Post Cass, it’s time to challenge the MOU


by Shelley Charlesworth

The landscape for the treatment of children and young people with gender distress has changed utterly over the last six months. The Cass Interim Report began the process in March, followed by news in July that the Tavistock’s gender clinic for children, GIDS, is to close early in 2023. These profound changes come as the Conservative Party is electing a new leader, which means a new government with a new legislative timetable. Whether the proposed bill to ban conversion therapy survives a change in leadership is in doubt. And while the bill at present would ban such therapy for sexual orientation alone, there’s still a strong lobby pressing to include gender identity in the ban.

The lack of evidence for such conversion therapy practices and the need to look at sexual orientation and gender identity separately has been documented extensively by Transgender Trend, including here, here and here and by the EHRC here.

But whatever happens with the bill, health professionals and therapists will remain constrained, and fearful of implementing the real changes outlined by Dr Hilary Cass while the ideological threat posed by the Memorandum of Understanding on Conversion Therapy (MoU) remains in place. Therapists who work with children are also bound by the strictures of the MoU. They have to agree that a patient’s belief in their gender identity, a girl’s belief that she is actually a boy for instance, is always to be affirmed. Any other approach is deemed conversion therapy.

It’s clear that the MoU now stands in direct conflict with the Cass Interim Report, compelling its signatories to an affirmative approach to treating patients. It demands that those treating gender confused young people agree:

“…. that the practice of conversion therapy, whether in relation to sexual orientation or gender identity, is unethical and potentially harmful.”

It goes on to imply that conversion therapy already takes place within NHS settings and may be:

“….covertly practised under the guise of mainstream practice without being named.”

Legitimate licenced therapists working privately and for the NHS have already felt the MoU’s silencing effect and have good reason to fear activists exploiting it.

The Impact of Cass

The publication of the Cass Interim Report in March reset the dial for NHS treatment pathways for children and in doing so ended the false equivalence between sexual orientation and gender identity. Her report described a complex area in which diagnosis was poorly evidenced and conflicted, based on models for very different patient cohorts to the ones now presenting at GIDS. She highlighted the disproportionate number of girls and looked after and neuro-diverse children attending the clinic. She found poor quality of evidence for puberty blockers, a lack of safeguarding in some cases, an absence of data on outcomes, dissent among clinicians over the affirmative model and stressed the fact that social transition is not a neutral intervention but one with profound consequences. She drew attention to the problem of ‘diagnostic overshadowing’, in which other mental health conditions are ignored by focussing on just one, gender.

In contrast to the certainties of the MoU she said:

“Primary and secondary care staff have told us that they feel under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.”

Her approach was based on the understanding that children with gender distress should receive the same level of clinical care as any other child seeking NHS treatment. Children being side-lined into the self-referential world of ‘transgender’ care clearly doesn’t meet this standard.

The Closure of GIDS

News that the GIDS clinic is to close as the national provider followed from Dr Cass’s recommendations in the Interim Report in which she said:

“It has become increasingly clear that a single specialist provider model is not a safe or viable long-term option.”

GIDS is to be replaced by two regional Early Adopter Services, one in London which will be a partnership between Great Ormond Street Hospital and Evelina London Children’s Hospital, with the South London and Maudsley NHS Foundation Trust providing specialist mental health support.

The second will be in the North West, led by Alder Hey Children’s NHS Foundation Trust and the Royal Manchester Children’s Hospital. Both trusts also provide specialist mental health services for children and young people.

Smaller regional centres with a stress on holistic care will be set up, which will be run by “experienced providers of tertiary paediatric care to ensure a focus on child health and development, with strong links to mental health services.” Children should be able to “access a broad range of services relevant to their individual needs, including supportive exploration and counselling.”

This stress on holistic care within a mental health setting for children is a fundamental break with the practices at GIDS and the approach to treating children with gender distress which is prescribed by the MoU.

MoU updated: March 2022

A few days before Dr Cass published her ground-breaking report yet another iteration of the Memorandum of Understanding on Conversion Therapy in the UK was published which included three new signatories and one new supporter.

