Opened in 1989, and closed following a litany of scandals last year, GIDS — the UK’s only specialist service designed to help children questioning their gender and/or identifying as transgender — drew on just one, since widely critiqued, study to underpin its practice. This, despite the fact that it has treated roughly 2,000 young people with hormone blockers and in some cases cross-sex hormones.

“The Dutch Protocol” describes a three-step treatment pathway for children with gender-related distress or incongruence. It starts at the brink of puberty with puberty blockers to prevent the development of secondary sex characteristics, is followed by cross-sex hormones that help to feminise or masculinise appearance, and then concludes with genital and/or breast surgeries in adulthood. The Dutch reported that, after puberty suppression alone, their cohort of 70 young people experienced a reduction in behavioural and emotional problems, decreased symptoms of depression and a significant improvement in functioning. Despite choosing to make medical treatments available to younger children from 2014 anyway, GIDS were not able to replicate the Dutch findings — a fact they didn’t share with the world until 2021.

Given the increasing polarity among professionals on the matter, Dr Hilary Cass, a former President of the Royal College of Paediatrics and Child Health, was employed by the NHS to conduct a review of the published evidence on the use of puberty blockers and cross-sex hormones in children and young people with gender dysphoria. In March 2021, she concluded that they had not been able to find evidence “strong enough to form the basis of a policy position”. It was clear then, at least to those paying attention, that the evidence needed to justify the existing clinical practice in Gids did not exist. And yet, it wasn’t until last month that the NHS announced it would no longer be offering puberty blockers to young people in England and Wales.

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Today, as Cass finally publishes the results of her wide-ranging review, the reason seems obvious: her 388-page report concludes that, for most young people, up to the age of 25, “a medical pathway will not be the best way to manage their gender-related distress”. Commenting further on the lack of evidence, she states that not only is there no way for a clinician to accurately determine who will continue to identify as trans for life and who won’t, but that the fundamental rationale for using puberty blockers in the first place “remains unclear”. She speaks of the need to balance medical innovation with the potential “creep of unproven approaches into clinical practice” and calls for the use of “standard evidence-based” interventions instead.

Cass also makes it clear that the factors influencing gender-related distress might be as much social as psychological or biological, with a particular focus on the new cohort of adolescent girls who now make up the majority of gender clinic patients. Instead, she suggests, we need to draw on bio-psycho-social thinking to ensure that future child patients receive the safe and effective care they deserve.

The motivation behind this isn’t hard to glean. The sociological “broken windows” theory hypothesises that, once something becomes damaged just a little, it sends a message that the thing is no longer of value at all, and leads to further vandalism. At heart, the Cass Report is an attempt to prevent this from happening: it punctuates a process that, left unchallenged, might have led to further extraordinary practices creeping into other areas of psychology or medicine.

For those of us working in the field of gender, the influence of social media on adolescent mental health, in multiple and complex ways, has been undeniable. What gets less attention is the impact on us, the adults and professionals. After all, we are just as vulnerable to social influence, including misinformation. One of the factors that has led to the increased demand for medical interventions from gender-distressed young people are the ideas, widely shared on social media platforms as facts, that the medical pathway is not only safe but effective, even life-saving, for all.

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Despite the absence of face validity or the long-term data needed for such certainty, some have claimed that regret rates for the surgeries many Gids patients received during early adulthood are lower than for knee surgeries. Yet, as the Cass Report highlights, some of the “facts” shared online are not certainties but myths. Sadly, for example, some young people do later experience profound regret — a reality that Cass acknowledges in her recommendation that “NHS England should ensure there is provision for people considering detransition”.

Yet rather than accept Cass’s rational, evidenced conclusions, a number of professionals and institutions will no doubt continue to argue with certainty that access to medical interventions is both a necessity and a human right. They already call for their colleagues to join them in becoming “practitioner-activists”. Others openly describe their motivation to pursue the medical approach Cass wishes to end as being “based on how passionate we are about the work”. Passion can be a good thing, of course, when aligned to evidence and fact. But when passion becomes untethered to these, or worse tethered to misinformation, it risks transporting us into a troublesome arena. Such an approach has already led to serious lapses in best practice and governance, particularly in relation to the use of puberty blockers for children. The question now is: will such extraordinary practices be able to continue post-Cass?

This is where a sense of concern starts to creep in. For while NHS England has refocused on the need for evidence-based interventions in recent years, some practitioners have already made clear their resistance to this. Last year, we heard that the endocrinologist responsible for prescribing to Gids patients had questioned whether the Cass Review was necessary in the first place. Leaders in the field of clinical psychology have also challenged the need for the review, and splits in the UK’s two psychology associations have been apparent for a while now, with one publicly criticising Cass. Remarkably, as today’s report discloses, the NHS’s adult gender clinics have also set themselves up in opposition to evidence and research, by refusing to participate in the Cass Review’s centrepiece longitudinal research study — an attempt, albeit retrospective, to follow into adulthood the 10,000 young people who’ve been through GIDS’s doors.

