Among many alarming features of the Cass Review final report was a statement made by Hilary Cass that “Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way”(page 20, para 5), seeming to imply that the NHS does not or should not consider the potential social justice ramifications of how it treats patients. Given the massive disparity in deaths of black women at the hands of the NHS in maternity, or the recent scandals about failures to address the needs of patients with ME, it is arguably correct that the NHS does not work in a way that respects social justice, but it is not clear that disregard for a concern for social justice is based in evidence either. This ironically uncited claim in the Cass Report now seems to have been capitalised on by associates of anti-trans pro-conversion therapy lobby groups such as Genspect and SEGM.
Writing in the Journal of Human Systems: Therapy, Culture and Attachments, twenty-three coauthors, some of whom are public advocates and/or practitioners of conversion therapy targetting minors, claimed that “guidelines across different countries were progressively shaped by a rights-based approach that removed previous safeguards and increased availability of gender-reassignment medical interventions for children and adolescents”. In the paper they play up the significance of harm and regret experienced within gender affirming healthcare while labelling healthcare regimes which they describe as following a “rights based model”. The paper also spreads unsubstantiated fears about conversion therapy bans, which are contradicted by other evidence cited in the paper itself quoting the laws as specifically excluding any impact on neutral, exploratory psychotherapy.
What even is the rights-based model?
The authors do not attempt to define what constitutes a rights-based model, nor does the paper cite a pre-existing definition of what a “rights-based” model would constitute. Rather it collates a list of health governance documents where the rights of the patient are referred to at all. As an example of this practice by the authors, they cite the Norwegian National Professional Guidelines for Gender Incongruence related healthcare.
As can be seen in the auto-translated screenshot, these professional standards guidelines remind clinicians that patients have a right to access care, including gender-affirming care:
- if they need it
- in the best interests of the child,
- and with respect for their right to self determination.
Another example they give of this claimed “rights-based” approach is the Australian New South Wales Model of Care for Gender Diversity. In this, the only reference to patient rights is a reference to the Australian Charter of Healthcare Rights, and its commitment to ensuring that all patients are cared for in a safe environment that respects their identity, beliefs and choices.
Respect for patients accessing a service is, by definition, not a question of evidence, but a question of quality of healthcare provision. None of these “rights” prescribe a particular universal medical pathway because these guidelines are designed to be flexible to the specific medical needs of each patient.
While the article does not rigorously define what it means by a “rights-based” approach, it is much more up front about prescribing what it considers to be an “evidence-based” approach, listing among other things the controversial Littman study of 2018 where a survey was gathered of parents linked to a ring of anti-trans activist groups, to gather speculative parental testimony about the root causes of their childrens’ trans identities. This paper gave rise to the pseudodiagnosis “ROGD” (invented on the parent anti-trans activist boards being surveyed) and has been subject to widespread criticism of its methodological basis as well as its stigmatising nature, leading eventually to a large international coalition of 62 psychiatric and psychological professional bodies making a public statement denouncing the ROGD model over the “lack of rigorous empirical support for its existence”, adding “There are no sound empirical studies of ROGD and it has not been subjected to rigorous peer-review processes that are standard for clinical science. Further, there is no evidence that ROGD aligns with the lived experiences of transgender children and adolescents.“ The preferred model of the self-identified “evidence-based” authors of this paper is anything but an evidence-based paradigm.
Trans Safety Network typically avoid weighing in on matters of unresolved scientific dispute, other than to highlight areas where established clinical consensus and the work of mainstream forums for clinical consensus has been marginalised by anti-trans lobbyists. We are not health researchers and do not attempt to present ourselves as such, but the widespread academic criticism of the quality of much of the research this paper is based on is the subject of considerable, noteworthy public and academic discussion at this point. We leave academic and scientific discourse to the academics and scientists. However, we feel that it is necessary to highlight this paper as a form of unrigorous science-washing of a poorly defined rhetorical concept - this new argument about "rights based" healthcare - which is constructed mainly in this case to act as a bogeyman to aid lobbyists in wider attacks on the rights of trans patients. That is the only reason we can conceive of for attempting to draw a false dichotomy between “rights” or “social justice” and “evidence” in this fashion when trans patient rights have nothing to say about what healthcare is best for any given patient. Patient rights charters exist instead to prevent doctors arbitrarily imposing their preferences on patients without regard for evidence or the preferences of the patient. Patient rights are not a question of science but a question of ethical practice.
