9 September 2024

Dear Professor Banfield,

Thank you for your response to our letter about the BMA Council’s decision to pass a motion to critique the Cass Review and oppose its recommendations. Our letter has now been signed by over 1500 doctors including 1000 BMA members. This includes many senior clinicians, medical leaders and academics.

Your letter does not provide assurance that the concerns we raised are being taken seriously and responded to appropriately.

You have not addressed our concerns about the lack of membership engagement and the secretive and undemocratic process underlying this motion.

You don’t explain which of the Cass recommendations the BMA opposes and why.

You have not explained why the BMA advocates the initiation of puberty blockers outside clinical trials for children with gender dysphoria, in the absence of evidence of benefit.

You have not shown that you have considered the ethical and safety concerns that led to the recent restrictions, including for private and overseas prescribing.

You don’t address the point that the BMA “evaluation” cannot be neutral when the BMA has already voted to reject and lobby against the Cass Review.

The BMA must rescind its opposition to the Cass Review, say how it intends to gather members’ views and engage members in policy development on this issue, and support the restrictions on private and overseas prescribing of puberty blockers.

Process: accountability, transparency and member engagement

We understand that members will not be told who proposed this motion, who supported it being put to Council, or who voted for it.

BMA Council has departed from its own behaviour principles which include:

“Be accountable – Explain your decisions and actions to your constituents” and

“Be representative – Where possible, seek the views of those you represent on the issues that affect them and take them into account when voting, even if you don’t personally agree with them.”

Transparency is necessary for accountability; as members elect Council members, they should know what they stand for and how they vote on Council, and to be representative member engagement is necessary so that Council knows the views of members.

From numbers reported in the press, there was a high proportion of abstentions during the voting, with more abstaining or opposing opposition to the Cass recommendations than supporting, demonstrating an uncertain Council in need of more information.

Council should not usurp the policy making responsibility of the representative body. This is particularly important with regard to contentious issues. The BMA has always facilitated extensive debate at ARMs over divisive issues and has previously sought members’ views via a survey in the case of assisted dying. Council has taken this decision without knowing what wider membership views are and there has been no attempt to find out.

The decision of Council to oppose the Cass recommendations lacks authority, credibility and membership support. It is not worthy of a democratic representative organisation.

Q1. How does the BMA intend to garner members’ views and involve them in discussion about transgender health care for children and adults in order to develop policy that properly reflects members’ views, and not just those of a small group within Council?

Unsubstantiated allegations against Cass

You implied that our letter said the Cass Review was beyond critique. That is not true; members questioned the one sided and damning rejection of the Cass Review and its recommendations based on weak and unsubstantiated allegations about its methodology, and the illogicality of claiming the BMA will be doing a neutral evaluation of something it has already decided to oppose. This is not the balanced response one would expect from a professional medical organisation. The motion has done great damage to the BMA’s reputation as an organisation that believes in evidence- based medicine.

To justify the motion, the BMA is relying on a non-peer reviewed paper published on the Yale Law School website, where the authors have multiple significant undeclared conflicts of interest. Despite your assertion that this is an international group all the authors are US based and have partisan involvement in the current litigation going through US courts about transgender healthcare. It is in their interests to discredit the Cass Review and their criticisms are inaccurate or untrue in many places, and politically and ideologically motivated.

Q2. How did it come about that the BMA relied on unsubstantiated allegations to dismiss the Cass Review?

Failure to state which recommendations the BMA opposes

You did not answer our question asking which of the Cass Review recommendations the BMA opposes. The motion implies rejection of all of them. Is the BMA opposed to children and young people having a holistic assessment of needs? Does the BMA think there should not be a run through services so young people don’t fall through net

between adult and CYP services? Is the BMA opposed to training of a wider workforce, or to the establishment of data collection, audit, research, clinical governance or quality improvement systems and the improved safeguarding that will follow?

Q3. Which Cass Review recommendations is the BMA opposed to?

The BMA press release goes further and calls for the implementation of the Cass Review recommendations to be paused while the Task & Finish Group carries out its work. Several of the Cass recommendations have already been implemented, including the establishment of new regional centres.

You said the NHSE puberty blocker policy would make an already meagre service non – existent, as if the only purpose of gender clinics for children and young people is the provision of puberty blockers. In fact, the new services are explicitly designed to increase available support, provide holistic care addressing all the issues that these children and young people have, and address such diagnostic overshadowing.

The BMA appears not to have considered the implications for children and young people of pausing implementation of these new services.

