By leaving transgender people out of their proposed conversion therapy bill, the government has angered trans activist and LGBTQ+ organisations. Allowing more time to consider the potential unintended consequences on professional treatment services for children experiencing gender-related distress is a responsible decision given the sobering findings of the Cass Review interim report. But the government faces huge pressure from the trans lobby to rush through the bill anyway, without proper pre-legislative scrutiny. A petition signed by over 145,000 people is to be debated in parliament on Monday June 13th.
On this issue there are two distinctly different messages we need to pay attention to. One (the louder voice) is a political activist message; the other is the voice of clinical facts and evidence. The first voice is Stonewall, the second is Hilary Cass, who was commissioned by the NHS to review the service at the Tavistock GIDS. It is interesting to compare the language of the activists versus the paediatric expert in order to assess which one has the best interests of children at heart and which voice should be listened to when considering the risks of adding ‘transgender’ to a conversion therapy bill.
It is also interesting to note who is listening to Stonewall and who is listening to Cass on this issue. The government in its decision has clearly, and rightly, listened to Cass. Conversely, a number of professional health bodies and counselling services, the Tavistock GIDS and the NEU have ignored Cass and are listening to Stonewall, along with other trans and LGBT+ lobby groups.
Stonewall’s position regarding children is clear in their response to the government consultation on the conversion therapy bill:
“We have travelled a path from Section 28, and the total suppression of LGBTQ+ identities in schools.”
“There must be a clear distinction between legitimate treatment and healthcare that supports people to be themselves, and targeted conversion practices that only seek to change, “cure”, or suppress.”
“Some of the young people who attend GIDS consider some sort of medical transition. No fully irreversible medical interventions are offered to children and young people. The decision to begin taking hormone blockers or cross-sex hormones is made between specialist clinicians, the young person and their family.”
“The Government should clearly state these established medical pathways for children and young people are not within scope of the proposed legislation.”
https://www.stonewall.org.uk/system/files/stonewall_-_response_to_the_government_open_consultation_on_banning_conversion_therapy_003.pdf
To summarise, Stonewall places children within a wide umbrella group of sexual and gender identities, frames ‘legitimate’ treatment as that which supports children “to be themselves” and prioritises the protection of a medical transition pathway for children, falsely claiming that hormone treatments are “fully reversible.” Stonewall campaigns from this politicised position.
The basis of Stonewall’s political campaigning is not consistent with the facts and evidence in the Cass interim report:
2.18. The disagreement and polarisation is heightened when potentially irreversible treatments are given to children and young people, when the evidence base underlying the treatments is inconclusive, and when there is uncertainty about whether, for any particular child or young person, medical intervention is the best way of resolving gender-related distress.
3.30. In the short-term, puberty blockers may have a range of side effects such as headaches, hot flushes, weight gain, tiredness, low mood and anxiety, all of which may make day-to-day functioning more difficult for a child or young person who is already experiencing distress. Short-term reduction in bone density is a well-recognised side effect, but data is weak and inconclusive regarding the long-term musculoskeletal impact.
3.32. A closely linked concern is the unknown impacts on development, maturation and cognition if a child or young person is not exposed to the physical, psychological, physiological, neurochemical and sexual changes that accompany adolescent hormone surges. It is known that adolescence is a period of significant changes in brain structure, function and connectivity.
We only need compare the language of Stonewall with the language of the Cass interim report to see that one is political sloganeering and the other is factual and evidence-based. Here is a summary of the main themes and who is expressing them:
1. Your ‘gender identity’ is ‘who you really are’ or ‘your authentic self.’
– An assumption of certainty and a fixed, immutable identity.
We imagine a world where LGBTQ+ people everywhere are free to be themselves. Stonewall
Mermaids’ overarching aim is to create a world where trans young people can be themselves. Mermaids
Anyone accessing therapy should be able to do so without fear of judgement or the threat of being pressured to change a fundamental aspect of who they are. British Association of Counselling and Psychotherapy (BACP)
The Centre is absolutely opposed to conversion ‘therapy’ and believes that all young people should be free to be who they are without any pressure to change, suppress, or deny their sexual or gender identity. Anna Freud National Centre for Children and Families
Cass assumes no such fixed certainty, including in cases where the young person themselves is very certain:
2.8 It is not unusual for young people to explore both their sexuality and gender as they go through adolescence and early adulthood before developing a more settled identity.
