ScotPAG Position Statement
The Scottish Government’s Response to the Cass Review: Implications for Scotland
The Scottish Government (SG) published its response to the Cass Review (CR) on 5th July (The Cass Review Implications for Scotland). The SG agrees with Dr Cass about the need for an ´holistic’ approach towards gender questioning children, BUT doesn’t spell out the details of what this should look like. Thankfully ScotPAG does! Read our ScotPAG Position Statement: The best response to gender questioning children
ScotPAG is a group of professionals who have come together collaboratively, to share our knowledge and concern about the present modes of understanding and treatment of what has come to be known as gender dysphoria, or 'transgender' issues. Our group consists of people who have worked in clinical psychology, education, educational psychology, medicine, midwifery, nursing, occupational therapy, pharmacy, physiotherapy, psychiatry, psychotherapy, public health, and social work. Collectively we have worked in the NHS, schools, universities, social services, and 3rd sector organisations. We take the view that a collective, multi-factorial approach is what matters in effectively managing and responding to any issue affecting society and its communities. To this end we are arguing that a public health response is the only way to support gender questioning children, their families, public services, professional bodies and society as a whole.
What are the Issues?
The Scottish Government report ‘Cass Implications for Scotland’ was published 5th July 2024 in response to the Cass Review’s recommendations (published 10th April 2024). The CR and its Scottish response both state that it is essential to take a holistic approach towards supporting gender questioning children. However, the Scottish Government report is limited in its response regarding what is really required across all Scottish public services because it fails to look at the broader context for the emergence of this health emergency in children. The SG also fails to understand that it has helped to create a child safeguarding concern.
Health services are not the start but the end of the pathway when it comes to gender questioning children. All our public services need to respond to children’s distress and questioning using an evidenced based approach to the Cass recommendations. The evidence from countries affected is that the source of the huge increase in gender questioning children stems from the known phenomenon of social contagion, media influence and “product placement” of the term ‘transgender’ within schools and nearly all other establishments. It should also be understood that the term ‘transgender’ is an ill-defined umbrella term (as described by Stonewall) which originally applied predominately to adult men with a range of mental health issues.
Based on the robust evidence provided by Cass and other international research, it is clear that our health, education and social services should remove gender affirming and social transition policies from all institutions with immediate effect. For the sake of the emotional wellbeing of all our children, and staff, the concept that any individual can change sex should be removed from all aspects of our public institutions. The Scottish Government along with those responsible for running and overseeing our public institutions, should recognize the embeddedness of gender ideology as a public health emergency affecting the safeguarding of all children and families which to a significant extent, they have helped to create. They must now take responsibility for its removal.
What needs to happen now?
The SG along with public services leaders must become ‘the grown ups in the room’ and do the following:
• Treat embedded gender ideology in our public services as a public health emergency
• Remove all guidance in public services endorsing gender ideology with immediate effect
• Remove gender ideology messaging from all public institutions e.g. from school curricula, health notices, social work language
• Remove gender ideology from training from all professionals’ social work, education and health training courses
• Third sector organisations promoting gender ideology do not have the knowledge base, specific training, or professional skills and should be removed from public services provision
• Evidence-based, systemic reviews should be recognized as the basis for interventions in the provision of public services
Health Services
The Cass report findings state about gender affirming care,
“There is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices”.
Dr Cass has identified the risks and harms that gender identity ideology can incur on the health and wellbeing of children and families, especially vulnerable children with additional support needs. The SG report responding to CR is written by health practitioners and attempts to define a health based gender service for children. The report provides a description of the Young Person’s Gender Service and outlines the increase in children on the waiting list for the Sandyford Clinic (around 1100) and how long these children have been waiting to be seen. 49% of referrals to the service are self-referrals, 73% of which are female. It also reports about difficulties in staff retention. The report goes on to consider the Cass recommendations and how a gender service might respond. It does not consider what a holistic response might look like. As Cass states,
’…no individual journey begins at the front door of the NHS, rather in the child’s home, family and school environment. The importance of what happens in school cannot be under-estimated; this applies to all aspects of children’s health and wellbeing. Schools have been grappling with how they should respond when a pupil says that they want to socially transition in the school setting. For this reason, it is important that school guidance is able to utilise some of the principles and evidence from the Review.’ (12.6 p158).
The issue of children stating that they feel they are the opposite sex has undeniably become a multi-factored problem. It is essential that social, educational, psychological and developmental factors are identified in order to support children who are vulnerable to gender distress or dysphoria. Cass found that these are children, overwhelmingly girls, with autism and/or other additional support needs; children who have suffered trauma and abuse, and children who are separated from their parents and families in care. There is already evidence of an increase in inequalities and harms across vulnerable children, for example: children with additional support needs; increasing numbers of children reporting mental health concerns; lack of health care services for detransitioners. Health care services are at the end of the line of public services which can address the problems caused by gender ideology. It is essential that public services are positioned to be most effective and targeted at harm prevention.