Q4. What mitigations does the BMA propose to help children and young people who would find themselves without any services if the pause to the implementation of the Cass Recommendations, requested by the BMA, were to be enacted?

The government ban on new or private prescription of puberty blockers

Your letter states that the NHS England and government measures banning prescription of puberty blockers in certain circumstances “go further” than the Cass recommendations. That is not true. The NHSE and government measures are in concordance with and are logical consequences of the Cass Review findings which were that there is not enough evidence about the safety and efficacy of puberty blockers to recommend their routine use, outside of a research framework.

You said that the impact of the government’s decisions means that “right now there are those who could benefit from care who are being denied that option.” But the Cass Review evidence is that we have no way of knowing who may benefit and who may not, nor do we fully understand the harms and risks. That is why Dr Cass has called for more research.

NHSE policy

You said that these measures by NHSE and government were “rapid and selective”, implying they were rushed and not properly considered. But the NHSE policy change was not rapid.

The March 2024 NHSE policy (ref 1) to restrict use of puberty blockers was based on Cass Interim Review recommendations which took account of an updated NICE review of the evidence (original NICE review 2020, update 2023), followed by a 90 day consultation in 2023, to which BMA contributed. NHSE concluded that there is not enough evidence to support the safety or clinical effectiveness of puberty suppressing hormones to make the treatment routinely available at this time and said that the policy would be reviewed in the event of a new evidence base, the means for which was being established. In the meantime, children already receiving puberty blockers prescribed by UK prescribers would continue to do so. The final Cass Review provided further evidence to support this measure.

Rather than restrictions on routine use of puberty blockers being too rapid, the evidence that puberty blockers were safe for such use “should have been established before they were ever prescribed”, as Wes Streeting confirmed.

Q5 How does the BMA justify advocating for the continued routine use of puberty blocking medications for gender dysphoric/incongruent and gender questioning children and young people before there is adequate evidence of their safety or efficacy?

Government policy banning private and overseas prescriptions

When NHSE announced that puberty blockers would only be prescribed under research conditions, and for those already taking them when prescribed by the NHS, there was evidence that private providers, mainly overseas, were prescribing puberty blockers. These providers are not subject to clinical governance standards that apply in the UK NHS gender service and are therefore deemed unsafe. This was explicitly raised in the Cass Review – “The Review understands and shares the concerns about the use of unregulated medications and of providers that are not regulated within the UK”.

The Cass Review also recommended that “the Department of Health and Social Care work with the General Pharmaceutical Council to define the dispensing responsibilities of pharmacists of private prescriptions and consider other statutory solutions that would prevent inappropriate overseas prescribing.” This is what led to the recent temporary government ban on private and overseas prescribing which is being consulted on now with a view to making it permanent.

You said, “the BMA believes that it is clinicians, patients and families who should be at the centre of an evidence-based decision-making process about their health, not politicians.” That misattributes the regulatory role of government to “politics” which is quite wrong, as is illustrated by the fact that both the previous Conservative government and the current Labour government are in agreement about the need for these restrictions. This is a regulatory decision of government fulfilling its duty to protect its citizens from harm, based on clinical evidence. The BMA is usually in favour of government regulations that protect the health of citizens and patients.

These measures, restricting private and overseas prescribing were introduced for safety reasons, so one would expect strong supportive evidence for the BMA to take a confident position in opposition to commissioners and regulators.

Q6. What evidence does the BMA have to support the safety of private and overseas prescribing of puberty blockers?

Department of Health and Social Care consultation on puberty blockers

You say the BMA will be responding to the upcoming Government consultation on puberty blockers. This consultation is about whether to make the ban on private and overseas prescriptions permanent.

The BMA must support the ban becoming permanent in the interests of the safety of children and young people, because an evidence-based approach requires us to base decisions on the current best available evidence and this does not support the routine use of puberty blockers. Private prescribers should be required to stay within the parameters of NHS policy on this because that policy is designed around safety and evidence.

The BMA does not have member support to take any other position on this question.

Q7. Will the BMA support the government proposal to make permanent the emergency ban on private and overseas prescribing of puberty blockers? If not, why not?

Task and Finish Group

The terms of reference of the Task and Finish Group imply it will be developing further policy on this area with no plans to engage members in the process. The Task and Finish Group will share its findings with the BMA Council, presumably for its approval. This is a continuation of Council usurping the policy making role of the membership representative body.

According to the BMA press release and your letter the Task and Finish Group has several tasks:
An evidence-led evaluation of the issues raised with the Cass Review, the subsequent decisions taken by NHS England and the UK government, and the state of transgender healthcare in the UK today.
A critique of the Cass Review methodology.
Response to government implementation of the Cass Review recommendations. Make recommendations on transgender healthcare.
Make recommendations about wider BMA transgender policy.

