Inside the fight against Britain’s trans healthcare ban
When the Cass Review into healthcare for trans youth published its final report in April, its recommendations – which involved restricting the use of puberty blocking medications and mandating psychological interventions for trans youth – were welcomed by NHS England, politicians on both sides of the aisle, and the gender-critical movement. Since then, two health secretaries, the Conservatives’ Victoria Atkins and Labour’s Wes Streeting, have used the report as an excuse to temporarily ban puberty blockers for trans youth under emergency legislation. Despite increasing criticism of the Cass Review, last week, Streeting renewed the ban until November, and the Northern Ireland Executive agreed to extend it to cover the whole of the UK.
In May, the World Professional Association for Transgender Health came out strongly against the Cass Review’s recommendations, and in June two groups of researchers released critiques of the review’s methodology, with the group from Yale University writing that it “misuses data and violates its own evidentiary standards”. The UK medical establishment, however, remained firmly supportive. The Royal College of Paediatrics and Child Health and Royal Colleges of Psychiatrists welcomed its recommendations, while the Royal College of General Practitioners not only offered its full-throated support, but used the Cass Review in an attempt to absolve its members of any responsibility to provide or monitor trans healthcare, even in consultation with more specialist services.
Dr Vasili Crispi (he/they), an academic neurosurgery trainee who sits on the British Medical Association (BMA) UK Council, and who is part of the doctors’ union’s new LGBTQ+ network, was concerned to see many of his colleagues ignoring concerns that had been raised about the Cass Review’s research methodology. In July, they brought a motion calling for the BMA to initiate an evidence-led critique of the Cass Review’s methodology and to oppose the government’s heavy-handed legislative approach to trans youth healthcare. His motion passed, but he was unprepared for the backlash from other doctors and the wider gender-critical movement after the motion was leaked to the New Statesman’s Hannah Barnes. Despite the ensuing controversy, the BMA will now carry out its critique, but it remains an outlier in a landscape where the Academy of Royal Medical Colleges released a statement calling on doctors to stop questioning the Cass Review, as doing so “risks greater polarisation”.
We spoke to Dr Crispi last month about why they brought the motion to the BMA UK Council, and what doctors should be doing to support trans patients at this difficult time.
Can you talk me through why there are questions about the validity and rigour of the Cass Review?
Dr Vasili Crispi: This is a large evidence-gathering project which was commissioned by an openly gender-critical government. It was funded by the [Conservative] government, and it was published by that government. This is a massive conflict of interest, and the BMA has never shied away from criticising reports from the government.
We have concerns with the way the research was undertaken: if you take flawed research and you analyse it to make a recommendation, you cannot be certain that your recommendation will be robust. Another potential issue with the Cass Review’s methods is that large research papers which demonstrate the benefits of gender-affirming hormonal therapy and gender-affirming mental health support for patients have been deliberately excluded [from consideration in the final report] because they were classed as poor-quality evidence. We want to undertake a large piece of work to understand: is this good research? Has it been undertaken in the way that it should have been?
“Doctors, have not been vocal enough in the past, and this is a time where we need to be fighting harder for our patients. It shouldn’t be just the gender-identity specialists or trans folks that do that. It should be allies who fight against this too” – Dr Vasili Crispi
Some people have suggested the BMA, as a trade union, is overstepping by intervening on this issue. What’s your response to that?
Dr Vasili Crispi: It’s important for the BMA to actually support [trans] patients, because there is significant political backlash within the medical profession. This is also the work of a trade union: we work not only for our colleagues, but also for the benefit of our patients.
The initial stance of the motion that I submitted to the BMA was to completely reject the Cass Review, but we have since come to understand that, actually, within the profession, this would have not been possible. It’s caused a lot of stir online, with some people questioning whether the BMA has the right tools to critique the Cass Review, and whether we should do it at all. Anecdotally, from tweets and messages that I’ve received, the gender-critical side argue that we are trying to indoctrinate colleagues and patients; that we’re trying to mutilate children; that we’re paedophiles. The accusations are awful. We’re being threatened with referrals to the [General Medical Council], and pressured to resign from our current positions, because of these severe accusations. We’re seen as people who are trying to push an ideology instead of working for the betterment of others, of patients’ care, and [gender-critical doctors] are being seen as the righteous people instead.
I think we, as doctors, have not been vocal enough in the past, and this is a time where we need to be fighting harder for our patients. And it shouldn’t be just the gender-identity specialists, it shouldn’t just be trans folks that do that. It should be allies who fight against this too.
Aside from the methodological flaws, one issue some trans people have with the Cass Review is that it’s trying to answer whether or not trans-affirming care improves mental health outcomes. Do you think that’s the right question to be asking?
Dr Vasili Crispi: I’m not sure whether that is the right question. What the Cass Review seems to be targeting is the symptom rather than the cause of the problem. We’re still categorising being transgender as a medical problem, which is not. Eventually, I know that history will prove us right. Hopefully, by undertaking this critique of the Cass Review, we will be able to get to that point.
We need to place the Cass Review within its political context. It’s coming from a gender-critical government; it’s coming from a panel of people who are closely associated with politicians such as [Ron] DeSantis in Florida, who implemented anti-gay legislation in schools. What we’re trying to do is remove some of that politicisation and actually look at how it’s been undertaken and whether we can trust the recommendations.
“There’s nothing worse for a teenage transgender person than to go through puberty in a body that they do not recognise as their own”
The service the Cass Review wants the NHS to create, aside from all the ethical issues, seems costly and resource-intensive to implement. Ignoring moral and ethical issues, how realistic do you think it would be to implement it in an already overstretched NHS?
Dr Vasili Crispi: [The service design Cass recommends] will be difficult, to say the least, to implement in the current NHS, and there are ethical and moral considerations that add additional barriers. There are multiple changes that we need to implement to what we already have, rather than creating something completely different. I think at present in the NHS, before we can deliver a new service, we need to boost the provision of trans healthcare in primary and secondary care services that we already have.
What do you want to see happen in those existing services?
Dr Vasili Crispi: We need to restore early access to assessments and prescriptions of hormonal therapy, which provide a level of stability for patients, and make them more willing to wait for any surgical treatment. The earlier we’re able to begin hormone treatment, the more likely they are to be willing to put up with the long waiting times for anything else.
We already have a number of GPs who prescribe on the advice of secondary care specialists, and actually being followed up by a GP who knows the ins and outs of your entire journey is beneficial, especially when they’re supportive.
We have evidence of 20 to 30 years, if not even longer, that hormonal therapy works for transgender patients. We know that it is safe. We know that no treatment comes without risks but we also know, anecdotally and also from the evidence, that trans patients do benefit from hormonal therapy. What we need right now is to lift that ban from GP practices and specialist centres across the four nations, so that patients can continue to receive their [puberty blocking] therapy. There’s nothing worse for a teenage transgender person than to go through puberty in a body that they do not recognise as their own.
