Are “Life Goals” Anything to Do with Health Services?
By Daniel Howard James
Among the final recommendations of the United Kingdom’s Cass Review of the treatment of children and young people is a curious statement regarding patient evaluations for “gender-affirming” medicine: “The central aim of assessment should be to help young people to thrive and achieve their life goals.”
The UK’s National Health Service (NHS) was set up to provide “cradle to grave” health care for a population unwilling to return to the mostly pay-as-you-go system which had existed before World War II. Many ordinary people had forgone basic medicine in an attempt to save their money during the hard years of the Great Depression, while some of those who saw a private doctor had paid for unnecessary treatments.
The dysfunction of the UK’s pre-war health system was chronicled by real-life doctor A.J. Cronin in his popular novel The Citadel (1937), made into a film the following year. These fictionalised accounts, which contrasted the medical treatment of the poor with the wealthy, reportedly helped build political pressure for health care reform in the UK.
Due to military and civilian casualties during World War II, the UK’s post-war economy was short of workers in good health. In these circumstances, the government was unlikely to relinquish the control of basic medical and surgical services which it had assumed during wartime, patching up the injured and treating the sick so they could return to their duties as soon as possible. It would have been redundant to say that NHS treatments had to be medically necessary.
The UK’s system of National Insurance payments deducted from workers’ wages is partly used to fund the NHS, with the rest of public health care funding from general taxation. In the financial year 2022-2023, over £155 billion was allocated by the UK government to the NHS in England alone.
As might be expected within a system where healthcare is meant to be free of charge at the point of use, demand on the NHS is virtually unlimited. Like any system for which resources are finite, whether funded by public or private insurance, a de facto system of rationing means doctors and administrators are meant to approve specific treatments. There is no right in the NHS to a specific treatment just because the patient wants it.
Some NHS staff have been known to complain about “Doctor Google”, describing a patient who arrives at the surgery with a bundle of print-outs from the Internet, already sure of both the diagnosis and the correct treatment pathway. Because the NHS always seems overstretched, there can be scepticism about potential treatments outside of mainstream medicine, especially if they are patient-led, expensive or not officially approved.
Reasonable doubt regarding patient-led medical treatment might be read from the detail of the finalised Cass Review, including the recommendation for a thorough professional evaluation for each patient. The mention of “life goals” in the review could be an unfortunate concession to the lobby groups and parents who were allowed to influence gender identity development services within the NHS. Paragraph 29 of the review states that it “prioritised input from people with relevant lived experience and organisations working with LGBTQ+ youth or children…” Could these be the very same lobby groups which had directed treatment pathways at the failed Gender Identity Development Service (GIDS) clinic within the Tavistock and Portman NHS Foundation Trust?
The UK’s public health care system was not designed for the achievement of personal life goals, or patient-directed treatment. Yet gender identity has somehow gained a special significance making it exempt from normal public funding principles. Doctor Google turns out to have specialised in ‘gender-affirming care’.
Paragraph 34 of the Cass review states “There is broad agreement that gender incongruence, like many other human characteristics, arises from a combination of biological, psychological, social and cultural factors.” It might be more accurate to say certain researchers have speculated about possible biological factors in gender identity, including Gooren (2006) or Garcia-Falgueras and Swaab (2009). If it was true that there is an underlying biological cause of gender incongruence in general, it could be the only difference of sex development with no objective diagnostic test available.
If a known biological difference between transgender and “cisgender” children existed, there would be no need for “gender-affirming” therapist-activists to refer these children for hormonal intervention, because a blood test or brain scan would suffice to diagnose them. We can predict that if any such diagnostic test was possible, following new discoveries about the biology of transgender people, its introduction would be resisted by activists opposed to the ‘gatekeeping’ of treatment.
The Cass Review has left open the possibility that medical gender transition can be made available for children “when indicated”, but the only basis for diagnosis for the time being is the status quo: self-report of gender incongruence. Paragraph 41 of the review states “Among those being referred to children and young people’s gender services, some may benefit from medical intervention…”, even though the review stated that the evidence base for this intervention is extremely weak. A fence is an uncomfortable place to sit.
Paragraph 77 of the review states “…lessons from studies of children with differences in sexual development (DSD) show that a complex interplay between prenatal androgen levels, external genitalia, sex of rearing and socio-cultural environment all play a part in eventual gender identity.” Here we learn the post-Cass rationale for medical and surgical intervention on physically healthy children. Gender incongruence is now to be considered somehow caused in utero but also by the child’s upbringing, and precise diagnosis is unnecessary.
It’s a case of apples and oranges to conflate known differences of sex development (DSDs) with gender identity issues. Not all persons with these rare physical differences experience problems of gender identity, and some are completely unaware that they are different from other people until diagnosed later in life. Nor is there sufficient evidence that the exponential growth in the numbers of children and young people presenting with transgender identity has an underlying biological cause since they have not generally been tested for one.
How does a transgender person leverage healthcare funding to address existential matters of identity, while simultaneously being in denial about possible mental illness? By claiming that their gender identity is the result of a physical condition, caused by androgen levels in the womb out of alignment with their natal sex, it seems. The question of exactly how these androgens became unbalanced in their mother’s body is left unanswered for now. If it does turn out to be the result of pregnant women’s diets, medication or chemical exposure, it might not explain why out-of-kilter androgens in the womb would cause gender fluidity in an adult, or teenage onset gender dysphoria, many years later.
The advocates of the hypothesis of a biological cause of gender incongruence should devise an experiment which reliably predicts the children who will grow to “be transgender”. Preferably a study that can identify “transgender children” when they are pre-verbal, and not so susceptible to parental socialisation. Without predictive power, this hypothesis is not falsifiable.
Should it turn out that gender incongruence is part of normal human diversity, it would be hard to justify public or insurance funding for medical and surgical interventions which “correct” this diversity. We’re supposed to accept people for who they are, rather than make them conform to an ideal. On the other hand, if medication side effects or industrial pollution causing endocrine disruption were discovered as the cause of an underlying biological phenomenon, transgender people could expect restitution from public funds such as the NHS.
Until then, the “prenatal androgen imbalance” hypothesis remains speculative when applied to the vast majority of people who have no known differences of sex development and have not been tested for any of them. To appropriate the DSD diagnosis for people who are biologically typical, to the best of our knowledge, is unfair to people dealing with the developmental and fertility problems that known DSDs cause.
Public healthcare systems like the NHS have to prioritise physical and mental health. Unlike the private patients described in The Citadel, who were spending their own money, gender identity activists have been successful in obtaining public money for patient-led “healthcare” with a dubious evidence base. They have apparently hacked the system by obtaining NHS treatment without being ill. The complexity of shifting definitions for gender distress in the Diagnostic and Statistical Manual (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD) have provided cover. But if gender incongruence is not a mental health issue and not a disease, there is no longer any ethical justification for invasive medical and surgical procedures, and no financial justification for public or insurance funding of those procedures. Perhaps that’s why “life goals” needed to be included in the Cass Review.
Photo by Ronnie Overgoor on Unsplash