In an attempt to explain away such behaviour, some have sympathetically described GIDS as a “justice project”. Yet, in her interim report, published in February 2022, Cass made clear that the implications of GIDS’s approach were far more serious than this: its clinical approach, she wrote, had “not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced”. Just over two years later, she ends her final report by remarking that, while GIDS clinicians were “passionate and wholly committed to their care, [they] had developed a fundamentally different philosophy and approach compared to other paediatric and mental health services”. This deviation from best practice was, in other words, an injustice, and resulted in one group of children receiving less robust standards of care than others.

To mitigate this, Cass invites a return to the ordinary, and an embrace of the scientific method. And this requires sensitivity: after all, understanding why gender-distressed and non-conforming people might have been reluctant to trust ordinary science, medicine and psychology/psychiatry should also be part of the post-mortem to come. Medical approaches and institutions haven’t always been a safe place for them. Sadly, this is not the first time that gender non-conforming people have been considered so different as to require extraordinary treatment. Perhaps Cass’s recommendation to offer regular treatments to our distressed, but still ordinary, children and young people is where the true justice will begin.

War tends to increase social cohesion, leaving those statistically at the edge, exposed. And in the aftermath of World War Two , discrimination against gay people reached its zenith. “Homosexuals” were thought too different to be tolerated: they were criminalised and given a psychiatric diagnosis and “treatment”. Considered relatively benign, the so-called “conversion therapy” was deemed a way for troubled people to avoid worse fates and social rejection. Some gay men and women requested the “therapies”, presumably with the hope of passing through life more easily and being socially affirmed as “acceptable”.

Today, conversion therapy is at the heart of another war, as the Government attempts to ban it. Again it involves a marginalised cohort, who despair of fitting in. But this time, “conversion therapy”, which was always ill-defined, has taken on several different meanings.

The term is used to describe a range of medical and psychotherapeutic interventions, early versions of which were offered to gay men and women on the NHS during the Fifties — although these were focused on aversion more than conversion. Pavlovian attempts were made to disrupt any association between (same-sex) sexual stimuli and sexual responses, with electric shocks or medically induced vomiting. Later therapists attempted to actively re-orientate people’s sexuality towards heterosexual stimuli. Methods also included religious counselling, talking therapies, and finally, for some gay men, hormonal treatments.

These attempts to either avert homosexuality or convert lesbian, gay and bisexual (LGB) people to heterosexuality didn’t work — and even killed people. Alan Turing committed suicide two years after opting for “chemical castration”, rather than imprisonment.  Eventually, though, society started to shift. In 1967, homosexuality was decriminalised in England. In 1973, the term was removed from the 2nd version of the Diagnostic Statistical Manual (DSM-II), a handbook used by healthcare professionals to guide the diagnosis of mental disorders. Outside of LGBT communities, the concept of conversion therapy may have comfortably drifted out of consciousness for a while.

The collective amnesia did not last long. In 2011, The Guardian reported that some religious therapists were still trying to convert gay men. This forced therapy organisations in the UK to confront their history, and in 2015 the first Memorandum of Understanding (MOU) on Conversion Therapy was signed by 16 organisations. All agreed that it was unethical for a therapist to try to change someone’s sexual orientation via any means. Two years later, a second memorandum — the MOU2 — was announced. This one had expanded the concept of conversion therapy to include any “therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other”. The inclusion of “gender identity” is significant.

Gender identity is the term used to describe the profound internal sense that some people have of their maleness, or femaleness, or neither. Gender non-conformity didn’t escape diagnosis for long; when the updated DSM-III was introduced in 1980, the concept of “gender identity disorder”, previously absent, slipped into the gap left by homosexuality.

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In July 2018, the day before the MOU2 was officially launched in parliament, the government presented the results of its National LGBT Survey. The online survey of more than 108,000 self-selected respondents stated that, overall, 5% of respondents had been offered conversion therapy, and 2% had taken it up. This rose to 9% and 4% of transgender respondents.

The idea that conversion therapy could still happen in modern Britain is abhorrent to most. And this is why there has been a move to ban it in parliament.. Yet feelings and facts matter. The LGBT survey did “not provide a definition of conversion therapy”. As such, the survey measures whether people perceived something to have been conversion therapy. Furthermore, for those who did feel they had been offered it, only 19% said that it was via a healthcare provider or medical professional. No one knows how many of these were in the NHS.

It is easy to think we understand what we are talking about when it comes to conversion therapy when maybe we don’t. And given the controversy over Government’s decision to include trans people in criminalisation of the practice, it’s vitally important that we do.

In 2018, no one claimed to be receiving electric shock treatments, or medically induced nausea. These interventions are of course already and rightfully illegal. So what is it exactly that people are experiencing? In the NHS, the only conversion therapy treatments that are still offered — albeit not with the aim of “converting” homosexuals — are talking therapies and hormonal interventions.

