5 November 2024

Dear Colleagues,

BMA reverses decision to oppose Cass Review

Congratulations!

Our open letter to the BMA had an effect and at the end of September BMA Council passed a motion that it will “remain neutral” on the Cass Review pending the outcome of its own appraisal. Here is the BMA
press release on the decision. The story was covered in the Press: BMJ, BBC, and New Statesman.
This would never have happened had it not been for our #NotinournameBMA open letter criticising the BMA Council decision to oppose the Cass Review, signed by over 1500 doctors including over 1000 BMA members.

See the website NotInOurNameBMA for list of signatories who agreed for their names to be published, and their reasons for signing in the comments.

While of course being pleased about this turn of events, it’s worth pointing out two important things which are unsatisfactory about the BMA’s response.

The press statement claims it is “retaining a neutral position” which is misleading as the BMA never did have a neutral stance but was hostile from the start. What has actually happened is a reversal of BMA policy as a result of the efforts of many of its members. The BMA has offered no explanation for its original position nor any apology or acknowledgement of the efforts of its members to bring about this change, which has actually rescued the BMA from a shameful situation which led to the resignation of hundreds of members. The BMA has not even replied to our follow up letter.

This disdain for the membership is reflected in the BMA refusal to conduct a survey of members’ views on the issue, despite our open letter request that they do so. A motion calling for a survey of members was defeated at the recent BMA Council meeting. The BMA has conducted many surveys of members in the past and has also discussed important policy areas at the Annual Representative Meeting, which it has avoided doing in relation to the Cass Review. We think this is wrong and that members should be consulted. In addition a balanced and informed debate should be organised for the next ARM.

Dr Hilary Cass in The Times

Dr Hilary Cass talked about the BMA’s attitude to her Review in this interview in the Times. Here are some quotes:

In the interview Dr Cass criticised the British Medical Association for its “puzzling” decision to oppose the findings of her review into NHS services for transgender children. She said that the doctors’ union had no evidence to back up its critique of her review, and that the BMA’s stance represented only a “small minority” of the medical profession.

Cass told BBC radio’s Woman’s Hour: “I found the BMA position puzzling because they haven’t actually said what it is they object to about my recommendations … Do they object to better training? Do they object to better research?”
Cass said the BMA’s critique was based on “online sources mainly from the US”, adding: “When thinking about evidence-based care, they haven’t produced any evidence that the review should be stopped.”

Dr Cass said it was important that the BMA’s critique, which will be published in January, did not “cherry-pick a small part of the experience and the evidence”. She added that, unlike her own review, the BMA “have not got the four years to do it”.

This is another good article in The Times: How the Cass Review has Reshaped Care for Transgender Children.

The article refers to the BMA efforts to halt the implementation of the Review’s recommendations and said implementing the findings of the report by Dr Hilary Cass has meant overcoming ‘disinformation’ from US sources spread by the British Medical Association. Some quotes from the Times article:

‘In July, the doctors’ union suddenly announced that it would lobby against the Cass report, without consulting its 195,000 members. To support their position, the BMA Council cited as their top source a 39-page document published by the Integrity Project, an organisation based at Yale Law School. The paper is titled “an evidence-based critique of the Cass Review”, and claims Cass’s work — which was the largest ever conducted and reviewed data from 113,000 children — has “serious methodological flaws”.

‘Its lead author is Dr Meredithe McNamara, a paediatrician who has argued that giving children puberty blockers is “one of the most compassionate things” a parent can do, and acts as an expert witness in US court cases arguing for gender-affirming care. This McNamara paper, which was widely shared online and fuelled an international backlash against Cass, has now been exposed as having a “significant number of errors and misrepresentations”.’

‘In an article published this week in the Archives of Disease in Childhood, a peer-reviewed British medical journal, a group of leading paediatricians identified a series of unfounded claims, misrepresentations and factual errors in the US paper that underpins the BMA’s stance. They found the McNamara paper was “tailored for the courtroom” and written with the “primary purpose” of supporting lawsuits in the US, where the issue of gender medicine remains bitterly divided along party political lines and is settled through legal action. It warned that doctors should not use the flawed paper to “jeopardise the implementation of crucial reforms” in the NHS’

‘The lead author Dr Ronny Cheung, a paediatrician based in London, said the US report had been “very influential in swaying online discourse” and he was “very surprised” it was cited by the BMA, whose stance is at odds with the rest of the medical profession. “The overwhelming response from medical royal colleges, and politicians on both sides of the debate, has been to recognise the potential for the Cass Review to help us move things forward,” Cheung said.’

Here is the article published in Archives of Diseases in Childhood rebutting the criticisms of the Cass Review: Gender medicine and the Cass Review: why medicine and the law make poor bedfellows

Across the pond…

For more information about the US court cases referred to in the article above see this article on the website of the Society for Evidence Based Gender Medicine (SEGM):

The Cass Review, the “Yale” Report, and the Importance of Keeping Special Interests at Bay

And down the rabbit hole…

For those interested in exploring more deeply the links between the Cass Review and the current US court cases this is an interesting read.
It is an amicus brief (Amicus curiae brief: “Friend of the court” brief; advice formally offered to the court by an entity interested in, but not a party to, the case) provided by the Alabama Attorney General in support of the state of Tennessee in the current US Supreme Court case where the US government (U.S. v. Skrmetti) is challenging the state of Tennessee’s decision to ban medical and surgical gender interventions in children under 18.

The amicus brief references the Cass Review as well as worrying revelations about the World Professional Association for Transgender Health (WPATH)’s ethics and credibility that were unearthed during the Alabama legal discovery process. These included removing lower age limits in WPATH’s updated guidelines Soc8 for “gender affirming” hormonal and surgical interventions at the behest of the US Assistant Secretary for Health Rachel Levine and suppressing the publication of research that WPATH itself had commissioned because it did not like the findings.