4.15. Clinicians and associated professionals we have spoken to have highlighted the lack of an agreed consensus on the different possible implications of gender-related distress – whether it may be an indication that the child or young person is likely to grow up to be a transgender adult and would benefit from physical intervention, or whether it may be a manifestation of other causes of distress.
5.12 Firstly, the clinician will seek to determine whether the child or young person has a stable transgender identity, or whether there might be other causes for the gender-related distress.
4.4. Most children and young people seeking help do not see themselves as having a medical condition; yet to achieve their desired intervention they need to engage with clinical services and receive a medical diagnosis of gender dysphoria. By the time they are seen in the GIDS clinic, they may feel very certain of their gender identity and be anxious to start hormone treatment as quickly as possible.
4.14. We have also heard from adults who identified as transgender through childhood, and then reverted to their birth-registered gender in teen years.
3.22. Regardless of the nature of the assessment process, some children and young people will remain fluid in their gender identity up to early to mid-20s, so there is a limit as to how much certainty one can achieve in late teens. This is a risk that needs to be understood during the shared decision making process with the young person.
1.7. At primary, secondary and specialist level, there is a lack of agreement, and in many instances a lack of open discussion, about the extent to which gender incongruence in childhood and adolescence can be an inherent and immutable phenomenon for which transition is the best option for the individual, or a more fluid and temporal response to a range of developmental, social, and psychological factors.
4.14. The issues faced by detransitioners highlight the need for better services and pathways for this group, many of whom are living with irreversible effects of transition but for whom there is no clear access to services as they fall outside the responsibility of NHS gender identity services.
2. Trans people are particularly at risk
– Stonewall and their supporters present claims that transgender people are more at risk of conversion therapy than gay people, using as evidence a poorly designed study which was not able to show such results:
Trans people are amongst the highest risk groups in our community. Stonewall
And we know that trans and non-binary people – including the young trans and non-binary people for whom we care – are most at risk. Gendered Intelligence
Trans people are already most vulnerable to being subjected to so-called conversion therapy. British Medical Association (BMA)
“The government’s own research found that transgender people were more likely to have undergone or been offered conversion therapy. British Psychological Society (BPS)
The Government’s own research suggests that trans people are much more likely to have undergone, or been offered, conversion therapy, so this exclusion simply makes no sense. Mind
The government’s own data illustrates that trans people are at much higher risk of being victim to this abhorrent practice than the rest of the LGBTQIA+ community. Mermaids
All the evidence that does exist points to clear ongoing and present damaging conversion practices being targeted at LGBTQ+ people, and that transgender, non-binary and other gender diverse people are proportionally at higher risk of this. Ban Conversion Therapy Coalition
The UK Government’s own data shows that Trans people are more likely to be subjected to so-called conversion therapy, with data showing even higher risk for Black Trans people. LGBT Consortium
From the Cass interim report it appears that within clinical settings the opposite is true: children are affirmed as transgender without sufficient exploration of any underlying issues or causes of their distress:
1.14. 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.
1.18. From the point of entry to GIDS there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision.
1.20. Within the Dutch Approach, children and young people with neurodiversity and/or complex mental health problems are routinely given therapeutic support in advance of, or when considered appropriate, instead of early hormone intervention. Whereas criteria to have accessed therapeutic support prior to starting hormone blocking treatment do not appear to be integral to the current NHS process.
3. Promotion of the Memorandum of Understanding on Conversion Therapy (MoU)
The professional practice guide the Memorandum of Understanding on Conversion Therapy allows for therapeutic exploration only if someone is unhappy about their gender identity, whereas adolescents are typically very confident and certain:
“For people who are unhappy about their sexual orientation or their gender identity, there may be grounds for exploring therapeutic options to help them live more comfortably with it, reduce their distress and reach a greater degree of self-acceptance.”
