerful thing to watch these transformations happen before your eyes. Some of these YouTubers look great — some of them look like boy band members — so there was an aesthetic that developed from that.”
Advertisement
The meaning of “affirmation” became entangled in messages of social justice. “Affirmation then became understood to be a human right and a movement developed around it. People who simply didn’t know about the lack of evidence assumed that any criticism was due to transphobia or lack of support for the kids.”
Mermaids, Gendered Intelligence and Gires all deny claims they promoted medical pathways as the preferred treatment for gender-confused children. In 2017, a tweet from Mermaids’ account claimed that “the teens we support whose parents refuse to listen are the ones at highest risk of suicide and self-harm”.
In 2019, Mermaids promoted puberty blockers as “an internationally recognised safe, reversible healthcare option which have been recommended by medical authorities in the UK and internationally for decades”. Such claims have since been discredited.
Mermaids defended the continued use of puberty blockers, despite the recent ban by NHS England due to lack of evidence over their safety.
In a statement, it said: “Mermaids exists to support trans children and young people and their families, many of whom tell us that puberty blockers have been an important part of their journey. Multiple studies have shown the positive benefits of blockers, which have been used safely for decades and continue to be available to cisgender children and young people.”
Advertisement
When The Times approached Gires in 2019 over concerns that it was encouraging vulnerable people down a medical pathway they may later regret, its founder and trustee, Bernard Reed, who has served on NHS England Clinical Reference Groups, insisted they did not intervene in individual cases.
However, he added: “A repressive approach leads to self-harm and even suicidality. In the medical literature, withholding physical treatment for young people experiencing gender dysphoria is acknowledged to be ‘not a neutral act’ and failure to provide timely treatment is described as ‘psychological torture’.”
Asked if he had changed his position in light of Cass’s findings, he doubled down on his support of puberty blockers. “Blockers, in fact, do not cause any permanent alteration of the body and are used in the treatment of precocious puberty,” he claimed.
He also criticised Cass for ignoring “significant important peer-reviewed literature”, even though her report is the biggest review of evidence ever undertaken in the contested field of trans healthcare.
He said: “Nobody would deny that clinicians have a duty to offer medical and surgical treatment, which might be risky and cause harm and suffering, if leaving patients without those treatments were to cause patients greater risks of harm and suffering. The decision to treat, and the decision not to treat, are seldom, if ever, neutral.”
Advertisement
In 2019, Gendered Intelligence described puberty blockers as a benign and wholly reversible treatment.
They “can give young trans people appropriate time and breathing space to ensure that they are sure about the permanent effects of cross-sex hormones, without the adverse effects of an incorrect puberty,” it advised.
Its website also included pages advising young people how to flatten their chests with binders, and what kind of swimwear to buy “if you are self-conscious about chest surgery scars”. The pages no longer appear on its website.
Gendered Intelligence maintained in 2019 that “we recognise that medical intervention is not right for all young people, and we support trans and gender-diverse young people to explore what is right for them”.
Jay Stewart, its chief executive, declined to comment on how — if at all — the charity’s approach would change in light of Cass’s findings.
Paul Barnes, a former political lobbyist who worked as an adviser to Stonewall in the 1990s, said the organisation bore some responsibility for the “toxicity” which Cass said had hampered scrutiny of transgender healthcare.
“Stonewall is at the heart of all this. Having won all the battles against legal discrimination of gay people — the reason we established it — it needed another cause to justify its continued existence. It used and squandered the trust, respect and position that gay people had spent years establishing to promote an aggressive and bullying campaign to promote their ‘no compromise’ position.
“When Stonewall adopted trans rights into [its] remit, the core principle that [it] chose to fight on made tackling any hostility towards trans rights more difficult. The key difference is that while previously we campaigned to change opinion, in this case [its] strategy [was] based on trying to change facts. That is a crucial difference.”
The Times tried to contact Ruth Hunt, who stepped down as chief executive of Stonewall in 2019, for her response to the Cass Review but she could not be reached for comment.
During her leadership, she told the Church Times that “my proudest achievement is that Stonewall became trans-inclusive in 2015, after a six-month consultation with more than 700 trans people.
“Being able to call Stonewall an LGBT organisation for the first time was a milestone moment for me. However, the real achievement is the progress that we and the trans community have made together since that point.”
She now sits in the House of Lords as Baroness Hunt of Bethnal Green, having been nominated for a life peerage.
