Thread by @AlexAshman

Hi @doctor_oxford, I'd like to give you some context as to why our democratic professional body, @theBMA, would decide to undertake an evaluation of the recently published Cass Review, with a view to recommending improvements to trans healthcare in the UK. 🧵

To be clear, these are my own thoughts and do not represent those of the BMA. I am a doctor, BMA member, EDI Advisory Group member, author on a paper critically appraising the Cass Review, I have lived experience, and I have done work on trans inclusion in healthcare.

First, you were critical of the BMA Council for making a strategic decision to evaluate the Cass Review. Surely, you thought, it is for the BMA's Representative Body (RB) to decide policy at ARM and for the Council to act strategically based on this policy.

The 2020 ARM, the RB passed a resolution including a call to govt to "ensure that under 18s are able to access healthcare in line with existing principles of consent established by UK Case Law and guidelines published by the public bodies which set the standards for healthcare;"

So we already have policy from the RB. But why not vote on this specific matter at the 2024 BMA ARM? Well, the Cass Review final report was published on 10th April, a week after the deadline to submit motions to ARM. Colleagues therefore submitted an emergency motion to ARM.

Anyone familiar with ARM will know there are hundreds of motions submitted by councils, conferences, and divisions. These are prioritised for debate by an elected committee, as not every motion can be debated at ARM, especially now there's only two days to fit everything in.

As a result, there was not time for ARM to debate the emergency motion regarding the Cass Review. The BMA are therefore acting on 2020 policy, along with a general duty to uphold inclusive high quality patient care, when responding to the Cass Review.

Why not just respond to Cass at an executive level and be done with it, like many other organisations? The BMA is a professional organisation for doctors in the UK and has a responsibility to be diligent, and to consider the views of the broad church of doctors it represents.

The emergency motion at ARM 2024 called for the BMA to publicly disavow the Cass Report; a more moderate motion went before Council calling for a public critique. This academic approach seems appropriate, as proponents of Cass often claim they are 'evidence-based'.

It is also appropriate as there has been international, multi-disciplinary criticism of the Cass Review. This included criticism of the Cass systematic review papers, published in a journal of the BMJ Group, which is wholly owned by the BMA but which has editorial independence.

The BMA has already had to write to the BMJ about its previous output on care for trans children, which lacked EDI awareness and patient voices, and has been used by transphobic lobby groups around the world.
bma.org.uk/news-and-opini…

So, will the BMA be able to bring sufficient expertise in its evaluation of the Cass Review? Certainly, as per the press release, the BMA is already aware of two international multi-disciplinary papers providing critical appraisal of the Cass Review and its scientific programme.

The press release also states that the BMA Board of Science, Medical Ethics Committee, Equality and Inclusion Advisory Group, and Patient Liaison Group will be involved. Appropriate expertise should be drawn upon from multiple angles.

Surely the Cass Review did all this? Well, actually, no. Cass is not an expert on trans healthcare. Subject matter experts were intentionally not included on the team, except for one who was (in my opinion) biased against affirming care. Experts who were trans were excluded.

There were also concerns that the Cass Review had (a) shown cisnormative biases, (b) misrepresented contributions from trans patients, (c) involved discredited and questionable input from anti-trans sources.


tandfonline.com/doi/full/10.10…
osf.io/preprints/osf/…
whatthetrans.com/cass-review/

Fundamentally, there are concerns that the Cass Review was methodologically flawed, did not represent the current evidence base, ignored the wider context, viewed trans people through a pathologising, patriarchal lens, and is being used inappropriately to withdraw access to care.

So it is entirely reasonable that the BMA evaluates the Cass Review, as empowered to do so by policy set by the Representative Body in 2020, and that it does so in an evidence-based manner including trans expertise which Cass excluded.

But, @doctor_oxford asks, can the BMA be calling for treatment of trans kids to continue in the meantime? What about safety? What about the evidence base for puberty blockers?

Well, kids *are* still receiving puberty blockers to reduce the psychological distress caused by puberty, allowing them time until they can start a puberty that is appropriate for them. The evidence says this is safe, and it isn't banned. Oh, but wait...

...we're talking about cís kids with central precocious puberty (CPP). As the BMJ says, "Treatment of CPP is usually straightforward with gonadotrophin-releasing hormone agonists."

Yes, puberty blockers.
Yes, "straightforward".
Yes, the BMJ.
bestpractice.bmj.com/topics/en-gb/1…

Not to mention there is also data on the use of puberty blockers in trans kids too, including qualitative data that was excluded from the Cass Review. Cass deemed this evidence insufficient, but it exists and is bolstered by all the data on cís kids.

It is telling that the ban on all new puberty blocker scripts (at least outside of a trial that Cass proposed but doesn't yet exist) is only for trans kids; the safety and efficacy of these same drugs, for essentially the same treatment aim, is not in question for cís kids.

Why not keep banning puberty blockers for trans kids until things are cleared up by a trial, several years from now? Seriously? Ok. Because the harm this will cause these children is excessive. Few children get to receive blockers, but the evidence shows that they need them.

(An aside: strictly speaking, trans kids could also, in theory, go straight onto cross sex hormones, as this would avoid them experiencing a puberty contrary to their gender. Puberty blockers are a compromise that allows "time to think" first.)

What would happen to these kids? We know from research that around 3-4% of these kids would desist (Horton, 2022), so they'll be fine. The other 96-7% would experience a puberty contrary to their gender. And what happens then?

We know from data on trans kids on waiting lists that 45% report attempting suicide and 84% report self harm (Stonewall, 2017). Affirming care is associated with a 73% reduction in odds of suicidality and 60% reduction in odds of moderate or severe depression (Tordoff, 2022).

Puberty blockers were meant to be the safe, reversible, compromise provided to stabilise things whilst trans kids worked things through. Banning them does not reduce risk, but increases it. This is analogous to bans on reproductive care.

And ultimately this is about political interference in a matter that is for patients, parents, and clinicians, and not for the state. All individuals have the right to make decisions regarding their own reproductive care and must have access to services that support that right.

Having a trans kid undergo their natal puberty is not a neutral or desirable act just because it is a natural occurrence, in the same way that continuing an unwanted pregnancy or having intrusive menopausal symptoms should not be considered the default option.

Given concerns about Cass, political overreach, the risk of harm to trans kids, and the specific limiting of trans people's rights to access care (whilst cís kids continue to have access to blockers), it is entirely reasonable to call for care to continue whilst this is sorted.

So, that's some brief thoughts from me. There is so much to say, and it's not for me to say it all. For one thing, please read our paper: osf.io/preprints/osf/…

And also the paper from the Yale authors:
law.yale.edu/sites/default/…

And the excellent work of Dr @FierceMum:
tandfonline.com/doi/full/10.10…

@FierceMum You'll note I've kept replies limited to those I follow, which obviously includes you @doctor_oxford. I've been dogpiled previously for speaking up about the BMJ article, and at other points just for being trans.

https://x.com/AlexAshman/status/1643373983251791875?t=iWZs-ay90byUw0gFW541Aw&s=19