https://www.bps.org.uk/news-and-policy/memorandum-understanding-conversion-therapy-uk
–The MOU is supported by Stonewall and other bodies, despite the fact that there has been no research carried out, nor any consultation with members to gather evidence that it has had no chilling effect on therapists and clinicians:
The dangers of conversion practices led leading psychological, psychotherapy, therapy, counselling and mental health organisations, along with NHS England and NHS Scotland to sign a Memorandum of Understanding to commit to ending the practice. Stonewall
The Government should adopt the MoU definition of conversion therapy. Coalition Against Conversion Therapy (CACT)
There is no justifiable reason to abandon this ban. The British Association for Counselling and Psychotherapy (BACP) produced a Memorandum of Understanding in 2016 that makes clear that conversion practices based on sexuality or gender are “unethical, potentially harmful and [are] not supported by evidence”. Gendered Intelligence
The BPS is clear that conversion therapy is unethical and potentially harmful, in line with the Memorandum of Understanding on Conversion Therapy which the BPS has signed. BPS
The Cass report however, in several places, references the concerns of therapists and clinicians who feel pressured to adopt an ‘affirmative’ approach:
4.20. Some secondary care providers told us that their training and professional standards dictate that when working with a child or young person they should be taking a mental health approach to formulating a differential diagnosis of the child or young person’s problems. However, they are afraid of the consequences of doing so in relation to gender distress because of the pressure to take a purely affirmative approach. Some clinicians feel that they are not supported by their professional body on this matter.
4.25. The importance of broad holistic interventions to help reduce distress has been emphasised to the Review, with therapists and other clinicians advocating the importance of careful developmentally informed assessment and of showing children and young people a range of different narratives, experiences and outcomes.
10: Any child or young person being considered for hormone treatment should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing. This formulation should then inform what options for support and intervention might be helpful for that child or young person.
Some clinicians also reported feeling unable to undertake the process of assessment and differential diagnosis that would be the norm in their clinical practice because they perceived that there is an expectation of an unquestioning affirmative approach. They felt that this was at odds with a more open and holistic evaluation of the factors underpinning the young person’s presentation, and consideration of the full range of possible support and treatment options.
4. Discrimination/abuse/torture/cruelty/suicide
–Historic abusive gay conversion practices are used to imply that transgender people face similar conversion practices today:
All forms of conversion practices are abusive and harmful. All forms, both physical and non-physical, subject individuals to ongoing messages that they are wrong, broken, or ill, and cause lasting psychological damage with higher rates of anxiety, depression, suicidal ideation, and suicide attempts.
He now proposes a partial ban, one that protects lesbian, gay and bi cis people, but leaves trans people, including trans children, at continued risk of abuse. It is apparent that trans people have once again been sacrificed for political gain. Stonewall
By actively excluding trans and non-binary people from the ban, the government has decided to condone conversion abuse for our community. Mermaids
To allow conversion practices of any kind to continue in law is to endorse violence against marginalised communities.To exclude trans and non-binary people from legal protections is to allow a legalised form of torture for a specific group of people. Gendered Intelligence
A total ban empowers people to leave abusive situations and creates a sense of safety that their Government supports them. Explicitly removing protection for transgender people sends the opposite message just as powerfully.
While the current patchwork of legislation may cover many activities that could be considered conversion therapy, vulnerable marginalised people experiencing this kind of abuse cannot be expected to understand what is and is not in that scope. Tavistock Gender Identity Development Service (GIDS)
That the Government can recognise a set of practices, methods and activities as ‘abhorrent’, damaging and cruel for one group but suggest that those same practices, methods and activities can be acceptably perpetrated on another group is profoundly troubling.
For those subjected to it, it can also increase the risk of long-lasting psychological harm, substance abuse, or even suicide. Many acts of conversion therapy amount to torture, inhuman or degrading treatment or punishment. British Medical Association (BMA)
We believe that the best way to reduce the high levels of distress that the trans community experiences is to challenge the discrimination, prejudice and violence that they disproportionately experience, to accept and celebrate people for who they are and who they want to be. Anna Freud
Conversion therapy causes severe physical and psychological suffering, violates the human rights of all LGBTQ+ people, and has been called a form of torture. Royal College of Psychiatrists (RCPSYCH)
The Cass report on the other hand, specifies the need for differential diagnosis and the importance of showing young people a range of different narratives and outcomes. By the MOU definition, this could be interpreted as a form of conversion therapy, all forms of which have been characterised as abusive and damaging by Stonewall:
4.10. Another significant issue raised with us is one of diagnostic overshadowing – many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be subsumed by the label of gender dysphoria.
5.18. As outlined above, it is standard clinical practice to undertake a process called differential diagnosis. This involves summarising the main points of the clinical assessment, the most likely diagnosis, other possible diagnoses and the reasons for including or excluding them, as well as any further assessments that may be required to clarify the diagnosis and the treatment options and plan. This is important when a medical intervention is being provided on the basis of the assessment, so the process is robust, explicit and reproducible.