Conversion therapy scaremongering
On the topic of ethics, it is worth discussing the connection between several authors of this piece and harm to trans people. One of the authors, psychotherapist Stella O’Malley, was recorded in 2022 in a Twitter Spaces conversation publicly claiming that for young teenage trans girls, their trans identity is a fetish induced by pornography, and affirming to her interlocutors in the meeting that they do not deserve compassion. She stated clearly that her goal is to prevent as many children from transitioning as possible. Another, Kenneth Zucker, is known for having had his clinic shut down in Canada after the country banned conversion therapy, owing to his practice of attempting to prevent young trans people from identifying as transgender. Patrick Hunter, also listed as a coauthor in this article was a key actor in campaigning for a trans healthcare ban in Florida, in coalition with anti-trans hate group SEGM, who the Southern Poverty Law Centre have described as being part of a “pseudoscience network”. Another coauthor, Rittakerlu Kaltiala who was a speaker at SEGM’s conference earlier this year has been the subject of allegations of sexually invasive questioning towards young trans patients in Finland. None of this bodes well for a respectful or sincere negotiation of the pros and cons of conflicting approaches to trans patients’ rights in healthcare.
It is notable that in one pararaph, the authors claim without citation “In a parallel process, “conversion therapy” laws, passed in many countries, closed access to exploratory psychotherapy that enables exploration of gender-identity issues from a neutral therapeutic stance.” That the authors were allowed to publish this claim without providing any citation of any jurisdiction where neutral exploratory therapy has been made illegal is startling. Later on in the same article, they define conversion therapy laws, saying “any therapist who engages in a practice that attempts to change or suppress a person’s sexual orientation or gender identity is, according to such laws, open to prosecution”. Given that efforts to change or suppress a person’s identity (or sexuality) are what is being described, this could hardly be considered “neutral” or meaningfully “exploratory” — these laws by definition ban a directed agenda-driven effort to effect change in identity. The article even quotes New Zealand’s conversion therapy ban as stating that “”facilitating an individual’s coping skills, development, or identity exploration, or facilitating social support for the individual” does not constitute a conversion practice". The contradiction here between the claim that these laws, which strenuously avoid banning genuinely neutral exploration and supportive non-directive therapy, are in fact banning neutral therapy, should be taken in the context of having been written by an array of authors including those with a known record of practicing and advocating non-evidence-based, agenda driven therapy to change the identities of trans subjects. This is crying wolf, with the intent of stirring up fear, uncertainty and doubt over protections for trans people against abusive clinical practices.
Summary
All in all the fact that this paper has been allowed to be published in an academic journal poses a worrying indication of the future of pseudo-scientific anti-trans advocacy. Activists for the anti-trans pro-conversion-therapy lobby have been given free reign here to post a thinly veiled opinion piece which can then be cited at a later date as evidence for their spurious claims, while serious evidence-based critiques of speculation and deviation from proper scientific processes happening in trans healthcare made by independent academics like the Yale Integrity Project are still yet to be taken seriously by healthcare ministers in the UK. As things stand, it appears that this type of pseudoscientific material is less about constructing a body of evidence through legitimate research, than it is about preparing excuses for further trans harm in health policy, dressed up in the appearance of scientific practice based on credentials of the authors and publication in ostensibly academic literature, despite contradictions in their own work with the actual evidence provided. Policymakers are then able to cherry pick these sorts of paper, without any need to reference or consult mainstream professional bodies in the field such as WPATH, or numerous other non-activist clinical expert groups on trans healthcare such as BAGIS, AuPATH, EUPATH, APATH, and so on who policymakers ought to be taking as the appropriate bodies to develop and refine the existing scientific consensus.
It’s important that a false dichotomy between evidence and patient rights is not given false credibility when the claim itself lacks a meaningful evidence base or definition. After all, patient rights can only be secured through rigorous application of evidence-based healthcare practice, without which there is no pathway to safeguarding key ethical principles like informed consent or respecting patient agency and self determination. There is no contradiction between a rights-based, and an evidence-based approach, much as anti-trans lobbyists and Hilary Cass want to construct one.