Letter to Cabinet Secretary for Health and Social Care

Nicola Sturgeon confirmed in Parliament that the Scottish Government will be disregarding the advice in the recently published Cass Review: Interim Report and NOT responding as Westminster has done, by calling for an urgent review of NHS care of gender-distressed children. Instead, Ms Sturgeon pointed to the new £9 million of funding aimed at cutting waiting lists, which will allow more children quicker access to the gender clinic – a service model which has been deemed flawed and harmful. Not only is this medically negligent, it is compounded by plans to legislate against conversion therapy which will potentially criminalise the best evidenced therapeutic practice as recommended by Dr Cass.

We sent the following email to Humza Yousaf (Cabinet Secretary for Health and Social Care), Shirley-Anne Somerville (Cabinet Secretary for Education and Skills) and Clare Haughey (Minister for Children and Young People) on 28th April 2022.

Dear Mr Yousaf, Ms Somerville and Ms Haughey,

Cass Interim Report: Independent review of gender identity services for children and young people – Implications for Scotland

As you will be aware, the Westminster Health Secretary has announced an urgent inquiry into gender hormone treatment for vulnerable children, stating that the system is “failing children”.1 Mr Javid was particularly alarmed at the pressures on staff to adopt an unquestioning affirmative approach to transitioning and is planning an overhaul of how health service staff deal with under-18s who present with gender distress.

We welcome this intervention as the responsible course of action following a series of legal actions by whistleblowers2 and a NICE report3 highlighting serious concerns with the low quality of evidence for both GnRH agonists (puberty blockers) and cross-sex hormones. The recently published interim report4 by Dr Hilary Cass, who was commissioned by NHS England to investigate child gender services, was damning, finding the Tavistock children’s clinic not a safe or viable long-term option for children. The politicising of a childhood condition and treatment based on ideology rather than facts and evidence has led to numerous children being harmed irreversibly by the medical profession.

It would be foolish to think this situation is confined to England. Many countries, including Scotland, follow the same treatment protocol for gender-distressed children, although following recent reviews some, including Sweden,5 Finland6 and France7 have now severely restricted use of medical treatments in preference for psychotherapy.

The Care Quality Commission deemed Tavistock, the London gender clinic for children, “inadequate” and critcised it for deficient record keeping,8 but at least it held information on the ratio of male to female patients, the number and age of those prescribed puberty blockers, and noted the disproportionately high rates of patients with autistic traits. The counterpart clinic Sandyford in Glasgow can give no such information,9 in fact it is unable to even ascertain if it is following the pattern of a reversal in mainly male patients to a 75% female one, for the simple reason that it permits children to choose, or omit, the sex recorded on their medical files.10 NHS Scotland also had to correct a Freedom of Information release and eventually disclose that 51 girls had been referred for elective double mastectomies.11 Both clinics have failed to conduct longitudinal studies or provide care for detransitioners who were mis-diagnosed, many of whom will attest to being fast-tracked into hormone treatment and surgery when good mental health care was more appropriate to address underlying issues.

Our recent Freedom of Information response shows a rapidly increasing and disproportionate number of gender-distressed children in Scotland – the referral rates have grown fifteen-fold in six years12 and 1,254 children are either receiving treatment or are awaiting a first appointment13 – almost twice the expected number given the relative population size with England, which has a comparable figure of 7,100.14

A crisis point has surely been reached when concerned GPs, unable to get answers to straightforward questions from their health board or NHS Scotland, feel they have to write to a national newspaper outlining their worries that referring children to a gender clinic will actually harm, rather than help them.15 The political climate in Scotland is such that doctors who follow best therapeutic evidence rather than affirmation of a trans identity and medical treatment risk litigation for “transphobia”.

In January 2021 the then Cabinet Secretary for Health said “We do not look to duplicate the work of the [Cass] review in Scotland and will closely consider the findings of the review when they become available”.16 Having chosen not to undertake the necessary and fundamental work to analyse the evidence and determine the best treatments, it is wholly incumbent on the Scottish Government to take heed of the outcomes and advice of those who have.