4.25. The importance of broad holistic interventions to help reduce distress has been emphasised to the Review, with therapists and other clinicians advocating the importance of careful developmentally informed assessment and of showing children and young people a range of different narratives, experiences and outcomes.
10. Any child or young person being considered for hormone treatment should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing. This formulation should then inform what options for support and intervention might be helpful for that child or young person.
9. Assessments should be respectful of the experience of the child or young person and be developmentally informed. Clinicians should remain open and explore the patient’s experience and the range of support and treatment options that may best address their needs, including any specific needs of neurodiverse children and young people.
Exploratory approaches: Therapeutic approaches that acknowledge the young person’s subjective gender experience, whilst also engaging in an open, curious, non-directive exploration of the meaning of a range of experiences that may connect to gender and broader self-identity.
5. Trans, cis, non-binary, LGBTQ+
–Stonewall and their supporters use ideological language and extend the range of (undefined) groups they demand to be covered by a conversion therapy ban:
Conversion therapy is happening to LGBTQ+ people in the UK right now, and every day without a ban is a day where LGBTQ+ people remain at risk of lifelong harm.
Similarly, the definition in the proposals makes it unclear whether all LGBTQA+ people will be protected.
Stonewall uses LGBTQ+ people here to include lesbian, bi, gay, trans, non-binary, queer, gender diverse and asexual people.
All forms of conversion practices are inherently discriminatory as their driving belief is that being LGBTQ+ is inferior, broken, an illness, and/or morally or ethically wrong or sinful, and that to be heterosexual or cisgender is superior, healthier, and/or the only acceptable way of being. Stonewall
The ban must extend to and protect trans and non-binary people equally.
This perpetuates prejudice and undermines the wellbeing and rights of LGBT+ people. National Education Union (NEU)
A person being gay, straight or another sexuality does not preclude them being trans or cis, or any other gender identity. GIDS
Conversion therapy can cause very serious harm and any ban that does not explicitly protect trans, asexual, non-binary and other people at risk of conversion therapy will not be fit for purpose.
We urge the government to work with us and other organisations representing the LGBTQ+ community and mental health professionals to rectify the situation. UK Council for Psychotherapy (UKCP)
We use ‘LGBTQIA+’ rather than ‘LGBT+’ to make clear that a ban must ensure protection for all marginalised sexual orientations, gender identities and intersex people. LGBTQIA+ stands for: Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, +=inclusive.
We use ‘trans’ as an umbrella term for people that are binary trans, non-binary, genderqueer, genderfluid, agender or of other non-cisgender genders, including those of non-Western origin.
The ban should cover all conversion practices in all forms and settings, for all LGBTQIA+ people of all ages. Mermaids
We believed then – as we know now – that the Commission had no intention of protecting the LGBTQIA+ community. Gendered Intelligence
EHRC has ignored the experiences of trans and non-binary individuals who have undergone unnecessary trauma. They suggest that LGBTQ+ lives are up for debate and medical scrutiny. LGBT Foundation
While the Government might feel they have secured a moral victory in banning ‘conversion therapy’ for gay and bisexual people, it means nothing until every member of the LGBTQ+ community is freed from this barbaric practice. BMA
Conversion therapy refers to attempts to change a person’s sexual orientation or gender identity, based on the assumption that being LGBT+ should be ‘cured’.
However, it should be acknowledged that lesbian, gay, bisexual, trans (LGBT) and other gender and sexual diverse people (e.g. asexual and non-binary people) are usually the targets of conversion practices. BPS
We urge Government to reconsider its plans to ban so called conversion therapy only for cisgender people, and we fully support calls for the ban to cover transgender people. RCPSYCH
Cass does not use ideological terms to describe the patient base, and does not place children within a wide group of people with a range of differing sexual and gender identities. The interim report does not use the terms ‘transgender children’ or ‘cisgender children’ but describes them accurately as “children and young people presenting with gender-related distress.”
5.14. When it comes to gender dysphoria, there are no blood tests or other laboratory tests, so assessment and diagnosis in children and young people with gender related distress is reliant on the judgements of experienced clinicians.
6.7. Additionally, children and young people with gender-related distress have been inadvertently disadvantaged because local services have not felt adequately equipped to see them. It is essential that they can access the same level of psychological and social support as any other child or young person in distress, from their first encounter with the NHS and at every level within the service.
Cass concludes:
6.8. A fundamentally different service model is needed which is more in line with other paediatric provision, to provide timely and appropriate care for children and young people needing support around their gender identity. This must include support for any other clinical presentations that they may have.