WPATH is relevant to this discussion for several reasons. Its guidelines were criticised by the Cass Review which said:
“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 appraisal
process to lack developmental rigour. ” and WPATH “overstates the strength of the evidence” in making its recommendations.
As the Cass Review pointed out, nearly all other national and international transgender health guidelines were derived from WPATH and Endocrine Society guidelines.

WPATH is being used as an expert resource in the US to challenge some states’ decisions to ban medical and surgical gender treatments in those under 18 , as WPATH contends there is a good evidence base for “gender affirming care” for those under 18. The Cass Review is being cited by those defending the bans because of the Cass Review’s conclusions that there is no good evidence for those interventions. That is why Cass has been dragged into the US situation and is the main provenance of the attempts to discredit the Cass Review.

The BMA appraisal of the Cass Review

Dr David Strain, chair of the BMA Board of Science, wrote an article about his plans for the appraisal in BMA News:

“…it is crucial that we move beyond polarising debates and focus on the nuanced realities of those affected, ensuring that their needs are met with compassion and evidence-based care. This process will ultimately contribute to a more informed and empathetic approach to healthcare for children and young people with gender incongruence and dysphoria, aligning with the BMA’s core principles of advancing medical knowledge and improving patient care.”

This is a paraphrase of the Cass Review which also called for an end to “polarising debate” and a focus on the needs of the children, so it is surprising that Dr Strain does not acknowledge that. His promise that his review will ensure the needs of children are met with compassion and evidence-based care implies that the Cass Review doesn’t do that.

Yet this is what Dr Cass said about her review reflecting the combination of compassion and a desire for safe evidence based care for children and young people that imbues the whole review:

“The aim of this Review is to make recommendations that ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care: care that meets their needs, is safe, holistic and effective. At its heart are vulnerable children and young people and an NHS service unable to cope with the demand. A compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines. The Review believes that each individual child and young person seeking help from the NHS should receive the support they need to thrive.”

Dr Strain is no doubt sincere in his assurances of neutrality, but that still leaves several questions about what the BMA is actually proposing. According to BMA press releases and Dr Strain’s piece, the BMA appraisal will be an “evidence led” review that will do all the following:
Critique the Cass Review methodology.

Review the actions that have been implemented in the name of the Cass Review, what is planned, and what remains to be commissioned.
Listen to people with lived experience and a range of healthcare professionals working in this area. Evaluate “the state of transgender healthcare in the UK today”

Make recommendations on transgender healthcare, and about wider BMA transgender policy.
That really is a tall order and when Professor Banfield says the BMA won’t be ‘re-running the Cass Review” perhaps he means that the BMA aims to do much more than the Cass Review, including evaluating and making recommendations about the whole of transgender care in the UK – and all in 4 months!

What does the BMA mean by “evidence led”, and how will that differ from the Cass Review?

Is the BMA going to re-run the University of York systematic reviews in the hope of finding good evidence for puberty blockers or other treatments that somehow eluded the York researchers?
Or is the BMA going to re-evaluate the evidence collected by the Cass review and draw its own conclusions/make its own recommendations from that evidence about service provision?

Or does the BMA intend to collect new evidence? Perhaps that’s what it intends to do during its conversations with people with lived experience and clinicians working in this area.
Dr Strain’s promise that he will listen to people with “lived experience and healthcare professionals working in this area” implies that Dr Cass did not, or did not do so adequately.

Yet we know that the Cass Review listened to over 1000 people, had 18 focus groups with children and young people, spoke to support and advocacy groups (Stonewall, Mermaids, LGBT Foundation, Gendered Intelligence etc) every 6 weeks, had weekly listening sessions that young people, parents, clinicians could book a slot on, had a round table on lived experience with various advocacy group policy leads and young people, and had a commissioned research programme which gathered perspectives from young people and young adults who had been through service and parents. It was continuous throughout the review with a full time stakeholder engagement lead.

It is difficult to imagine the BMA will do better in 4 months than Cass did in 4 years, and with far fewer resources.

Any of these versions of an “evidence led review” look very much like a rerun of a substantial part of the Cass Review. If the BMA is going to look again at the evidence presented in Cass and re-evaluate it, the implication is that Cass is incompetent or compromised in some way. It is hardly a “neutral” position if your starting point is that the Cass Review is so significantly flawed you have to do your own assessment of the evidence and recommendations.

One wonders if this ill-judged appraisal is the right place for the BMA to be putting its energy and resources, instead of responding to the calls from the Cass Review and the Academy of Medical Royal Colleges to get behind the Cass recommendations and help to ensure they are properly resourced and well implemented – including improving on them in the light of further evidence and insights from experience and research.
Dr Cass never said her review was the last word on the matter: she admitted there is still a lot we don’t know and appealed to professional bodies for support in gathering the evidence for improvement. She talked about creating a “living systematic review” with proper data collection, clinical governance and follow up so we can learn from experience – something tragically missing from youth gender services until now.

Conclusion

We think the authors of the Archives article got it right when they concluded:
“The Cass Review is not an end in itself but establishes the basis from which better clinical care can evolve through collaboration between young people, their families, and clinicians and researchers. We believe this is both a crucial and exciting opportunity to advance the holistic care of gender questioning children and young people. The opportunity for unity among concerned clinicians, afforded by the findings and recommendations of the Cass Review, should not be missed. It is time for the UK clinical community to move forward and focus its attention on the Cass Review recommendations to develop a new service model for gender dysphoric children and young people, which is, above all, safe, holistic and robustly underpinned by the evolving evidence base.”