However, the Government has instead forged ahead with a £2 million allocation of funds this year, primarily aimed at addressing waiting times17 and an update to the Gender Reassignment Protocol (GRP) is also underway.18 In our view, both these projects must be halted and reassessed in light of the interim Cass report. The GRP update is looking to follow the new WPATH guidelines19 which are not based on evidence, follow an affirmation-only model and now also seem to incorporate eunuch as a gender identity20 – something we hope the Scottish Government does not wish to introduce into our schools. There is little point cutting waiting lists to allow quicker access to a service which has been found to be clinically flawed and harmful to children. It would be irresponsible and negligent of the Scottish Government to continue down this path. Dr Cass concludes that “A fundamentally different service model is needed which is more in line with other paediatric provision”.

Of course, the pathway for children confused about gender is set long before they reach Sandyford’s door, in a large part due to the Scottish Government’s irresponsible policies in schools which advocate affirmation-only.21 Political lobbying groups such as LGBT Youth are introducing material telling young children they can change sex, and this is reinforced by teachers who have received training from the same groups – none of which have medical or educational expertise. Pupils who are confused about gender are receiving the message that there is something wrong with their body that needs to be fixed and teachers are unquestioningly “socially transitioning” pupils, often changing names and pronouns behind their parents backs. As Dr Cass states, these are not neutral interventions, and are being done without medical oversight and are incredibly damaging to our young people.

It is imperative that political impartiality should be reinstated in schools and lobbying groups not permitted to continue introducing unscientific beliefs to children, especially organisations that have already been found by Scottish Ministers to have introduced school guidance which was “not legal”.22 It would be helpful if the Government would issue a message similar to that by the Department of Education which states harmful stereotypes should not be reinforced and no inferences should be drawn about a gender identity from a child’s personality or preference for certain clothes or activities, and nor should schools work with external groups that produce such material.23

We hope you agree that there is ample evidence in the interim report that is alarming and needs immediate attention, and appreciate the implications for the upcoming plans to legislate for banning conversion therapy and to make Gender Recognition Certificates (GRC) available for under-18s. The joint submission from Stonewall and others24 is of the opinion that therapy for gender-distressed children should be focussed on understanding and learning to accept their stated gender identity – otherwise it will be captured as conversion therapy. This is contrary to evidenced therapeutic practice and Cass points out there are many causes of a child’s distress and many pathways to a number of outcomes, only one of which will be an adult trans identity. Counsellors and therapists should be able to fully explore issues and help a child feel comfortable with their body, without any pressure of possible criminalisation. Even now concerns have been raised about the chilling effect of the Memorandum of Understanding25 and the likelihood of therapeutic outcomes being compromised by early state affirmation by way of a GRC,26 on what may turn out to be a transient trans identity.

We would welcome a meeting for further discussion and look forward to hearing what steps will be implemented to urgently address the issues raised.

Yours sincerely,

Trina Budge, Marion Calder and Susan Smith
Directors, For Women Scotland

cc: Dr Sandesh Gulhane, Shadow Cabinet Secretary for Health and Social Care
Oliver Mundell, Shadow Cabinet Secretary for Education and Skills 
Meghan Gallacher, Shadow Minister for Children and Young People
Jackie Baillie, Shadow Cabinet Secretary for Health
Michael Marra, Shadow Cabinet Secretary for Health
Martin Whitfield, Shadow Minister for Children and Young People
Jane Grant, CEO, Greater Glasgow and Clyde NHS
Gregor Smith, Chief Medical Officer
Bruce Adamson, Children’s and Young People’s Commissioner, Scotland