No other service model affirms a child’s self-diagnosis (even if the child is very certain of it) and prescribes the medication the child wants. No other clinical or psychological condition is politicised and tied in with an adult activist agenda as this one is. Although Mermaids and Gendered Intelligence published short responses to the Cass interim report, not one of the professional bodies has done so.
Stonewall claims to have read the Cass interim report and on March 10th promised an in-depth analysis would be coming. We are still waiting.
In her BMJ article, Hilary Cass makes this plea:
“However, with the best will in the world, the commissioner cannot effect change without strong support from clinical staff at all levels in the NHS. It is particularly important that Medical Royal Colleges and other professional organisations support their members to engage in meaningful and respectful debate about the underlying issues, to work with the Review team to develop consensus solutions to some of the thornier questions about assessment and treatment, and to take on the care of this important and under-served group of children and young people.”
A simplistic political aim to ban conversion therapy for transgender people without fully examining the impact this may have on the treatment of children and young people experiencing gender-related distress will not achieve this.
We hope that the professional Health and Education bodies will listen to Hilary Cass with an open mind. The political stance they have taken, reflected by the language they use, represents a fixed and closed view which does not serve the best interests of children who deserve the best standards of clinical care and support.
All quotes taken from the following published statements:
Stonewall https://www.stonewall.org.uk/system/files/stonewall_-_response_to_the_government_open_consultation_on_banning_conversion_therapy_003.pdf
https://www.stonewall.org.uk/safe-to-be-me
Coalition Against Conversion Therapy https://www.bacp.co.uk/media/13524/mou-key-messages-on-the-governments-conversion-therapy-consultation.pdf
Ban Conversion Therapy Coalition https://static1.squarespace.com/static/5efc4344362f4379c92231da/t/61f2823b986c781146487ff9/1643283003599/BCT+coalition+response+to+EHRC+FINAL.pdf
Mermaids https://mermaidsuk.org.uk/news/the-government-condones-trans-conversion-abuse/
https://mermaidsuk.org.uk/news/safe-to-be-me-conference/
Gendered Intelligence https://genderedintelligence.co.uk/latest/conversionpractices-010422.html
https://genderedintelligence.co.uk/services/publicengagement/ehrc-26thjan
LGBT Consortium https://www.consortium.lgbt/banconversiontherapy/
LGBT Foundation https://lgbt.foundation/news/lgbt-foundation-to-sever-all-ties-with-the-ehrc/455
British Association of Counselling and Psychotherapy https://www.bacp.co.uk/news/news-from-bacp/2022/1-april-disappointment-on-conversion-therapy-ban-proposals-latest/
UK Council for Psychotherapy https://www.psychotherapy.org.uk/news/ukcp-statement-conversion-therapy-ban/
Tavistock and Portman NHS Foundation Trust https://tavistockandportman.nhs.uk/about-us/news/stories/a-ban-on-conversion-therapy-should-include-protections-for-trans-people/
British Psychological Society https://www.bps.org.uk/news-and-policy/decision-exclude-transgender-people-conversion-therapy-ban-deeply-worrying-says-bps
https://www.bps.org.uk/news-and-policy/banning-conversion-therapy-consultation-response
Royal College of Psychiatrists https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2022/04/01/government-should-reconsider-its-plans-to-not-ban-conversion-therapy-for-transgender-people
Anna Freud National Centre for Children and Families https://www.annafreud.org/insights/news/2022/04/statement-on-government-decision-not-to-outlaw-trans-conversion-therapy/
British Medical Association https://www.bma.org.uk/bma-media-centre/ban-on-conversion-therapy-must-extend-to-every-member-of-the-lgbtqplus-community-says-bma
National Education Union https://neu.org.uk/press-releases/conversion-therapy
Hilary Cass
Interim report: https://cass.independent-review.uk/publications/interim-report/
British Medical Journal article https://www.bmj.com/content/376/bmj.o629
Gendered Intelligence response to Cass report https://genderedintelligence.co.uk/services/publicengagement/cassreview-140322
Mermaids response to Cass report
https://mermaidsuk.org.uk/news/the-cass-review-interim-report-mermaids-statement/
Thank you again for all the hard work that you do in disseminating all the nonsense and bringing it into the light.
Thank you. It is frightening to watch how Stonewalled they are, trotting out falsehoods and repeating the word ‘abhorrent’. What happened to safeguarding children?