Education Services
The Scottish Government currently presides over school guidance and school curricula (Relationships, Sexual Health and Parenthood, RSHP) which embraces the ideology of gender identity, an ideology for which there is no robust evidence. Schools and children’s services are at the heart of the processes of affirmation and social transition. The original guidance on Supporting Transgender Young people in Schools was published in 2017 and was written entirely by members of LGBT Youth Scotland and the Trans Alliance Scotland. In response to widespread criticism 2021 the Government published only slightly amended guidance Supporting transgender young people in schools. This guidance told schools that children of any age should be supported to “explore their gender identity” and to “transition” to the sex that they identified as. The evidence base provided is poor and has been repeatedly criticized (Cunningham 2023, Brown 2022, 2023, 2024). The guidance also provides misinformed positive recommendations: e.g. the use of breast binders; and recommends Mermaids for support. Currently, it continues to be used as a basis for reference in most schools in Scotland. The majority of Scottish schools also have incorporated the charters promoted by third sector organisations (e.g. LGBTYS, TIE) which not only promote gender ideology in schools but have successfully encouraged schools to embed gender ideology in all their procedures and processes
Social Work Services
In child protection and children’s care, approaches with no reliable evidence base have been widely adopted. Local policies can often include directions that non-affirmative approaches by parents should be investigated as a child protection concern. Remarkably, the Care Inspectorate issued guidance in the wake of the interim report of the Cass review which endorsed the existence of gender identity in children and recommended that children in care homes should be allowed to use the accommodation and toilets/bathrooms of the opposite sex if they felt they were “trans”.
The SG report highlights the importance of services beyond those of health but is weak on detail in terms of what actually needs to happen,
’Education also has a key role as the main interface between children and young
people and their community. Local multi-agency Children’s Services Plans, and
individual child plans, can provide a framework for ensuring that children and young people and their families have access to appropriate supports.’
Staffing, Training, and Psychological Modalities
The SG’s consideration of professional knowledge, expertise, and governance, in their appraisal of the phenomenon of ‘gender identity’ is inadequate. Whilst the SG agrees with the CR recommendation that any future services ‘must operate to the same standards as other services’, NHS, Education, Social Work services have all acted on guidance received from lay, third party organisations. If, as the SG proclaims, ‘gender dysphoria’ is a ‘highly specialist’ area, then the public, and the courts of law, would surely demand that highly qualified and experienced clinicians, already dealing with complexity in psychological services, would be consulted for their expertise, in order to have the same standards as other specialist services?
In its introduction to the Sandyford Clinic as the main hub of clinical activity, the SG makes a significant acknowledgement of the chronic difficulties in recruitment and retention of staff. This admission of problematic service provision is accompanied by the inconclusive observation:
‘The reasons for this are varied but include the highly specialist nature of the field and the polarised context of the work.’
The notion of professionally trained and experienced clinicians being put off from applying for posts, or unable to retain their employment, on the grounds of something being categorised as a specialty in medicine, is unlikely. The fact that introducing ideological aims and lay trainings into this ‘highly specialised’ clinical arena of complexity, co-morbidities with a politically-charged public profile has served to severely distort professional practice. Third sector training materials are much more likely to account for ‘the polarized context’ that engulfs these establishments. As a result, the essential and embedded processes of staff support and peer supervision by experienced clinicians and practitioners, are severely undermined in the context of contradictory theoretical standpoints.
The choice of language used in SG documents, concerning psychological modalities, should reflect the knowledge of those clinicians with extensive trainings (usually 6 years or more and over 1000 hours of supervised clinical work with many complex conditions involving body/mind anguish). The use of popular and misleading lay terms (e.g. finding the ‘true self’, ‘non-binary’, ‘cis gender’ etc.), used by third sector organisations in their training, is unhelpful. It is no wonder that staff find themselves forcibly uncoupled from their trainings and professional bodies, in a situation where opposing views of basic biology and the human condition permeate the ethos of the clinic.
Reduction of Risks and Harms: A Public Health Emergency
There is a clear need for the Scottish Government and all public services to respond to the following risks:
1. Use of clinical evidence-based practice. The lack of evidence around medical and surgical interventions being provided to children and young people is established by CR. Any harms caused to date by these unevidenced treatments must be acknowledged
2. There are significant risks of litigation and compensation due to the provision of affirmation, social transition, medical, and surgical non-evidence-based interventions
3. Education, care, and workplace safety: lack of provision of single sex safe spaces for children and staff
4. Increasing inequalities: changes in language, use of pronouns, omissions etc. risks confusions, anxieties, and the creation of more barriers, and an increase in inequalities in health
5. Sex-based service provision in all public services: e.g. changing rooms, intimate care – ensuring intimate care for vulnerable children is essential to ensuring safety
6. Financial risk /value based Healthcare: long term health of those who have had cross sex treatments, necessitating a lifetime of ill health
7. Realistic medicine: minimal medical and surgical intervention - current practice flies in the face of a Realistic Medicine approach
8. Population health and safety: increase in misogyny, INCEL and transmaxxing within youth culture
9. Psychological harms: the embedded nature of gender ideology in schools is resulting in reports of pupils thinking inappropriately that they can change sex. It is also resulting in other pupils becoming confused and anxious as they are being told to collude with a false belief
References
Blakemore, S., 2018, Inventing Ourselves: The Secret Life of the Teenage Brain, Transworld.
Brown, C., 2022, Gender ideology a hindrance if a pupil identifies as trans November 17th www.thetimes.co.uk
Brown, C.,2023/4 scotpag.com
Care Inspectorate, 2023, Guidance for Children and Young People’s Services on the Inclusion of Transgender Including Non-Binary Young People.
Cass Review, 2022, Independent review of gender identity services for children and young people: Interim Report.
Cass Review 2024, Independent review of gender identity services for children and young people: Final Report.
Cunningham, J., 2023, Transgender Ideology in Scottish Schools: What’s wrong with government guidance? Scottish Union for Education.
Scottish Government, July 2024 Cass Review - Implications for Scotland
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