Genspect UK

The Cass Review

Published in April 2024, the Cass Review is the most comprehensive assessment of medical care for gender-distressed young people so far undertaken. The Review commissioned a series of systematic reviews of the evidence base underpinning so-called ‘gender affirming’ puberty blocker and cross-sex hormone treatment, finding that there is little to no high-quality research demonstrating benefit from such treatments. The Review criticises the widespread prescription of these drugs, stating that:

This is an area of remarkably weak evidence…The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.

And, in reference to puberty blockers specifically:

The adoption of a medical treatment with uncertain risks, based on an unpublished trial that did not demonstrate clear benefit, is a departure from normal clinical practice. 

Going forward, the Review recommended comprehensive and holistic assessment of young people presenting with gender distress, taking particular account of co-occurring mental health conditions, trauma history, and psychosocial factors. Psychotherapeutic interventions should be provided as the first-line treatment for gender distress. As a result of the Review’s recommendations, the UK has restricted puberty blocker prescriptions for gender distress to young people participating in clinical trials. While cross-sex hormones remain available to gender-distressed young people aged 16 or over, the Cass Review advised ‘extreme caution’ in their prescription to people under 18.

Genspect UK fully supports the findings of the Cass Review. We believe Genspect’s expertise in treating gender distress psychotherapeutically can help clinicians deliver Cass-compliant care and improve outcomes for gender-distressed people.

Puberty Blocker Ban

In May 2024, the UK government banned the prescription of puberty blockers to gender-distressed youth outside the terms of a clinical trial. The ban was extended to the private sector after concerns emerged about young people and their families obtaining puberty blockers from unscrupulous private providers. The NHS puberty blocker trial is due to start early in 2025.

Genspect UK supports the puberty blocker ban, and we would like to see it extended to cross-sex hormone prescriptions for those under the age of 18. Gender-based medical interventions are experimental, a form of radical body modification that places a heavy burden on the body. We do not believe that minors can consent to these procedures before reaching the age of majority.

New Regional Gender Clinics

The scandal-ridden Tavistock Gender Identity Development Service (GIDS) was closed in March 2024 following the findings of the Cass Review. The NHS has replaced the single national provider model with regional gender clinics working in close partnership with other local services, particularly Child and Adolescent Mental Health Services (CAMHS). Six regional centres are due to open over the next two years, with the first two in London and Liverpool already operational and the Bristol clinic scheduled to open before the end of 2024.

The referral pathway has also been amended. GIDS was unusual among specialist NHS services for accepting referrals from a wide range of non-clinical sources, including schools and charities. Referrals to the new regional gender clinics can only be made by CAMHS or specialist children’s services.

Genspect UK welcomes the NHS’s new model and the emphasis on comprehensive assessment and support for co-occurring mental health and neurodivergent conditions. We hope the amended referral pathway and more holistic model of care will end diagnostic overshadowing and gender exceptionalism, ensuring that the full range of reasons for a young person’s feelings of gender distress are explored. However, we remain concerned about the ongoing prescription of cross-sex hormones to people under the age of 18 and the huge NHS backlog, which leaves many patients waiting months or years for support, whether it be from CAMHS or specialist gender services.

The Gender Recognition Act 2004

The Labour government has pledged to “modernise, simplify, and reform” the process of obtaining a Gender Recognition Certificate (GRC) while retaining the requirement for a gender dysphoria diagnosis. At present, the Gender Recognition Act (GRA) 2004 allows a person to change the gender recorded on their birth certificate and passport if they have a medical diagnosis of gender dysphoria and have ‘lived in the acquired gender’ for two years. According to the GRA:

Where a full gender recognition certificate is issued to a person, the person’s gender becomes for all purposes the acquired gender (so that, if the acquired gender is the male gender, the person’s sex becomes that of a man and, if it is the female gender, the person’s sex becomes that of a woman).

There has been heated debate about the meaning of the phrase “for all purposes”, particularly in relation to the single-sex exemptions provided for in the Equality Act 2010. These exemptions allow service providers like rape crisis centres and sports teams to legally exclude people of either sex if this is “a proportionate means of achieving a legitimate aim”. For example, rape crisis centres can legally exclude males in order to provide a service that is exclusively for females because this is a ‘proportionate means’ of achieving the ‘legitimate aim’ of providing sensitive care to victims of male sexual violence. Some people have argued that transwomen with a Gender Recognition Certificate (GRC) cannot be excluded from female-only spaces on the basis of the single-sex exemptions, because their GRC makes them “for all purposes the acquired gender” of female, even though they remain biologically male. According to this view, trans-identified males with a GRC should be treated as female in all circumstances and allowed to access spaces and services intended exclusively for women.

Genspect UK supports the repeal of the GRA. For reasons of safety and data integrity, we do not believe people should be able to falsify their sex in official documents. The legal protections afforded to trans-identified people under the Equality Act 2010 are not reliant on possession of a GRC, meaning that transgender people are not at greater risk of experiencing discrimination if the GRA is repealed. Only a minority of trans-identified people apply for a GRC, suggesting it has little practical utility in day-to-day life. Worryingly, there is no clear process for revoking a GRC if a trans-identified person detransitions and wishes to revert their official documentation to reflect their birth sex. Providers can take steps to be alert to gendered communication preferences without changing official documentation, and we strongly believe these kinds of preferences should be socially negotiated between individuals, not mandated by law.

