What is Clinical Advisory Network on Sex and Gender (CAN-SG), who is it comprised of and what are its concerns?

CAN-SG is a network of over 100 healthcare professionals based in the UK and Ireland, including doctors, nurses, psychologists, therapists, surgeons and midwives.

Several of our members formerly worked in the Tavistock GIDS [Gender Identity Development Service clinic for children and adolescents], and many are currently providing clinical care to people with gender-related issues. Our aims are to:

• Enhance professional and public understanding of the nature of sex, gender, gender roles and identity, with respect to medicine and healthcare
• Improve knowledge about the causes, consequences and treatments of gender dysphoria, drawing on best evidence
• Promote free and respectful discourse on sex, gender and gender identity between healthcare professionals

Earlier this month Dr Hilary Cass completed her NHS England-commissioned review of gender identity services for children and young people. What are the main takeaway points of the Cass report in your view?

The main takeaway points of the Cass Review are that the care of children and young people who are distressed by gender issues is based on “shaky foundations” and in particular that there is no evidence for the safety and effectiveness of puberty blockers and cross-sex hormones, or that they improve mental health or reduce suicide risk.

Puberty blockers and cross-sex hormones should no longer be routinely prescribed to children or young people under 18.

The review recommends that gender-questioning children and young people should receive the same standards of holistic evidence based care as are expected in other branches of healthcare.

This requires a completely different approach for their care — one based on psycho-social support and integrated with local child and adolescent mental health and paediatric services which can address all the complex needs of this group.

The review recommends research into the reasons for the rapid growth in referrals to gender services, especially of adolescent girls with complex mental and social problems, and into the best ways to help and support them, including their wider mental health and psycho-social problems.

Services for detransitioners must be provided and there should be curbs on the operations of unregulated private providers. There must be good clinical governance, data collection, accountability, safeguarding standards and open professional discussion in order to ensure safe effective services in future.

What are the main concerns surrounding use of puberty blockers in children? 

The main concerns surrounding use of puberty blockers in children are the lack of evidence for their safety, benefits and long-term effects. As well as the known harmful effects on bone development, there are serious concerns, based on multiple trials in animals, that puberty blockers could affect brain development and social and cognitive functioning.

Puberty blockers prevent the maturation of sexual and reproductive organs which, in combination with cross-sex hormones, causes sterility and lack of sexual function. There is no evidence that puberty blockers buy “time to think” about gender, because 98 per cent go on to take cross-sex hormones, suggesting that puberty blockers are the first step on an irreversible pathway.

The fundamental rationale for puberty blockers — that the solution for young people who are distressed by their gender is to prevent them going through puberty — was never clear and is being openly questioned. 

Cass focused on the GIDS service for children. Are there issues in adult care too?

Some of the same concerns that prompted a review of services for children and adolescents have prompted the recommendation for a review into adult gender services, including changes in the demographics and lack of evidence.

The Cass Review found evidence of similar demographic changes in referrals to adult services as has been seen in referrals to children’s services since 2014. Over 70 per cent of referrals to adult services are in the 17-25 age group, with over two-thirds being female and exhibiting the same complex social and mental health issues as is being seen in the children’s services.

This raises the question whether similar socio-cultural influences are operating in relation to young adults as with children and adolescents, with similar risks of “diagnostic overshadowing” of other issues for which a young adult may need help and support, in particular for mental health and neurodiversity issues.

There are also questions about the quality of evidence to support medical and surgical interventions in this group, and the rise in the numbers of regretters and detransitioners.

What would you like to see happen next in the NHS in England? And also the devolved services in Scotland and Wales?

We hope that important lessons will be learned. There should be accountability, proper investment into new service development, a welcoming and facilitating of debate where all perspectives are listened to and clinicians are no longer afraid to ask questions.

The NHS must examine why it and other health institutions (regulators, professional bodies, clinical training institutions) allowed gender ideology to get such a grip on them, to the detriment of proper scientific inquiry, evidence-based care, good clinical governance, safeguarding and the normal and necessary clinical discussion and debate about novel treatments. 

