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Sex and gender

When unfolding reality collides with belief…

Professor Sallie Baxendale with a response to the Cass Review of gender identity services.

20 May 2024

"Doubt is an uncomfortable condition, but certainty is a ridiculous one"


The conclusions of the Cass Review make sobering reading. In painstaking detail, Cass sets out over 388 pages how the treatments offered by a psychology-led, NHS service for children with gender related distress raced far ahead of the 'shaky foundations' that formed their evidence base. Given the complexity of factors that fuelled the unprecedented rise and fall of the Gender Identity Development Service (GIDS), it's understandable that the demands for a formal inquiry into how this happened are growing.

Cass describes how exceptionalism isolated the service from the holistic approaches used in the routine Children and Adolescent Mental Health Services (CAMHS) and an unquestioning 'one size fits all' treatment pathway began to develop. As an ideology became embedded into a medical service, the ethos of clinical enquiry, or even a cautionary approach, was effectively crushed via accusations of bigotry and transphobia (see Hannah Barnes' book Time to Think). Many clinicians who saw what was happening left the service, leaving a core who were so convinced that the science was settled, their certainty eclipsed the flimsy evidence base. Post Cass, if anyone remains in any doubt that something unusual is happening in gender medicine they only need to look at the veneration given by gender clinicians to the WPATH  'Standards of Care'. The infallibility of the circular, self-referential statement of expert consensus continues to be defended by many with a missionary zeal usually reserved for sacred texts. Those of us who toil away crafting cautious, caveat-ridden NICE guidelines can only dream that our conclusions could command such reverence from our colleagues.

The Cass Review recognises that there is no solid evidence to support the use of puberty blockers in the treatment of children with gender dysphoria. The rationale that these drugs are lifesaving and prevent suicide is not supported by the evidence. Few who have been following this story will be surprised by this, as 'life saving' is just the latest in the evolution of evermore urgent rationales for giving these drugs to children with gender related distress. Whilst their purpose continues to evolve, concerns about the wide range of potential harms associated with these drugs have steadily mounted.

Evidence doesn't stop at national borders: if Cass's conclusions are true in England, they are true elsewhere. It is time for gender clinicians who are clinging to the mantra that puberty blockers are safe, effective, fully reversible and life saving to produce the evidence that supports these claims. Cass and her team have looked and not found it. Batting away the conclusions of the Cass Review on the basis that 'the science is settled' isn't going to cut it anymore. Outright dismissal of her findings due to bigotry, transphobia or cis supremacy in action would be risible if the subject matter weren't so serious and some of the people making these accusations weren't clinicians.

Clinicians who work in gender medicine are now faced with a number of choices. They could challenge the conclusions of the Cass Review and produce the evidence that supports their claims. Psychologists are trained in the hierarchies of evidence and it should go without saying that 'expert consensus' does not trump systematic review. Systematic reviews and meta-analyses are at the top of every evidence hierarchy pyramid, and expert opinion is always at the bottom, for good reason. Expert consensus is frequently wrong in medicine, often with catastrophic consequences. Advice to put infants to sleep on their front was the expert consensus until the early 1990s. However, a systematic review of the evidence available in 1970 would have identified the elevated risks of sudden infant death syndrome associated with babies sleeping on their front. It has been estimated that if such a review had been conducted at that time and the results acted upon, over 50,000 infant deaths in Europe, the USA, and Australasia may have been avoided. As it was, the harmful 'expert consensus' continued to guide clinical practice for over two decades after the evidence base clearly pointed in a different direction.

If, like Cass, gender clinicians are unable to find robust evidence to support their practice, they could engage with the findings of the Cass Review, re-examine their practice and modify their treatments accordingly to ensure that the children in their care receive appropriate evidence-based treatments. Confronted with the calm, compassionate, child-centred conclusions of the Cass Review, this option looks to be a no brainer. 

But when unfolding reality collides with belief, strange things happen in the human mind. As psychologists we are well aware of how the mind reacts when our core beliefs are challenged. Something has to give. Some are able to adjust their beliefs, but those who are most committed, tend to strengthen their beliefs by developing evermore elaborate rationalisations to bridge the gaping chasm of incongruity. 

Festinger's seminal studies of cognitive dissonance played out in real time on social media in the days following the publication of the Cass Review. Confronted with the unease of an official report contradicting their core beliefs, many resorted to ad hominin attacks on Cass and her team, attributing underlying transphobic motives to the conclusions. These attacks began within hours of the report being published, long before anyone could have truly digested the contents. By the end of the day, straw man arguments quickly circulated online, with people arguing that Cass had discarded the vast swathes of positive evidence or that the team had held gender medicine to the impossible standards of double blind, randomised controlled trials and found it wanting on this basis alone. Cass has repeatedly made it clear that this is absolutely not the case but this narrative has taken a firm hold nevertheless, 

Tragically for the children and families who seek their help, it is likely that many who work in the increasingly unmoored private sector of gender medicine will choose to refuse to engage with the conclusions of the Cass Review, and will double down on their 'faith based' clinical practice, ultimately harming more children in the process. 

Dr Cass chose the following quote to open her review "Medicine's ground state is uncertainty. Wisdom - for both the patients and doctors - is defined by how one copes with it." As a blueprint for any clinician hoping to gain this wisdom, her review is an excellent place to start. 

Professor Sallie Baxendale

Consultant Neuropsychologist, UCLH, London

Professor of Clinical Neuropsychology, University College London