The wording of the March 2022 version of the MoU remains the same including a promise to hold a formal review of the text in July 2021. Clearly no-one was paying attention to what they were signing. The new signers were NHS Wales, the mental health charity Mind and Spectra, a sexual health and well-being provider based in London, which offers ‘trans services.’

Control of the MoU is in the hands of a small group of activist therapists called the Coalition Against Conversion Therapy, CACT, chaired by Dr Igi Moon. Attempts to find out who else is part of the group, what decisions they take and even how to reach them by phone or email has been unsuccessful. Yet this secretive and unaccountable group is in charge of the rules for professional practice that governs every health worker, doctor, nurse, and the vast majority of therapists and counsellors working in Britain.

Dr Moon appeared before a committee of Scottish MPs in September 2021 where she made the unevidenced claim, at 11.04 on the recording, that patients, including children, were:

“pressurised to access services to change or suppress their identity. We know that the impact of that leads to anxiety and depression requiring medication, suicide attempts, self-harm and eating disorders. In young people, it leads to poor mental health, suicidality, internalised homophobia and transphobia, and psychiatric morbidity.”

This is the hyperbolic thinking behind the MoU; suppression of gender identity leads to dangerous co-morbidities and suicide. It illustrates perfectly how ‘diagnostic overshadowing’ works. And it couldn’t be further from the approach to be taken by the new gender identity services recommended by Dr Hilary Cass, which will treat gender distressed children within the broad range of mental health services.

Ghost signatories

That the MoU is an activist intervention rather than a reputable code of professional practice is made clear by looking at the names of the signatories on the March 2022 update. Eleven of the twenty-nine organisations are signed off by people who are no longer in post. NHS England’s backing for the MoU is signed by their National Medical Director, Sir Bruce Keogh, who stood down from the role in 2018. Similarly, Catherine Calderwood who signed for NHS Scotland is no longer their Chief Medical Officer. Other organisations with out of date signatures include the Royal College of GPs, the British Association for Counselling and Psychotherapy and the Association of Family Therapy.

This careless cut and paste job to the MoU, evidenced also by the March 2022 promise to review it in July 2021, indicates that those signing are not being contacted each time there is a change to the wording or a new supporter is included. It’s proof too that the promised oversight has not happened. Paragraphs 20 – 22 state:

“Signatory organisations will meet regularly to oversee the implementation of the MoU and monitor progress towards realising its intentions and goals.

Within the next five years, if funded, signatory organisations will seek to ensure appropriate research into the prevalence and effects of conversion therapy in the UK, and into how best to work with gender and sexually diverse clients.

The text of the MoU will be kept under review and altered, if necessary, in the light of new research or the appearance of unintended consequences. A full formal review will be conducted every three years from the date of the MoU hard launch (July 2018). The next formal review is due in July 2021.” 

This matters because all NHS staff in England, Wales and Scotland as well as most therapists are bound by this shoddy code. It’s also of note that the MoU says research into the “prevalence” of conversion therapy is needed. It’s clear the code of practice has no mechanism to monitor or research the very thing it outlaws and seeks to ban by legislation.

Influence of trans activists

New signatories show a strong alignment with the activist beliefs of the group controlling the MoU. The Anna Freud Centre, which was added to the MoU in 2022, has previously used GIRES training materials and currently lists Stonewall and the Intercom Trust as resources on its Mentally Healthy School pages. A video from Mermaids gives advice on supporting a ‘transgender child.’ No other approach to gender distress is offered. A search for the Cass Interim Report brings up no results.

A similar search of another new signatory, the mental health charity, Mind, shows no engagement with the Cass Review. Their LGBTIQ+ pages direct those needing support to Mermaids, Gendered Intelligence, Stonewall and GIRES. Co-morbidities experienced by trans identifying young people are explained as being a result of being trans, not as worthy of investigation in their own right.

Another recent signatory, Northern Ireland Humanists, has no expertise in mental health or the treatment of children with gender distress. Their team of six has however an LGBT coordinator.

