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 letter 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.

It was also sent to the Labour and Conservative shadow ministers, the Chief Medical Officer, Chief Executive of NHS Greater Glasgow & Clyde, and the Children and Young People’s Commissioner.

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 whistleblowers [2] and a NICE report [3] highlighting serious concerns with the low quality of evidence for both GnRH agonists (puberty blockers) and cross-sex hormones. The recently published interim report [4] 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] Finland [6] and France [7] 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 years [12] and 1,254 children are either receiving treatment or are awaiting a first appointment [13] – 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 times [17] 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 guidelines [19] which are not based on evidence, follow an affirmation-only model and now also seem to incorporate eunuch as a gender identity [20] – 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 others [24] is of the opinion that therapy for gender-distressed children should be focused 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 Understanding [25] 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_
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
ETA (now removed info from NGICNS website): http://web.archive.org/web/20220430192530/https://www.ngicns.scot.nhs.uk/wp-content/uploads/2021/12/SOC8-Chapter-Draft-for-Public-Comment-Eunuch.pdf

[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

On 30th May we received the following reply on behalf of the Cabinet Secretary for Health:
(PDF of response)

To which we replied on 27th July with:

Dear Ms Leath,

Re: Implications for Scotland from the Cass review of gender services for children

Thank you for your response. Both Ms Sturgeon and the previous Health Secretary said the Scottish Government would consider the findings of the Cass Review. However, it is greatly disappointing to discover from a FOI response on internal communications that the Government was more concerned with composing a response to a media request than giving any consideration whatsoever to the important findings of the Cass Interim Report.

You point out that the Supporting Transgender Young People in Schools Guidance “makes clear the distinction between gender non-conforming people, and transgender young people who are likely to be ‘persistent and insistent’ in their wish to express their gender identity”, without any apparent recognition that the specialists in the field have yet to find any method for determining which young person’s claim to a trans identity is likely to be sustained into adulthood. We do know most are transient, and it is reckless in the extreme to suggest otherwise and push teachers into affirming children’s belief that they are the opposite sex – a decision they are not qualified to take and goes against the initial conclusions by Dr Cass that the best way to support young people experiencing gender distress has not been determined. 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, and social transition is an active intervention that may have significant effects on the child in terms of their psychological functioning.

Increasing funding for NHS gender identity services to reduce waiting times is misguided and will only lead to more young people accessing an inappropriate and failing service, one which GPs say is dangerous for their patients and which Dr Cass concludes has a severe lack of evidence on which to base its affirmation model. Does the Government agree with Dr Cass on the danger of diagnostic overshadowing?

We understand that the Gender Reassignment Protocol will now not be updated in line with the new WPATH guidelines. Not because you heeded our warning that it is not evidence-based and is seeking, bizarrely, to introduce eunuchs as a gender identity, but because of media reports that Scotland’s NHS NGICNS website hosted a WPATH document on eunuchs which led readers to horrific castration fantasy and paedophilia content. Is there any good reason why the Health Secretary did not take action on receipt of this information?

You state it is important to note that legal gender recognition and clinical decisions about gender identity healthcare are entirely separate issues. We would suggest it is more important to recognise that no law is made in a vacuum and the official recognition of a young person’s trans identity elevates the importance and permanence of what, according to Dr Cass, may otherwise be a transient stage. It forecloses options for young people and reduces incentive to engage in explorative psychotherapy. Bestowing state affirmation without a medical diagnosis may lead, as NHSGGC has warned, to additional pressures on gender identity clinics with heightened expectations from GRC-holders for hormonal and surgical treatments, for which the NHS say they do not meet the diagnostic criteria. They also warn “six months may be too short a period to fully consider all aspects of a social transition” for which we have yet to see any indication this has dented the Government’s fixed views. The EHRC has also echoed the medical concerns raised by Cass to the committee looking at gender recognition reform, with advice to wait for the full report, to a seemingly complete inability of the Cabinet Secretary to understand the significance that best practice, as likely to be recommended by Cass in due course, will contradict the Government’s flawed position on GRA reform.

It is abundantly clear that the Scottish Government is paying no heed to the Cass review and is determinedly not listening to the significant and well-founded concerns raised. Instead it is hurtling down a path in the opposite direction against rhyme and reason, on which there are clear indications of harm to our children and the unnecessary creation of lifelong sterilised medical patients.

Our offer to meet still stands and we would appreciate a commitment from the Government, since it is not conducting its own review, to fully take on board the recommendations in the final Cass report.

Yours sincerely,

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

The only other response we received was from the Chief Medical Officer who replied with the following on 1st June:
(PDF of reply)

to which we replied with:

Dear Professor Steedman,

Re: Implications for Scotland from the Cass review of gender services for children

Thank you for your response. There was far more to the initial findings detailed by the Cass Interim Report than the points you mention and we are rather disappointed and puzzled that you have not addressed those raised in our previous letter.

Does it not concern you that Dr Cass has stated we do not know the best way to treat gender distressed children and that there is a severe lack of evidence to support the affirmation model – which Sandyford Young People’s GIC is based on? Are you not worried about the evidence presented for diagnostic overshadowing? Does the social transitioning of young children by teachers on the advice of trans lobby groups not give you pause for thought? Or the conclusions already drawn that NHS provision for children needs a complete overhaul and a very different type of service provided to bring it into line with the normal standard of paediatric care?

We can appreciate the NHS is grateful to be in receipt of increased funding from the Scottish Government but it is already clear from Dr Cass’s report that these funds are being channelled in the wrong direction. Patients deserve the best evidence-based treatment regardless of prevailing political views and the findings in the interim report should not be disregarded in the main. Will you commit to fully taking on board the conclusions in the final Cass report and to bring service provision in Scotland in line with its recommendations?

Our offer to meet still stands and we would really appreciate the opportunity to discuss this in more depth.

Yours sincerely,

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

We received a reply from the Health Equity and Equalities Unit on 1st September on behalf of the Cabinet Secretary for Health, and simultaneously on behalf of the Deputy CMO to whom we’d separately written a quite different letter to:

Update: 1st September 2022

We have yet to receive a response from the Deputy Chief Medical Officer to our follow-up letter. The other Cabinet Secretaries have not responded at all. Neither have any of the shadow Ministers. Nor has the Chief Executive of NHS Greater Glasgow & Clyde, or the Children and Young People’s Commissioner.