Gender identity treatment needs greater caution

When considering the interim report by Dr Hilary Cass on gender identity services for children and young people, your article overemphasises the long waiting list and underemphasises that it was a waiting list for the wrong treatment, as Cass makes clear (‘A contentious place’: the inside story of Tavistock’s NHS gender identity clinic, 19 January).

A clinician you quote says some staff left the Gender Identity Development Service (Gids) “in a destructive way”. They did not – they raised serious concerns with their managers which resulted in their intimidation. These concerns were borne out by the Cass review – particularly that as a result of the ideological penetration of Gids, it abandoned clinical neutrality and downplayed the significance of other serious conditions in this patient group. The Cass report makes clear that these children have been disadvantaged and that there is a lack of evidence for the “Dutch Approach” to treating them, involving puberty blockers.

Almost all children on puberty blockers continue to opposite-sex hormones; an unknown number progress to major surgery. The ethical weight of the decision to commence the medical pathway is freighted with that knowledge.

The employment tribunal case brought by Sonia Appleby, child safeguarding lead for the Tavistock, revealed an intimidating culture dismissive of risk. And Keira Bell did not “sue” the Tavistock, but won a judicial review on the issue of consent. While this was overturned, serious concerns raised by the judges on clinical governance – record-keeping, complete absence of follow-up etc – still stand. The CQC found Gids “inadequate”.

Your article makes no reference to the growing group of detransitioners – those who regret the irreversible damage done and feel that their “treatment” was based on ideology, not appropriate clinical concern. Many suffered from confusion in relation to same-sex attraction; when I investigated Gids, this was largely ignored.

A child’s wishes must be taken seriously, but can be only one factor in reaching an overall decision about their best interests, in a highly charged and complex situation. Given the uncertainty surrounding diagnosis and treatment of gender dysphoria, the UK should, like Finland, Sweden and France, follow a more cautious path; we should end medication and medical transition for children and adolescents now.
Dr David Bell
Former staff governor, Tavistock and Portman NHS foundation trust