We hope that the devolved nations will take the Cass Review on board and institute similar changes to their services as England is doing. After all, they are similar populations and if Cass found no good evidence for the safety and efficacy of hormones in gender-questioning children and young people, the devolved nations have a moral obligation to take this seriously; anything else would be negligent.

What are the main problems facing clinicians attempting to provide care for those with gender issues?

The main problems facing clinicians attempting to provide care for those with gender issues are the lack of evidence for different treatment options, the intimidating atmosphere making it difficult to question what we are expected to do for fear of accusations of “transphobia,” and the lack of services — not just the long waiting times for gender clinic referrals, but the lack of mental health and neurodiversity services for children and young people, with typical waiting times of one to two years.

Wider issues impacting clinicians include our professional bodies’ unwillingness to facilitate open professional discussion from different perspectives; the difficulties doing or publishing clinical research that questions the safety and efficacy of current gender treatments; and the influence of charities and lobby groups, operating via the internet or in schools, on the expectations of children and young people and their families, who firmly believe hormones are the answer to their problems.

Clinicians had few alternative sources of advice and support for their patients which were not part of the dominant gender-affirming ideology. Hopefully with the development of new integrated services and pathways of care, as well as evidence-informed educational and informational materials, this will now change. It is hoped that professional bodies will now facilitate open respectful professional discussion and that research will provide the evidence to help clinicians feel confident they are providing safe, effective care for their patients.

What should the government be doing to prioritise child healthcare and safeguarding?

The government must provide adequate investment, staffing and support for the proposed new integrated services for gender-questioning children and young people as well as for their wider mental health needs, including investment in CAMHS [Child and Adolescent Mental Health Services] and neurodiversity services, and services for detransitioners. It should rapidly move to legislating to ban the provision of hormones to children and adolescents by private providers, including those based overseas. 

The government must recognise that the unchecked spread of dangerous and unevidenced treatments for children and young people was a child safeguarding failure and institute an inquiry into how this failure was able to happen.

This review should investigate why gender medicine was treated as exceptional and outside the normal requirements for evidence-based medicine and child safeguarding; why those who raised or simply wanted to discuss concerns were vilified and silenced; and why our professional and regulatory bodies failed in their duties to promote safe, evidence-based care.

The government must look at how gender ideology has influenced the education system through unregulated third-party organisations teaching children that if they don’t fit in with gender stereotypes then they may have been born in the wrong body. This has been one of the main contributors to the rapid rise in referrals of children and young people to gender clinics, and the false belief that interventions to irreversibly change one’s body are “lifesaving.”

The government must give clear guidance to schools and end the influence of gender lobby groups within schools.

How can clinicians and scientists better communicate with the public on gender-related care and how can disinformation in the public domain be guarded against?

This is where the press comes in. They could help by providing a range of views and in particular by giving a platform to those clinicians and scientists who have been asking questions and expressing concerns. Professional bodies need to be prepared to host discussions where different points are aired and enable the wider public to be engaged with this.

Clinicians and scientists need to explain to the public the principles of evidence-based medicine, and counter some of the myths and misinformation spread by the gender lobby, for example the myths that it is possible to be “born in the wrong body” or that medical transition reduces suicide risk, or that sex is a spectrum and can be changed by medical intervention.

How can our readers find out more about CAN-SG and what are the group's next plans and priorities?

Readers can find out more about CAN-SG from our website www.can-sg.org webinars and conference report. Our future plans and priorities include pressing for services for detransitioners; contributing to the public consultation reviewing services for 17 to 25-year-olds; educating and facilitating discussion with other healthcare professionals and the wider public on the issues of sex and gender in medicine and healthcare; and encouraging our professional bodies and employers to allow respectful professional discussion.

Looking more widely, we would like to help tackle the capture of our clinical institutions by gender ideology, whereby “sex” has been replaced by “gender,” leading in particular to the erasure of language that describes women and their health problems and health needs; and reinstating in medicine and medical education an understanding of the relevance of “sex” for clinical care, research, data collection and healthcare communication.