Let’s address talking therapy first. There is no doubt that some “therapists” will have actively tried to alter their patients’ gender and sex-related thoughts, feelings and/or identities. We have troubling anecdotal evidence that this has happened to some trans-identified people in modern Britain. Whether this is happening away from religious settings — in the NHS or mainstream clinical or psychological practice — is harder to ascertain, but it is possible. After all, potentially damaging interactions between mental health professionals and trans- or gender-questioning people aren’t a new phenomenon.

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Treatments attempting to convert gay and lesbian people to heterosexuality were just as unethical and also failed. But they gave rise to an affirmative practice which has taken hold today and which includes medicalisation. “Gay Affirming Therapy” was developed in the early Eighties as a reparative response. This approach wasn’t intended to be a whole-scale model of care, but a therapeutic position wherein the clinician demonstrated warmth and acceptance of a client’s non-heterosexual identity to counterbalance negative messages from society.

It is this affirmative position which has been adopted, and adapted, by clinicians working with transgender adults and gender-incongruent children. But the term “affirmative care” has changed. It has morphed to include, the offer at least, of “medical affirmation” — or hormonal intervention. Medical gender affirmation aims to help reduce an individual’s suffering by trying to better align their physical body with their felt gender identity. The World Health Organization defines it thus: “Gender-affirmative health care can include any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.” Note here how the idea of hormonal interventions has been turned on its head, previously offered as a “conversion therapy” for gay men.

Despite the fact that there is no consensus or good quality evidence to demonstrate that — on balance, on average and over time — these novel gender-affirming medical interventions do reduce suffering, and despite the evidence that they will certainly harm some, many people report that for them, personally, they have felt “life-saving”. These evocative first-person narratives have led some to argue that access to gender-affirming medical interventions should be a human right. From this vantage, anything other than immediate affirmation can be considered equivalent to conversion therapy. As a result, psychotherapy, which might explore different ways of understanding ourselves and in doing so may delay medical intervention, is now understood by some as inherently harmful.

This leaves us in a position whereby offering a medical intervention to someone who identifies as LGB is very clearly understood to be conversion therapy, while not offering the (sometimes same) treatment to someone who identifies as transgender is also understood, by some, to be conversion therapy. Meanwhile, offering psychotherapy that aims to reduce distress by increasing self-acceptance without the need for change is seen as the right approach for LGB people but, sometimes, the wrong one for transgender people.

To complicate things even further, the population of people understood to be transgender has broadened. “Trans” has become an “umbrella term” under which a broad range of experiences are collated. As well as those who identify as the opposite sex, the category now includes gender-questioning people, gender non-conforming people and the gender fluid, among others — depending on who is defining it. The term non-binary, used to describe people who identify as neither male nor female, entered the clinical literature less than a decade ago, but is already being medically treated in the NHS.

We must also note that the demographics of those who identify as trans have also changed significantly over the recent years. No one yet knows why. These changes are particularly striking in younger people, with the number of adolescents and young adults questioning their gender and sexuality has increased exponentially in recent years in particular among young women.

On top of this, sometimes the same individuals move between identity categories — from LGB to T or T to LGB for example — increasing the risk that a treatment felt to be right, lifesaving even, the first time can be experienced as devastatingly wrong for the same person the second time. One person’s affirmation therapy might be another person’s conversion therapy — but no one can agree on which is which.

History doesn’t repeat but it often rhymes. And the NHS is once again trying to reduce the suffering experienced by some gender non-conforming people. Once again, it is offering a range of treatments that don’t — yet — have sufficient evidence to allow us to guarantee any outcome. Once again, people seeking to pass through their lives with more comfort are requesting treatments. And once again, the profound uncertainty about what will work for whom leads to inevitable medical risk-taking. If a patient can’t always predict how they will feel about something in the future, then a doctor or therapist certainly can’t.

No one can envy Dr Hilary Cass, the paediatrician charged with delivering an independent review of the NHS’s gender identity services and find a way forward, for children and adolescents at least. She finds herself on a battlefield where people are fighting over how to define key clinical terms, not least the concept of conversion therapy itself. Yet a quick search of her interim report makes it clear that Cass isn’t too worried. The word “conversion” doesn’t feature once. Instead, without taking medical treatments completely off the table, she calls for the NHS to increase access to psychotherapy. According to Cass, then, gently supporting people to explore identities in therapy is not akin to conversion therapy as most people understand that term.

As we turn our minds to the future, we must keep one eye on the past. Wars, cultural or otherwise, aren’t good for anyone, particularly minority groups. No ethical clinician wants to repeat history and inadvertently hurt the very people they are trying to help. We must focus now on developing therapies that will be acceptable to and appropriate for everyone who might seek them, minimising the risk of current or future harm. To do this we must accept that when it comes to issues of sex and gender, uncertainty and cultural change are the only things we can predict.