Not only does this look like a mammoth set of tasks to complete in 4 months, and we question whether the BMA has the resources and expertise for all that, but in as much as it will be making recommendations on transgender healthcare it is mimicking the terms of reference of the Cass Review which was to make recommendations on how to improve services for children and young people experiencing issues with their gender identity or gender incongruence, and ensure that the best model/s for safe and effective services are commissioned.

It is over-reach on the part of the BMA to think it can do better than the Cass review which took 4 years to complete, commissioned 7 systematic reviews and qualitative research, 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 had a full-time stakeholder engagement lead who worked throughout the period of the review.

Assuming the Task and Finish Group is going ahead, the BMA has not explained why it has decided to oppose the Cass recommendations before the Task and Finish Group completes its evaluation. The decision to do an evaluation negates part ii of the motion, to oppose the recommendations. You claim this is scientific, but the scientific process draws its conclusions after it has appraised the evidence, not before. The BMA has no basis for currently opposing or lobbying against any of the Cass recommendations and the neutrality of the Task and Finish Group is compromised from the start.

The BMA should not oppose the Cass Review and its recommendations if the Task and Finish Group is to be neutral as promised. The BMA should therefore rescind the motion rejecting the Cass Review.

Q8. Will the BMA rescind the motion to reject the Cass Review, pending the outcome of the Task and Finish Group?

Evidence based medicine and the scientific approach

You wrote that the BMA supports evidence-based medicine and further research to achieve a “solid evidence base”. This is exactly what the Cass Review recommends, acknowledging the gaps in our knowledge and recommending a full programme of research.

Your letter implies that the NHS England research programme on puberty blockers was implemented as a result of the BMA announcement of its evaluation of Cass. In fact, plans for a puberty supressing hormone study have been in the pipeline for a couple of years. Following the Interim Cass report two years ago NHS England established a national Children and Young People’s Gender Dysphoria Research Oversight Board to develop a study to improve understanding of the relative benefits and harms of ‘puberty blocking’ treatments in children approaching, or experiencing, puberty.

As the Cass Review said: “The evidence base underpinning medical and non-medical interventions in this clinical area must be improved. Following our earlier recommendation to establish a puberty blocker trial, which has been taken forward by NHS England, we further recommend a full programme of research be established. This should look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services. The puberty blocker trial should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.”

Contrary to your assertion, the BMA is not taking an evidence-based approach. It is calling for children and young people to continue to get poorly evidenced and potentially unsafe medicines, including from private unregulated providers before there is adequate evidence of safety and efficacy. 

How can the BMA possibly justify such a position and still claim to be evidence-based?

Q9 Is the BMA opposed to the Cass recommendation that a full programme of research be established in order to improve the evidence base for care for this vulnerable and complex group of children and young people?

If you would like to meet to discuss any of these points in person, with me and some of the key signatories then we would be delighted to arrange this.

In summary, we have four requests:

Yours sincerely

Dr Louise Irvine (on behalf of signatories to letter raising concerns about BMA decision on Cass Review)

Copied to BMA chief officers and CEOs

Questions:

1. How does the BMA intend to garner members’ views and involve them in discussion about transgender health care for children and adults in order to develop policy that properly reflects members’ views, and not just those of a small group within Council?
2. How did it come about that the BMA relied on unsubstantiated allegations to dismiss the Cass Review?
3. Which Cass Review recommendations is the BMA opposed to?
4. What mitigations does the BMA propose to help children and young people who would find themselves without any services if the pause to the implementation of the Cass Recommendations, requested by the BMA, were to be enacted?
5. How does the BMA justify advocating for the continued routine use of puberty blocking medications for gender dysphoric/incongruent and gender questioning children and young people before there is adequate evidence of their safety or efficacy?
6. What evidence does the BMA have to support the safety of private and overseas prescribing of puberty blockers?
7. Will the BMA support the government proposal to make permanent the emergency ban on private and overseas prescribing of puberty blockers? If not, why not?
8. Will the BMA rescind the motion on the Cass Review, pending the outcome of the Task and Finish Group?
9.  Is the BMA opposed to the Cass recommendation that a full programme of research be established in order to improve the evidence base for care for this vulnerable and complex group of children and young people? 

Reference

(ref 1) https://www.england.nhs.uk/wp-content/uploads/2024/03/clinical-commissioning- policy-gender-affirming-hormones-v2.pdf