The highest profile activist supporters of the MoU are Gendered Intelligence and Stonewall, both centrally involved in the campaign to ban conversion therapy for gender identity. Neither have any medical or clinical expertise. Stonewall should not have any role in writing a professional practice code for therapists. Their recent claim that two-year-olds are able to recognise their trans identity should be enough to bar them from any involvement with this or any other body dealing with children’s health.

Gendered Intelligence has joined the Good Law Project in seeking to overturn, by Judicial Review, the NHS’s decision to maintain an oversight body, the Multi Professional Review Group. This is the body set up to safeguard children after the Keira Bell Judicial Review exposed the failings at GIDS. Jay Stewart, who’s run the organisation since 2008, calls for bodily autonomy for children, denying that puberty blockers are harmful:

“Currently when we are born we are given a gender – an emphatic ‘it’s a boy’ or ‘it’s a girl’. That decision is based on genitalia. Each of us has no say in the gender that we are given. One could argue that it’s the first non-consensual act.”

“We need to do away with the false dichotomy of ‘reversible’ and ‘irreversible’ when talking about young trans people and decision making. It’s not useful. What is useful is for adults to process their fears of gifting children their right to autonomy.”  

The beliefs of these two groups are entirely at odds with the solid evidential base of Cass, which has shown that a person’s identity continues to change until their mid-twenties and that there is no good data as yet on the safety of puberty blockers.

Failure at the highest level

To date both NHS Wales and NHS Scotland, both MoU signatories, have yet to respond the Cass Interim Report or to the closure of GIDS. It’s unlikely that NHS Scotland will be able to engage with Cass given the dismissive response already expressed by Scotland’s First Minister, Nicola Sturgeon. Mark Drakeford, First Minister of Wales, was equally dismissive of the Interim Report calling it just  one source of evidence among others, implying that Wales was in possession of different research or that children in Wales are perhaps different to children elsewhere.

NHS England finds itself in the ridiculous position of implementing Dr Cass’s recommendations while remaining a signatory to a document that contradicts everything that Cass has written about the treatment of gender distress in children. The Royal Colleges of GPs and Psychiatrists are in the same untenable position.


Therapists have told us they cannot see how Cass can be fully implemented while the MoU remains in its present form. They have already felt its baleful influence. It gives activists in signatory organisations the right to demand policing of dissidents and space to promote gender ideology. The British Association for Counselling and Psychotherapy, with its membership of around 50,000 therapists, recently hosted a training session titled, Queering Therapy Spaces, and has a history of silencing dissent on the treatment of young people experiencing gender identity issues.

The next government and health secretary will need to face up to the contradiction of having a code of practice which undermines the very basis of the Cass Review. They have to decide whether to back the authority and expertise of Dr Cass and her careful child centred approach or those who would transition a toddler and give them life changing drugs at puberty.

It may be that the Cass team will draw up a code of practice to guide all those who work with gender distressed children, one that will supersede the MoU and give clarity and protection to clinicians and therapists to operate without fear of prosecution. Such a move would be widely supported.

Then we could leave the activists to talk to themselves, deaf to the overwhelming evidence against their treatment model, while their MoU fades rightfully into irrelevance. 

This Post Has 2 Comments

  1. Adam Hibbert

    This YouTube video from TACT was instructive. Talking amongst themselves, they rehearse quite openly in public the reasoning behind the MoU. Moon is there, with Dominic Davies hosting.

    Notice how they first discuss the challenge of a gay client presenting with a desire to become straight, opting into conversion therapy – they talk about this patient’s goals as coming from a place of fear, and how a good therapist will judge accordingly and work around that to help the patient come to terms with what they actually are.

    The conversation moves on to the discussion of ‘trans’ patients presenting with a desire to become the other gender, and the story flips. Here, it would be ‘infantilising’ of the therapist to make any judgement about the validity of the client’s goals, to consider the possibility they’re driven by fear, or to help them come to terms with what they are.

    It’s a really salutary, glaring example of the anomalous nature of affirmative care in gender protocols.

  2. Kitty

    What is the best thing to do with your article? I will forward to my MP for a start.

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