Tox Report extra: After Cass

What was gender, anyway?

It was Recommendation 32 that got to me:

Recommendation 32:

Wider guidance applicable to all NHS services should be developed to support providers and commissioners to ensure that innovation is encouraged but that there is appropriate scrutiny and clinical governance to avoid incremental creep of practice in the absence of evidence.

Maybe it was the implicit statement that gender services for children had not, in fact, received “appropriate scrutiny and clinical governance”. Or maybe it was the matter-of-fact mention of the “absence of evidence” for the life-altering treatments that were being offered to children who presented as trans (but who, in most cases had a complicated mix of traumas, co-morbitities and social distress).

Actually, it might have been the acknowledgement that all this could happen all over again with something else. There are, I think, specific things about gender identity that made it particularly rich ground for an episode of terrible clinical overreach and policy groupthink, but no reason to believe that it’s unique: this will all repeat, in slightly altered terms, if explicit safeguards are not established. I know some people who share a lot of my positions have found vindication in the Cass Review. I think the most positive emotion I can claim is “catharsis”, which is how you’re supposed to feel at the end of a tragedy.

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It’s been a little over ten years since I first articulated my fear that trans politics had taken a destructive direction — an often uncomfortable ten years, especially early on, when the dominant left position in journalism was that only Nazis thought like me, while the mainstream right held that I was preoccupied with an absurdly niche obsession which would never catch on. It was possible to be cancelled in one arena and completely incapable of explaining why to people in another arena.

But once I’d started to write about gender (thanks to Helen Lewis’s intelligent and rigorous commissioning on the New Statesman), I started to hear from people with first-hand experience in gender medicine who not only confirmed my fears, but made me realise things were far more troubling than I’d suspected. (And these people — the whistleblowers — are the actually brave ones.) Whatever bromides I held to about medical ethics, they did not reliably apply in the real world.

The watershed for me was probably my 2016 feature “What Is Gender, Anyway?” — which ended up on the New Statesman website after being initially commissioned, and then spiked, by Mosaic, the (now defunct) popular science magazine of medical research foundation the Wellcome Trust. It was a typically sorry series of events, the kind of “soft cancellation” I would get very used to over the following years — although at least in this case I was privy to some of the processes behind it.¹

I had pitched a feature which would explore the competing models and ideas about gender in medical and political practice; the editor had enthusiastically accepted, and I had conducted a series of interviews with trans people, clinicians and neuroscientists. Then I had a slightly troubling email about the visuals for the feature. “Ideally,” wrote the art director, “I would like to keep this simple and do a series of portraits of people that are happy and open about themselves.” Clearly, while I’d been working on the piece as commissioned — a piece fundamentally about doubt — a different, much more certain vision had overtaken the editorial side.

There was a phone call: could I make it less academic, more about “the experience of being trans”? In other words, junk the senior medical voices like endocrinologist Joshua D. Safer (founding Medical Director of the Center for Transgender Medicine and Surgery at Boston Medical Center and Boston University School of Medicine, and a strong advocate for the “inherent gender identity” model),² and credulously transcribe some gender identity talking points from other people’s “lived experience”.³And then the inevitable email: “Following our chat on Thursday and having discussed the story more here, we have decided not to use the feature on ‘what is gender?’ in Mosaic. While gender is a topic we want to cover, we don’t think that this story is the right way for us to do so right now.”

The rejection alone was so galling (remember, this was my first big feature and one I’d hoped would be a career calling card) that I don’t think I let myself reflect fully on what a terrible moment this was for science journalism. The public-facing magazine of an organisation ostensibly dedicated to researching hard medical questions had, apparently between me pitching and submitting, adopted the Stonewall-enforced no-debate stance.

I’ve got no reason to believe that this reflected the overall policy of Wellcome. That editor, however, now has pronouns in her username and is at a new institution promoting a “listening project” that will “work directly with trans and non-binary communities to explore the impact of this debate on their daily lives” (the debate, of course, is described as “toxic”), so it’s fair to say that we were traveling in different directions.

But I think it’s equally fair to say that one of us was right (me), and one of us was wrong (her). One of us was asking the appropriate questions (or at least, questions in the appropriate area), and one of us had decided there were no questions at all. This editor’s position was a replication of the one that existed within gender services: the matter had been decided in advance, so any investigation was heretical.

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I’ve seen different varieties of cope since Cass was published — and all, of course, have infuriated me. There are the nice liberals who situate themselves as having always been aligned with Cass (not that they ever made a public statement to that effect). Of course there are questions about puberty blockers! No one has ever denied that! (Having been called a child killer for writing critically about puberty blockers in the past, I think the correct word for this is “gaslighting”.)

Then there are the ones who blatantly try to undermine Cass: the evidence bar was set too high (no, the quality of the evidence for child transition as a medical treatment is hopelessly weak), trans people weren’t included (they were, extensively, in carefully structured focus groups), it’s predicated on the assumption that being trans is bad (no, it’s predicated on the assumption that transitioning is a significant and lifelong medical intervention: like any such intervention, it should only be offered if it works and only to the people who will benefit).

But most aggravating, to me anyway, are the ones who claim that Cass isn’t actually a gender critical “win” because it calls for more research into child transition, which of course the terfs could never want. Let me shock those people: more research into how best to help children who disidentify with their sex is necessary and appropriate and could have been done by the jackasses who ran GIDS at any time this century. NHS gender services have always had the power to structure studies and conduct follow-up with patients. Not only did they fail to do this, but six out of seven adult NHS clinics refused to share data with Cass that could have given insights into the long-term efficacy of transition.⁴

The people practising gender medicine appear to be, on the whole, just not serious people. Unfortunately they have done very serious harm — not just the harm of guiding children towards transition when they could very well have lived fine without committing to a lifetime dependency on exogenous hormones and all the complications that come with that, but the harm of opportunity cost. The therapy unexplored, the serious conditions unrecognised because it was an article of faith that “treating the gender” would resolve everything else. (For more on this, see Hannah Barnes’ excellent investigative book Time to Think.)⁵

I hope I never hear the dread phrase “puberty blockers are just a pause button” again. I hope I never again have to listen to someone tell me the “science says” transition works for children and children “know who they are”. I hope the people who have already transitioned receive all the attention and care they deserve when it comes to living with their altered bodies, whether they continue to identify as the opposite sex, or choose to detransition. But more personally, I hope that my trade — journalism — looks on this episode and recognises what a sorry job (with a few honorable exceptions) it made of all this. I wonder if the editor who spiked my feature is asking herself what else she might have missed. I regret to say that I doubt she is.

1. I had one of these last year when a podcast cancelled me because of unspecified “illness” and then shockingly did not get in touch to reschedule.

2. Also, if you read the NS piece, a man of quite remarkable social conservatism when it comes to gender roles.

3. My account of this phone call is based on recollection. The quotes from emails are copied and pasted from the original correspondence.

4. Actually there’s a fourth kind of reaction to hate: the gloating “I was right, the normies were wrong” take from people who had their “come to physical reality” moment approximately two minutes ago and managed to get into being a terf only when, conveniently, the market for terf opinions was well established. I feel like you should run the marathon before you get the victory lap. Oh OK, and another one: the gender criticals saying Cass should have “gone further”. Take the W, my friends.

5. Perhaps one reason Hannah was well equipped for this topic: she previously reported on the “satanic panic”, another instance of faith wildly outrunning evidence at great cost to children. And another reason not to complacently assume that debunking gender medicine is the end of anything.