Critical thinking and open debate are pillars of scientific and medical research. Yet experienced professionals are increasingly scared to openly discuss their views on the treatment of children questioning their gender identity.
This was the conclusion drawn by Hilary Cass in her review of gender identity services for children this week, which warned that a toxic debate had resulted in a culture of fear.
Her conclusion was echoed by doctors, academic researchers and scientists, who have said this climate has had a chilling effect on research in an area that is in desperate need of better evidence.
Some said they had been deterred from pursuing what they believed to be crucial studies, saying that merely entering the arena would put their reputation 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 freedom to answer questions to problems without fear of judgment,” said Dr Channa Jayasena, a consultant in reproductive endocrinology at Imperial College London. “I’ve never quite known a field where the risks are also in how you’re seen and your beliefs. You have to be careful about what you say both in and out of the workplace.”
Sallie Baxendale, a professor of clinical neuropsychology at UCL’s Institute of Neurology, received abuse after publishing a systematic review of studies that investigated the impact of puberty blockers on brain development. Her review found that “critical questions” remained around the nature, extent and permanence of any arrested development of cognitive function linked to the treatment.
The paper, which summarised the state of relevant research, was met with an immediate backlash. “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away,” Baxendale said. “Imagine what it’s like if that is the first thing that comes up when people Google you? Anyone who publishes in this field has got to be prepared for that.”
The lack of high-quality research, highlighted by Cass, has been a subject of growing 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 gender services, the lack of long-term outcome studies on treatments, and insufficient evidence on the long-term effects of hormone blockers.
She said raising questions such as what was driving the unprecedented rise in birth-registered girls presenting with gender-related distress in puberty appeared to be deemed “unacceptable” by some senior leaders at Tavistock.
“There’s been a shutting down of anybody who has suggested we need to think about a deeper understanding of why these young people are in such distress,” she said. “It’s been remarkable the difference from other ordinary clinical practice.”
Others have found that commenting publicly on the scientific merits of work by other academics – normally 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 receiving hate mail after welcoming a US study in which a trans woman was given hormones to be able to have the experience of breastfeeding and, separately, being accused of transphobia after commenting on research about athletic performance in trans women.
“I felt concerns for my safety,” he said. “I find my quotes are weaponised. That is very worrying and most colleagues would never go near this type of topic for that reason.”
Another senior researcher in endocrinology, who wished to remain anonymous, said medical professionals had resorted to sharing concerns and views on anonymous WhatsApp groups.
“The bad-mouthing and the social media destruction of people’s reputation and careers is so damning,” the academic said. “Professional people are worried about how they will be characterised on social media and cannot express dissent without it resulting in very aggressive, inappropriate behaviours. It’s causing people to stop talking and just move away from it and not get involved.”
She added: “This isn’t how good scientific debate happens – it happens when people can talk honestly and without fear.”
The risk of being attacked is enough to deter younger researchers from entering the field, Baxendale believes. “It’s tough, I think most people would just walk away. Why risk your reputation? There are many people early in their careers, and I do not blame them one bit, who would not be prepared to accept that,” she said.
The situation hampers efforts to establish a firm medical basis for treatments, Baxendale believes. If the best researchers avoid the field, there is a danger it will become dominated by less rigorous scientists and those who have an interest 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 has been a perception of research being dominated by “a self-selected cohort of people who will be on either side of the fence and perhaps not so interested in advancing the field”. And in the absence of a robust evidence base, there has been greater scope for ideology to fill the knowledge gap.
“Ultimately, I’ve seen completely unhelpful views on both sides,” Jayasena said. “There’s an overly affirming view of let’s just do everything. This results in what I’d call bro-science. We’re getting that disconnect between evidence and assumed knowledge because the internet is an echo chamber. Then there’s the other side of things – a more rightwing, moralistic view. Unfortunately, some members of the medical community are immersed in these views.”
This can act as a disincentive for learned societies, NHS bodies and scientific journals to become involved at any level.
In an effort to find common ground among academics, doctors, patient groups and campaigners that might serve as a springboard for objective research, Singer attempted to organise a conference at Great Ormond Street hospital in 2022.
The meeting was an invite-only academic conference for specialist child psychiatry trainees and consultant child psychiatrists in London, and Cass was due 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 just bring together people with different perspectives,” she said. “So clinicians working with children and adolescents can hear different perspectives and, with an open mind, come to appropriate clinical and research questions to ask.”
However, after fielding significant numbers of complaints and making concessions aimed at achieving a balanced programme, the conference was cancelled by Health Education England the day before it was due to take place after a “protected whistleblower’s report” was sent in from someone describing themselves as a researcher on anti-trans conspiracy theories. Despite reassurances that the conference would be reorganised by HEE and the Royal College of Psychiatrists, it is yet to happen.
Others spoke of the challenge of getting studies published in high-profile journals, raising concerns that some journal editors may prefer to reject studies rather than face potential criticism. As a consequence, papers that flag knowledge gaps in gender medicine can become ghettoised in particular journals, making those publications appear overly critical.
Fuelled by concerns about the poor quality of research, the Cass report has set the stage for a major NHS trial that should start this year. It will look at the safety and efficacy of puberty blockers, but also cross-sex hormones that are used to masculinise or feminise people, and psychosocial interventions, with the aim of establishing a robust evidence base.
Many are hopeful that the Cass report, and the NHS trial it recommends, are 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’s allowed people to breathe and feel confident in questioning treatments,” said Singer. “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 it.”
Baxendale is acutely aware that many patients and their families, reading 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 distressing for them,” she said. “But I think there is hope. The NHS research will be rigorous, it’s balanced to look at benefits and harms, and I think once we’ve got the results we will have a proper service for these kids.”