Equality Act 2010

The Equality Act 2010 protects people from less favourable treatment in employment and service provision on the basis of their ‘protected characteristics’. ‘Sex’ and ‘Gender Reassignment’ are the protected characteristics relevant to sex and self-identified gender.

‘Sex’ in the Equality Act is currently defined as “a reference to a man or to a woman”, while someone has the protected characteristic of ‘Gender Reassignment’ if they are:

proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex.

Importantly, the Equality Act also confers protection on people who are perceived as having a protected characteristic, even if they do not in fact have it. For example, ‘Religion and Belief’ are protected characteristics in the Equality Act. If someone of the Sikh faith is mistakenly believed to be Muslim, and they are treated less favourably because of this perception, this would still count as discrimination under the terms of the Equality Act.

The campaign group For Women Scotland (FWS) is pursuing a judicial review of the meaning of the term ‘sex’ in the Equality Act, with their appeal against the initial ruling due to be heard in November 2024. In that initial ruling, handed down in 2023, a court concluded that a biological male with a GRC should be treated as legally female for the purposes of the Equality Act. In practice, this would mean that a male with a GRC could bring a complaint of discrimination if he was prevented from accessing single-sex services intended exclusively for women, rendering the single-sex exemptions in the Equality Act virtually meaningless. FWS argue that the protected characteristic of ‘Sex’ should be understood to mean biological sex, not ‘legal’ or ‘acquired’ sex as modified by a GRC.

Genspect UK supports campaigns to clarify the meaning of ‘Sex’ in the Equality Act. Biological sex is a fixed, immutable characteristic that is not changed by cosmetic, social, or medical interventions, and people of both sexes are entitled to spaces and services that provide privacy from the opposite sex. Trans-identified people would not be disadvantaged by the adoption of a biological definition of ‘Sex’ in the Equality Act. They are already protected from discrimination on the basis of trans identity by the protected characteristic of ‘Gender Reassignment’, and additionally by the perception-based provisions of the Equality Act. While some have argued that a biological definition of sex would make it harder for transwomen to bring claims of sexist discrimination arising from misogyny, the perception-based provisions make this a non-issue: if a trans-identified male is mistakenly perceived to be female and treated less favourably on this basis, then they can claim for discrimination on the grounds of the perception that they were of the female sex.

Conversion Therapy Ban

The Labour government has pledged to introduce “a full trans-inclusive ban on conversion practices, while protecting the freedom for people to explore their sexual orientation and gender identity”.

The Cass Review was deeply critical of plans to ban conversion practices for gender identity:

The role of psychological therapies in supporting children and young people with gender incongruence or distress has been overshadowed by an unhelpfully polarised debate around conversion practices…children and young people with gender dysphoria may have a range of complex psychosocial challenges and/or mental health problems impacting on their gender-related distress. Exploration of these issues is essential to provide diagnosis, clinical support and appropriate intervention…The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve.

Conversion practices for both sexual orientation and gender identity are mercifully rare in the UK and are not endorsed by any major medical organisation. Conversion practices involving violence, coercion, or sexual abuse are already illegal under existing laws against assault, harassment, and sexual violence. Sadly, conversion practices occur most often in conservative religious communities where gender non-conformity and same-sex attraction continue to be highly stigmatised. Same-sex attracted and gender non-conforming people inside these communities can face tremendous barriers to accessing support and cultivating self-acceptance, including complex issues of personal conscience in addition to pressure to conform from the wider community. Previous attempts to legislate against conversion practices have struggled to account for issues of religious freedom and consent.

Genspect UK agrees with the Cass Review: psychotherapy is not about imposing preconceived ideas about gender or sexual orientation onto patients. But the widespread misconception that medicalisation is the only way to alleviate gender distress has led some people to characterise standard psychotherapeutic interventions as attempted conversion therapy if they are offered to gender-distressed people. Self-identified gender is not a fixed, immutable characteristic, and gender-distressed patients may self-identify in different ways at different times. This makes it hard for legislation to quantify what someone is being converted from and to at any given point. Most worryingly, gender distress can sometimes manifest as a result of internalised homophobia or confusion over sexual orientation. Many people who experience gender distress in childhood and adolescence grow up to be same-sex attracted and comfortable with their biological sex. Facilitating medical transition for someone who may simply need support in coming to terms with same-sex attraction could be characterised as a form of conversion therapy in itself.

Genspect UK does not feel this is an area where policy makers can impose legislation with any clarity and without inadvertently criminalising those who support a non-medicalised approach to gender issues. Particularly given the complexities arising from the religious context of most conversion practices, we believe resources would be better spent in constructive efforts to destigmatise gender non-conformity and to reach and support gender non-conforming and same-sex attracted people who may be isolated within conservative religious communities.