Ccritical thinking and open debate are pillars of scientific and medical research. Yet experienced professionals are increasingly afraid to openly discuss their views on the treatment of children who are questioning their gender identity.
That was the conclusion reached by Hilary Cass this week in her review of gender identity services for children, warning that a toxic debate has resulted in a culture of fear.
Her conclusion was echoed by doctors, academic researchers and scientists, who said this climate had a chilling effect on research in an area that in desperate need of better evidence.
Some said they were deterred from pursuing what they believed to be crucial studies, saying that just entering the arena would put their reputations at risk. Others spoke of abuse on social media, academic conferences being shut down, biases in publishing and the personal cost of speaking out.
“In most areas of health, medical researchers have the freedom to answer questions about problems without fear of judgement,” says Dr Channa Jayasena, a consultant in reproductive endocrinology at Imperial College London. “I have never known a field where the risks also lie in how you are seen and your beliefs. You have to be careful about what you say inside and outside the workplace.”
Sallie Baxendale, a professor of clinical neuropsychology at UCL’s Institute of Neurology, received abuse after receiving a systematic review of studies who investigated the impact of puberty blockers on brain development. Her review found that “critical questions” remain about the nature, extent and permanence of any established improvement in cognitive function linked to the treatment.
The paper, which summarized the state of relevant research, received an immediate backlash. “I’ve been accused of being an anti-trans activist, and that’s on Google now and it’s never going to go away,” Baxendale said. “Imagine what it’s like if that’s the first thing that comes up when people Google you? Anyone who publishes in this field must be prepared for that.”
The lack of high-quality research highlighted by Cass has been a subject of increasing unease among doctors, according to Dr Juliet Singer, a consultant child and adolescent psychiatrist and former governor of the Tavistock and Portman NHS foundation trust.
In 2020, Singer conducted a survey of specialist child psychiatry trainees, which highlighted concerns about the lack of explanation for the exponential growth in referrals to adolescent sex services, the lack of long-term outcome studies on treatments, and insufficient evidence on the long- term effects of hormone blockers.
She said that raises questions such as what drove the unprecedented turnout birth-registered girls presenting with gender-related distress in puberty appears to be “unacceptable” by some senior leaders at Tavistock.
“There was a shutdown of anyone suggesting that we should think about a deeper understanding of why these young people are in such distress,” she said. “It was remarkably different from other usual clinical practices.”
Others have found that publicly commenting on the scientific merits of work by other academics — usually a routine part of media coverage of science and health — has put scientists in the firing line when it comes to trans-related issues.
Jayasena described how he received hate mail afterwards An American study welcomed in which a trans woman was given hormones to have the experience of breastfeeding and was separately accused of transphobia after commenting on research on athletic performance in transwomen.
“I felt concern for my safety,” he said. “I find my quotes are weaponized. It is very worrying and most colleagues will never go near this type of subject for that reason.”
Another senior researcher in endocrinology, who wished to remain anonymous, said medical professionals shared their concerns and views on anonymous WhatsApp groups.
“The bad mouthing and the destruction of people’s reputations and careers on social media is so damning,” said the academic. “Professionals are concerned about how they will be characterized on social media and cannot voice dissent without it resulting in very aggressive, inappropriate behavior. It causes people to stop talking and just move away from it and not get involved.”
She added: “This is not how good scientific debate happens – it happens when people can speak honestly and without fear.”
The risk of being attacked is enough to deter younger researchers from entering the field, Baxendale believes. “It’s hard, I think most people would just walk away. Why risk your reputation? There are a lot of people early in their careers, and I don’t blame them one bit, who wouldn’t be willing to accept that,” she said.
The situation is hampering efforts to establish a solid medical basis for treatments, Baxendale believes. If the best researchers avoid the field, there is a danger that it will be dominated by less rigorous scientists and those interested in their results supporting particular beliefs.
After publishing her review, Baxendale was contacted by a senior expert outside the UK who said they had walked away from a study after being told the team would only publish “positive” findings.
Jayasena says there is a perception that research is dominated by “a self-selected group of people who will be on either side of the fence and may not be that interested in advancing the field”. And in the absence of a robust evidence base, there was greater room for ideology to fill the knowledge gap.
“In the end, I saw completely unhelpful views on both sides,” Jayasena said. “There is an overly affirmative view of let’s do everything. This leads to what I would call bro science. We get that disconnect between evidence and assumed knowledge because the internet is an echo chamber. Then there is the other side of things – a more right-wing, moralistic view. Unfortunately, some members of the medical community are engrossed in these views.”
This can act as a disincentive for learned societies, NHS bodies and scientific journals to get involved at any level.
In an attempt to find common ground between academics, doctors, patient groups and campaigners that could act as a springboard for objective research, Singer sought to organize a conference at Great Ormond Street Hospital in 2022.
The meeting was an invitation-only academic conference for specialist child psychiatry trainees and consultant child psychiatrists in London, and Cass was to present her interim findings, alongside speakers with a diverse range of perspectives, including former gender identity development services clinicians.
“What I wanted to do with the conference was to bring together people with different perspectives,” she said. “Clinicians working with children and adolescents can therefore hear different perspectives and, with an open mind, arrive at appropriate clinical and research questions to ask.”
However, after significant numbers of complaints were lodged and concessions made to achieve a balanced programme, the conference was canceled by Health Education England the day before it was due to take place after a “protected whistleblower report” was submitted from someone who described themselves as a researcher on anti-trans conspiracy theories. Despite assurances that the conference would be reorganized by HEE and the Royal College of Psychiatrists, this has yet to happen.
Others spoke of the challenge of getting studies published in high-profile journals, raising concerns that some journal editors may choose to reject studies rather than face potential criticism. As a result, papers indicating knowledge gaps in sexual medicine may be ghettoized in specific journals, making those publications appear overly critical.
Fueled by concerns about the poor quality of research, the Cass report paved the way for a major NHS trial due to start this year. It will look at the safety and effectiveness of puberty blockers, but also cross-sex hormones used to masculinize or feminize people, and psychosocial interventions, with the aim of establishing a robust evidence base.
Many are hopeful that the Cass report, and the NHS hearing it recommends, is an opportunity to draw a line under the infighting and abuse and establish a more constructive field of gender medicine.
“It will take time, but it has allowed people to breathe and feel confident to question treatments,” Singer said. “People work in this field because they want to help young people and that drive will still be there. It’s important and valuable work. Cass has now given us permission to do so.”
Baxendale is well aware that many patients and their families, reading the coverage of the Cass report this week, will be left wondering whether help will be available, whether treatments work and whether they can trust their doctors.
“It must be so upsetting for them,” she said. “But I think there is hope. The NHS research will be rigorous, it will be balanced looking at benefits and harms, and I think once we have the results we will have a proper service for these children.