  1. https://www.thetimes.co.uk/article/sajid-javid-inquiry-into-gender-treatment-for-children-wc3r3d9sn
    Archived: https://archive.ph/UeSs2
  2. https://www.telegraph.co.uk/health-fitness/body/right-blow-whistle-tavistock-clinic-puberty-blockers/
    Archived: https://archive.ph/qgqrI
  3. https://segm.org/NICE_gender_medicine_systematic_review_finds_poor_quality_evidence
    Archived: https://archive.ph/BgTqT
  4. https://cass.independent-review.uk/publications/interim-report/
    Interim report: PDF
  5. https://segm.org/segm-summary-sweden-prioritizes-therapy-curbs-hormones-for-gender-dysphoric-youth
    Archived: https://archive.ph/REUCE
  6. https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors
    Archived: https://archive.ph/Yph2R
  7. https://segm.org/France-cautions-regarding-puberty-blockers-and-cross-sex-hormones-for-youth
    Archived: https://archive.ph/0TLtI
  8. https://www.theguardian.com/society/2021/jan/20/gender-identity-development-service-for-children-rated-inadequate
    Archived: https://archive.ph/ofDbt
  9. https://forwomen.scot/wp-content/uploads/2019/12/Sandyford-FoI-response-27Sep19.pdf
  10. FOI follow-up question: https://forwomen.scot/wp-content/uploads/2019/12/FoI-followup-question.png
    and answer: https://forwomen.scot/wp-content/uploads/2019/12/FoI-followup-reply.png
  11. https://twitter.com/ForwomenScot/status/1439889272224485378
    Archived: https://archive.ph/u5bsw
  12. FOI showing 37 referrals in 2013:
    https://forwomen.scot/wp-content/uploads/2019/12/Sandyford-FoI-response-27Sep19.pdf
    NGICNS document showing 559 referrals in 2019 (para12, page 27): https://forwomen.scot/wp-content/uploads/2021/11/Gender-Service-Mapping-report-v1-1.pdf
  13. FOI showing 1,253 at Sandyford: https://forwomen.scot/wp-content/uploads/2022/04/Sandyford_response_22Apr2022_anon.pdf
    plus 1-4 17 year olds on adult waiting list in Inverness: https://forwomen.scot/wp-content/uploads/2022/04/Inverness-Gender-Clinic-response-18Apr2022.png
  14. https://www.thetimes.co.uk/article/sajid-javid-inquiry-into-gender-treatment-for-children-wc3r3d9sn
    Archived: https://archive.ph/2rDhj
  15. https://www.scotsman.com/news/opinion/columnists/time-for-measured-debate-on-role-of-gps-in-helping-children-with-gender-dysphoria-dr-angus-mckellar-and-dr-anthony-latham-3658081
    Archived: https://archive.ph/jB4F6
    and https://www.thetimes.co.uk/article/scotland-needs-own-child-gender-inquiry-claim-gps-2k2c6ntfx
    Archived: https://archive.ph/zjgab
  16. https://www.parliament.scot/chamber-and-committees/written-questions-and-answers/question?ref=S5W-33706
    Archived: https://archive.ph/2VPsB
  17. https://www.gov.scot/publications/nhs-gender-identity-services-strategic-action-framework-2022-2024/pages/1/
    Strategic action framework: PDF
  18. https://www.sehd.scot.nhs.uk/cmo/CMO(2021)GRP.pdf
  19. https://www.wpath.org/soc8
  20. https://twitter.com/genspect/status/1468207960996429834
    Archived: https://archive.ph/dLSYq
  21. https://www.gov.scot/publications/supporting-transgender-young-people-schools-guidance-scottish-schools/
    Supporting Transgender Pupils: PDF
  22. https://www.gov.scot/publications/foi-201900003278/
    Archived: https://archive.ph/Og2mH
  23. https://www.transgendertrend.com/department-for-education-rse-guidance-schools/
    Archived: https://archive.ph/QvFiw
  24. https://yourviews.parliament.scot/ehrcj/petition-end-conversion-therapy-views/consultation/view_respondent?sort=excerpt&order=descending&uuId=768193465
    Archived: https://archive.ph/kBxIc
  25. https://thoughtfultherapists.org/
  26. https://twitter.com/BayswaterSG/status/1491347695591890946
    Archived: https://archive.ph/QuNLU