On 21 September 2023, Daniel Sanderson, the Scottish Correspondent for The Telegraph, published an article in which a letter, from a Scottish GP, to Gregor Smith, Chief Medical Officer of Scotland, is extensively quoted. The GP maintains that NHS Scotland's proposals for the treatment of transgender children would create a 'medical scandal as bad as lobotomy or thalidomide', and warns that proposals set out under SPATH would 'cause harm to many vulnerable children'. The letter was, in fact, dated 16 November 2022, and its comprehensive message strongly cautioned Dr Smith against going ahead with the SPATH proposals, which are still in abeyance, and yet to be made public. There is no evidence that Dr Smith has responded to the letter. Here is that letter in full, with names redacted:
Sent: 16 November 2022 23:12
To: Chief Medical Officer <CMO@gov.scot>
Subject: Re: Gender issues
It was good to hear you speak at the Fulton Lecture recently. I was glad to hear you say that the interim Cass review had been read within your department and that the findings were going to be considered. I am therefore dismayed to read the Scottish Pathway for Trans Healthcare - Subgroup considerations and recommendations, which has been published online. There are multiple, serious concerns with this document which, if taken into practice, I am in no doubt will cause harm to many vulnerable young people.
In terms of the guiding principles, there is no statement of the need to provide evidence-based healthcare, or of avoiding overmedicalisation and/or overtreatment. The use of NHS-funded third sector organisations, is recommended, but no mechanism to ensure these are offering evidence based interventions (there are numerous examples of NHS funding being used to deliver non evidence based alternative treatments and therapies which I have raised locally within support services.) This has the potential to make dysphoria worse and ineffective intervention more likely.
The new assessment approach recommended is that of merely exploring 'the aspect of gender affirming healthcare it is considering initiation'. Elsewhere it states that counselling "is never mandatory' before intervention. Leaflets are to be rewritten with "the importance of gender affirming care - reassuring in tone rather than a focus on assessment" This is appalling. The young person should not proceed straight to a 'hormone readiness assessment' (which could include irreversible puberty blockers) but to an evaluation and understanding of what has caused the dysphoria, the persons' medical and psychological history, any neurodevelopmental factors, family and environmental issues, etc, and allow an understanding of the distress. The words used to describe surgery are euphemistic eg 'genital surgery readiness assessment' - and not explaining in factual terms e.g. castration, loss of fertility. They present a particular point of view - that surgery to affirm is straightforward and routine. To state, as the report does, that "counselling or psychotherapy for trans people specifically focused on their gender identity is not a prerequisite for any gender affirming healthcare" would be negligent. To proceed to irreversible surgery without adequate assessment is dangerous. The statement in the report 'In fact, access to hormones and surgeries can act as a prophylactic measure against distress' is not based in evidence. I am alarmed by the fast track route to irreversible intervention without ensuring adequate assessment.
Nor is not clear what evidence base the "GP prescribing long-term hormones and annual health check" will be expected to work to, since it does not exist. There appears to be no consideration of the harms that using the NHS sex marker as a gender marker will do to accurate record keeping, risk management and result interpretation. This is in contrast to the recommendations of the RCGP, who have called on a separate sex and gender marker to be used in medical records. Using a model of assessment where the patient is seen by a lower skilled person but "the actual prescription may be issued by another practitioner" is a recipe for disaster. This will allow the responsibility for patient care to be delegated, especially in the private sector, with little, remote or no oversight. It risks the abdication of responsibility.
Throughout the report, it is unclear who with lived experience was listened to. Several detransitioners (who consider themselves overdiagnosed and overtreated and harmed by medical intervention) were not allowed to give evidence in the recent Scot Gov GRA consultation. I know you are concerned about medical harms. I am unclear why no critical voices seem to have been sought or used. There is a recommendation that primary care clinicians should offer information about hormone treatment at the point of referral. This would not seem to be a neutral act.
The statement "Processes should be equitable to other groups of patients who receive similar treatments for different indications, for example other groups prescribed testosterone and oestrogen" is non sequiter. Use and monitoring for one condition does not automatically translate into another. The idea of a "A robust educational offering should be available to Primary Care to ensure adequate knowledge and skills within the team. NES should be commissioned to develop a transgender problem based small group learning (PBSGL) module specifically on shared care agreements, CHI change counselling, screening, hormone monitoring and ongoing care" would only be useful if it also reflected the gaps in the evidence and uncertainties about benefits of medical intervention and their potential harms. It should not simply be about service delivery.
"Healthcare Improvement Scotland (HIS) should support this by quality assuring private providers of gender identity assessments and prescribing through regulation and accreditation." It is uncertain how this will be done, given that the NHS own standards, as described here, are for intervention without psychological assessment. What standards will HIS be assessing against - these are far lower than in England. I note "Systems within NHS Scotland need to allow for increasing gender identities for patients, specifically including non-binary identities. This should be done as part of a general move away from gendered healthcare". A move away from gender (social roles) would be good, as these are generally stereotyped and unhelpful. However, sex is immutable and cannot be changed. We rely on accurate sex coding for interpreting lab results, imaging, screening invitations, risk assessments, research, etc. Is this proposal about de-sexing the language (increasing confusion for women)? Are single sex spaces for women under threat ? Clarity would be appreciated.
The document notes that the aim is for an "evidence-based approach, the Cass Review and a trans affirmative approach" - but the first two are competing with the latter. It is very worrying to read that "parts of their review may be further informed by the Cass Review, but were in agreement that this should not delay progress". Given the seriousness of the concerns raised in the Interim report, what justification for continuing can there be?
I honestly think that the treatment of gender dysphoric children as we are now doing - intervention, medication and surgery rather than understanding, exploration and minimising intervention - will go down as a medical scandal as bad as lobotomy or thalidomide. I fear that the medical profession, rightly ashamed of how [Redacted - s.38(1)(b)] medicalised homosexuality, is looking for ways to make amends. Yet [Redacted - s.38(1)(b)] are getting involved with little to no evidence of benefit and much of harm. [Redacted - s.38(1)(b)] I have seen young women hate their bodies, from anorexia and self harm - this is just the same pattern.
I know that you are committed to Realistic Medicine and have had the experience of being a GP for many years and will recognise my concerns. I hope that Scotland can regroup and find a better way through this very challenging area which does not do harm to young people. I look forward to your response.
The Telegraph article: