Understand This Dynamic

Evan Barker writes:

In the past week, a tidal wave of bad news has crested for Republicans. Ruby-red states like Texas have shifted to “lean Democrat” on pollsters’ spreadsheets. In Iowa, Democratic prairie populists are gaining momentum. Abdul El-Sayed still leads the polls in Michigan, despite having campaigned with controversial figures like Hasan Piker. States that have trended to the Right over the last decade are now causing Republicans to bite their nails in nervous anticipation for the midterms.

Have these red- and purplish-state Democrats found the winning message not just for today, but for 2028? What are they doing right — and what can the party learn from them? The short answer is that, with a few exceptions, these nominees are breaking with the party’s ultra-progressive messaging on cultural issues.

Consider Iowa, a state hard-hit by the bad trade deals of the past, alienated by the cultural Left, and now hurt economically by President Trump’s war in Iran. There, two self-described “prairie populists” are in close races. Barack Obama won Iowa in 2008 and 2012. Since then, it has been solidly red — aside from one candidate who became state auditor in 2022.

But Iowa isn’t a conservative red state — it is what I call “populist red.” The state has areas that vote red, but aren’t traditional Republican strongholds the way, say, South Carolina is. Populist red states switched to Republican because Trump dropped the GOP’s neoliberal orthodoxies on immigration and trade. This, even as the Democrats began catering aggressively to college-educated professionals at the expense of their historic blue-collar constituencies.

That combination — a Republican president who could sound remarkably like the old labor Left and a Democratic Party that didn’t — proved disastrous for the Dems in places like Iowa. Rob Sand, the Democrat running for governor, seems to understand this dynamic.

Sand has broken with his party on several issues. He has advocated against “political agendas” in children’s schools, arguing instead that basic education fundamentals should be the central focus. He supports Iowa’s law barring biological males from competing against women and girls in sports. He is pro-gun. This might make him sound like a “moderate”, but his economic policies mirror those of his populist GOP opponent, who wants to regulate data centres and ban limited liability corporations from buying Iowan land. Sand combines economic-populist ideas with Left-coded ones that are also populist — raising the minimum wage and legalising cannabis [boo!] to cover the state’s looming fiscal crisis.

Like Rob Sand, the Democrats’ nominee for US Senate, Josh Turek, has also broken with the national party on the trans sports issue. But on gun rights, Turek toes the party line, and is on record for wanting to ban assault rifles. Other red-state Democrats like Amy Acton, running for governor in Ohio, and Annie Andrews, running for Senate in South Carolina, have broken with the national party on trans ideology. Both women have stated that biological boys can’t compete in girls’ sports and have come out against trans surgeries for minors. Both have also faced substantial backlash. The Ohio Democrats Progressive Caucus, for example, released a statement criticising Acton’s remarks — even suggesting some may not vote or canvass for her. 

Annie Andrews’s ad, released this month, in which she came out against trans surgeries for minors, was reviled by progressives online. Cory Archibald, a powerful progressive activist, wrote: “Democrats who throw my trans siblings to the wolves will never get a dime out of me or a minute of my time.” Democrats like Acton, Sand, and now Andrews are paving the way for reining in the party’s excesses on issues like gender ideology, which proved consequential for Kamala Harris in the 2024 election. Progressive activists who criticise red-state Democrats for diverging on these issues often live on the coasts, inside blue bubbles, detached from the realities of working-class and rural areas; much of their success comes from electing progressive candidates in blue districts.

These activists dismiss issues like biological boys in girls’ sports, insisting that it only affects a small minority of people and that Democrats should stop playing into “Right-wing hysteria.” They contend that Trump’s defining political ad against Kamala Harris was an economic argument and had very little to do with gender ideology. But by taking the wrong side of an 80-20 issue, Democrats undermine their authority on health care and the economy, too. Voters in red states see these views as “lacking common sense” across the board, and espousing them discredits Democrats on all other issues, even when the party may genuinely have better ideas than the other side. Trump’s poll numbers are in the gutter right now, but the Democrats’ brand tracks even lower. Winning the midterm elections on backlash to the affordability crisis and the Iran war alone is not a long-term strategy for Democratic politicians, especially those in red and purple states.

El-Sayed, the progressive firebrand running for the Senate in Michigan, is an exception to this trend. He’s solidly on the Left when it comes to economics. But unlike his counterparts in Iowa and Ohio, El-Sayed has remained unapologetically progressive on most cultural issues. In a Fox News interview, for example, he stuck to the progressive line on gender, and he has made little effort to critique 2020-style peak woke-ism. “Not all of those were bad ideas,” he told one interviewer, referring to the Democratic Socialists of America’s “abolitionist” positions on prisons, borders, and policing.

For progressives, El-Sayed’s campaign is do-or-die. Winning in a purple state like Michigan will be a powerful sign that the progressive agenda is viable beyond deep-blue districts. Progressives will use this energy to advance their policy goals into the 2028 presidential contest, the same way they did in 2020, when 10 presidential candidates ran on AOC’s Green New Deal. AOC herself recently declared: “If Abdul can win in Michigan, anybody can win anywhere.”

Another (partial) exception is James Talarico, who is running a surprisingly competitive race for the Senate in Texas. Campaigning in far redder territory than El-Sayed’s Michigan, Talarico has been largely unwilling to separate himself from the national Democratic Party brand — saying he was against biological boys competing in girls’ sports if it is “unfair” but quickly reversing his position after receiving backlash from his own party. But even Talarico has come out against gender surgeries for minors.

Given the political climate, candidates like Abdul El-Sayed, Rob Sand, Josh Turek, and James Talarico have a real chance of flipping red states. But if the likes of El-Sayed and Talarico lose while Amy Acton and Rob Sand win in Iowa, it should be a glaring sign to the party that winning in areas they used to win but no longer do requires rethinking progressive culture stances.

That is the central lesson. In my experience, progressive operatives are unlikely to heed it. In Texas, they will blame Elon Musk for Talarico’s loss. In Michigan, they’ll whine that the establishment media sabotaged El-Sayed by focusing too much on Hasan Piker. They will blame everyone else before confronting their own unpopular ideology. On the other hand, as one Democratic strategist told me: “If Amy Acton, Josh Turek, and Rob Sand win — it proves you can tell LGBTQ activists to go take a hike.”

No such luck over here, though. The Bill Committee for the Conversion Practices Bill is to be chaired by Alex Barros-Curtis, until 2024 the Head of the Labour Party’s Governance and Legal Unit, where he was a scourge of members who held legally protected sex-realist views. And Julie Bindel writes:

“The gender capture is making a mockery of our profession,” says Lianne Smith*, an experienced clinical psychologist who works with children. “We save lives — I save lives. This approach is destroying lives.” Smith is in no doubt about the damage she believes is being done within — and by — her profession. Psychology should be a lifeline for youngsters struggling with their mental health. Yet according to a small but growing number of clinicians, their ability to help is being undermined when it comes to those experiencing gender dysphoria.

At the centre of their concerns is the rise of so-called “affirmative care”: an approach which treats a young person’s declared gender identity as something to be validated rather than explored. Complicating the matter yet further is the Conversion Practices Bill, which will criminalise any attempt to instigate conversations around sexual orientation and gender. In other words, it will criminalise those psychologists who attempt to prompt deeper thinking in minors who are gender confused.

I spoke to dozens of psychologists for this investigation, all of whom expressed fears about the professional consequences of speaking openly. The institutions that should be defending them have instead helped create a climate in which voicing scepticism can carry serious consequences — both for clinicians themselves and for the vulnerable young people in their care.

*** 

Michael Kerr, 34, describes himself as “a walking example of what’s wrong with trans ideology and affirmative healthcare”. When he was 18, and not long out as a gender non-conforming gay man, Kerr was raped in a nightclub. Traumatised by the experience, he used drugs and alcohol to cope, wanting to dissociate from his body. He fell in with a queer crowd in the gay scene, which tried to persuade him that he was really transgender, and should live as a woman. His GP referred him to the Sandyford gender clinic (known as the “Scottish Tavistock”) in 2018, and his first appointment was in 2020.

He was, he says, affirmed by every medical professional he met. “From GPs, to receptionists, the gender clinic — [they] all instantly started referencing me as a woman. It was almost intoxicating to be recognised like that.” After a couple of sessions, he was told he could go straight onto a course of hormones even though he was also struggling with depression and self-doubt. No questions were asked, except which pharmacy he wanted oestrogen to be dispatched to.

From then on, Kerr says he was led down a path to full transition. “I now know that my problems came about because I had been raped and had no support to deal with it,” he tells me, “but I was just sent on a single path towards transition, and ended up living as a woman for seven years before realising it was a huge mistake, and starting on the path to detransition.”

Kerr, who set up Detransition Pathway UK this year, has suffered numerous health conditions since stopping oestrogen and starting testosterone. He is almost always in chronic pain, and has gynecomastia — excess breast tissue. But, he says, there are no agreed protocols to support people like him. Neither his GP nor anyone at Sandyford suggested Kerr might try generic mental-health support. “Any decent clinical psychologist should be able to recognise that so many of the young people presenting with gender identity issues have got underlying trauma under conditions,” he argues. “I am a living, breathing example of how not to deal with someone in mental distress.”

Transactivists have long argued that the number of those who regret transitioning, or revert back to their actual sex, is small, tending to estimate the figure at perhaps 0.1%. Kerr believes the figure is far higher, and suggests this is the fault of medical professionals looking after them. Even when he voiced doubts about his gender treatment, he says, the clinic told him to “keep going”.

Hilary Cass foresaw the problem back in 2024 when she published her review of gender identity services for children and young people. Back then, she addressed the fact that some practitioners had become reluctant to provide psychological support because they feared being accused of “failing to affirm a young person’s gender identity or of practising conversion therapy”. Cass was anxious that any future legislation “should not make workforce problems worse than they are”.

The British Psychological Society (BPS) does have a Code of Ethics and Conduct (2021). This outlines four key principles to adopt when working with patients: dignity, privacy, consent and self-determination “of all persons”; working only within one’s trained expertise; avoiding harm and safeguarding welfare; and honesty and transparency. These principles are particularly vital when working with children and young people, for obvious reasons. The trouble is, the body that is supposed to be advocating for children and professionals is failing to properly care for either.

Two years on from Cass’s review, the psychologists I spoke to attest that, if anything, things have got worse. Underlying complex presentations remain unexplored and insufficient time is given to evaluate psychological needs. As the conversion practices bill strides ever closer to legislation, fear within the profession is growing — yet hardly anyone dares to speak out. Of that small but significant minority of child clinical psychologists who have questioned the affirmative approach of “gender medicine” — all have been roundly punished. Some have lost their income, been labelled transphobic, or worse, held responsible for the deaths of “trans kids”.

“I’m seeing kids now who really need a psychologist who isn’t going to instantly affirm them and send them down the ‘gender’ route,” says Nancy Reed*. Clinicians are afraid to speak out, says the clinical psychologist based in London. “If they heard bad things about me [professionally] and their parents took them away from my care, they would be instantly affirmed by someone else, and that would be the end of that.”

The current model for gender treatment resembles what clinical psychologist Leslie Jones* describes as a “trans conveyor belt”: the affirmation approach leads to social transition, which in turn leads to puberty blockers, cross-sex hormones, and seriously risky life-long medical trajectories. We already know this. But what’s surprising is that the direction of travel isn’t changing. Jones was “horrified” by the “ideological stance” that had gripped the private gender clinic he worked in. Gender became the sole focus, with all of the problems which may have been behind the gender distress unexplored and left to fester. And as another clinician confirmed, we have “gone miles from evidence-based psychological thinking. It’s infiltrated everyone as well as the systems, the people, society.”

*** 

Consultant psychiatrist Az Hakeem believes the ideological capture of the mental health establishment first took hold two decades ago. When he began practising in 2000, Hakeem specialised in using psychotherapy to treat adult gender dysphoria. He trained in forensic psychotherapy at the Portman Clinic. This went on to become part of the Tavistock, where the now-disgraced and closed Gender Identity Development Service (GIDS) clinic, itself entirely focused on clinical psychology, was located. For Hakeem, who worked at the Tavistock until 2012, psychology was a crucial part of the diagnosis and treatment. He has always seen gender dysphoria as a “symptom” of broader mental-health problems, not simply a medical one. There is a significant distinction, as he saw it, between the work the psychologists were doing, and the work the physicians carried out. “The surgeons [carrying out sex reassignment procedures] were like master craftsmen,” he tells me. “They didn’t know what was happening in the mind of the patients; the psychiatrists simply referred them for surgery.”

In the early days at the Tavistock, he says he couldn’t keep his mouth shut. “It was just horrific what I was seeing. All I could see were children who’d just be gay. They were like camp boys and tomboy girls. And I remember saying to the person who ran it, ‘Isn’t what you’re doing mad?’” Hakeem was an early heretic, one of eight clinicians working at Tavistock to sign a 2002 letter published in the Telegraph which criticised a European Court ruling allowing a trans-identified male to marry his same-sex partner. The signatories described it as “a victory of fantasy over reality”. He knew, unlike many outsiders, exactly what was going on because he had worked closely with both preoperative and postoperative transsexuals. “They gave me a very good insight into how transitioning unhappy people with psychological problems is not the answer,” he told me. “In fact, their problems are almost always exacerbated. Some of the post-operative group members warned those that hadn’t yet had surgery to avoid it at all costs.”

In any other context, he says, the medical professional would explore a patient’s beliefs and motivations, in order to understand what else might be going on. And yet, right from the start, this was not the approach taken by mental health professionals with gender confused patients. As far back as the early 2000s, in other words, concern was being expressed, and indeed allowed to be expressed, about the fact that little, if any, treatment other than cross-sex hormones and surgery was available to gender-distressed patients. But if Hakeem was able to be relatively open about his views, the professional culture soon started to change.

*** 

Sam Wood*, a clinical psychologist for some decades, says the rise of transactivism “really hit hard a decade or so ago”. Such is the degree of its current entrenchment that the vast majority of clinical psychologists will avoid expressing any disagreement in public. Indeed, many are choosing not to work with gender distressed children because of the requirement to either affirm them or be accused of practising conversion therapy. “You’re going to get attacked by transactivists, including colleagues,” she tells me. “They can wreck you.”

Many clinical psychologists warn of this “chilling effect” when discussing the draft conversion practices bill, currently at the pre-legislative scrutiny stage. The Government claims the legislation is designed to criminalise abuse, as opposed to punishing parents or psychologists who resist the push to affirm. The problem is that what Cass suggested in her review two years ago is already coming to pass. Clinicians fear they will be accused of conducting conversion therapy if they take an exploratory approach with the patient — essentially, doing what they were trained to do. And so, instead of questioning the kids, they are urged to enable them. Psychology, it seems, has forgotten what it is for.

As Anna Hutchinson, a clinical psychologist with significant experience in child and adolescent mental health says: “Psychology is not just a profession that provides support and reassurance. It is supposed to be a scientific and clinical discipline, which requires us to question assumptions, scrutinise evidence and consider different explanations in all kinds of ways for all sorts of things. Gender shouldn’t be made an exception. If we lose the freedom to do all of this, we lose something really fundamental.”

Tony Lane*, who trained as a clinical psychologist in 2020, makes a similar point. “One of the first things I was told was: ‘If you have a butch-presenting girl, or a feminine boy… you’re going to have to affirm them as trans, unless their parents are hostile to the idea, and then you’d probably be sacked for conversion therapy’.” He added: “I thought they were exaggerating, but it turned out they weren’t.” More worrying still, Lane says he was constantly told that being transgender was not a mental health problem despite the repeated insistence that if these children were not seen and affirmed urgently, they might end up suicidal. “Surely that is a clear sign of extremely precarious mental fragility?” he asks. “I felt like we were being told: ‘agree with everything your patient says, do not scrutinise, meet their demands or they might die, and then you’ll have blood on your own hands’.”

It hardly helps, Sam Wood* says, that there “isn’t much of a backbone in the profession”. She tells me that as a result of this lack of resolve, “trans activists can easily steamroll, and just take over, delivering the training courses on gender, and writing the rules pretty much”. The backbone should be provided by their representative body, the BPS, which is supposed to advise and advocate for its members. But instead, supported by charities and lobbyists such as Gender Plus, Gendered Intelligence, and Pink Therapy, it is delivering courses which pretty much uniformly encourage the affirmation approach. As one old hand who attended such a course complained: “It was hard-line DEI, with constant talk of how race, class, disability, and all the other currently popular oppressions overlap with gender identity.”

That politicisation is now standard, with the BPS silencing any scepticism and pushback. “Their view is, anyone who hasn’t worked with gender is ‘not an expert’,” one former GIDS employee told me. “This mystical ‘expertise’ simply means being willing to affirm anyone and everyone who says they are the opposite sex.” “If you want an easy life as a psychologist affirming people, [it’s] a dream!” says Lianne Smith* who isn’t smiling. She is deeply frustrated by what has happened to her once meaningful clinical practice. “It takes a high cognitive load to sit with someone for 50 minutes trying to attune to their words, body language, [and] subconscious. Then there are the deeply traumatic stories of rape, childhood abuse, and loss. Gender affirming care takes away all the negativity and just leaves clinician and patient feeling happy and productive.”

What particularly upsets her is, somewhat ironically given the avowed commitment to diversity, is the one-size-fits-all approach. “The kids I work with, they are so varied,” says Smith. “The fact they’ve got the same diagnosis is utterly ridiculous.” “There’s a lot of victimhood about,” another whistleblower tells me. “There are individual [practitioners] using the fact that they are LGBTQ+, or autistic, or black as a qualification, as opposed to their skills as an actual clinical psychologist.” Indeed, she goes as far as to say that within the profession there are those “who are not cut out to be psychologists” — they simply want to “‘be kind”’.

If the affirmative model dictates that gender dysphoria is not a disorder — and the only “treatment” which can be offered is to kindly say “yes” to any request from the patient, fearing that to do otherwise would be an inducement to suicide — then the inevitable result is medicalisation. As Smith explains: “All identity is socially constructed, trans is no different. And in the case of ‘trans’, the identity has been constructed by and with medics and psychologists. No other identity needs medical affirmation to be legitimate, but this one does. It wouldn’t exist — in its current form at least — without medical and psychological compliance.”

There are some who dare speak out. But the consequences can be grim. Anne Woodhouse is an independent consultant clinical psychologist with over 25 years of experience. She nearly lost her job when, in 2022, she was reported to the Health and Care Professions Council (HCPC) for posting and interacting with Twitter posts critical of transgender orthodoxy. Only after three years of investigation was she cleared when no compelling evidence was found that she was unfit to practice. Regardless of the outcome, though, “the process has been the punishment,” she says. “Those three years were so stressful, and to have this serious threat to my professional integrity and career, pretty hellish.” “I had completely missed how all the organisations had been captured,” she continues. Her case perfectly illustrates the stakes of professional disagreement. Any questioning of the orthodoxy could lead to complaints not just from within the professional body, but also from the general public. In fact, Woodhouse was referred to the HCPC by the deputy head of her child’s school — a part-time drag artist.

I did find another psychologist to push back on the record. But Sandra Pertot is retired and in Australia, whose psychological society likewise refuses to support any form of mental health practice that does not “affirm” children who say they are transgender. Pertot specialised in sex therapy before retiring as a clinical psychologist four years ago. “In the Seventies and Eighties, I saw a lot of young kids who were confused about their sexuality. I used what has become called ‘watchful waiting’ with them and didn’t tell them whether they were gay or not gay.”

In 2006, Pertot moved to a small town and “naively” began airing her concerns about the rise in children presenting with rapid-onset gender dysphoria at her practice. “I knew nothing about this transgender drama that was going on in the rest of the world,” she says. “And I saw these young kids come in saying they were trans and I didn’t think anything of it. I just did some work, watchful waiting and the interesting thing was none of them suicided, none of them threw hissy fits.” Then, around 2019, Pertot saw two girls who both independently determined they were male. Unconvinced they met the criteria of persistent gender dysphoria, she sought the opinion of a psychiatrist who specialised in gender. She was told: “Sandra, If they’re saying they’re trans, they are trans.” “Both of them ended up going on hormone therapy, but it really bothered me,” Pertot continues. “So I started to question this, and this is where I got into trouble.” Like Woodhouse on the other side of the world, she received a complaint against her, and was told she was “the most hated woman in the Sydney queer community”. She’s only speaking out now because she’s retired. As she told me: “They can’t do anything to me now!”

*** 

So who protects the psychologists? The BPS, which represents 50,000 practitioners and shapes standards and the public debate, is the profession’s representative body. It should advocate for the integrity of the profession. But every single person I spoke to for this investigation holds that the BPS is, at least in part, responsible for the current climate of fear. It has failed to reassure practitioners that legitimate clinical disagreement will be protected. Indeed, it has shut down attempts by those within psychology to stand up to activism — and it has failed to stop activists from embedding themselves within the profession.

Pat Harvey, a retired BPS office holder, is among the Society’s most outspoken critics. She helped set up BPS Watch with other retired clinical psychologists concerned about the organisation’s direction. For her, the problem is not merely the BPS’s public position on gender, but how it has responded when members have challenged it. Its position is represented by the in-house magazine, The Psychologist. Harvey has made several official complaints about Jon Sutton, its long-standing editor, accusing him of personal bias and failing to foster balanced debate around gender ideology. Instead, she claims the publication has “regularly promoted the views of proponents of transgender ideology… actively suppressing those of gender critical or sex realist psychologists”. She also claims that BPS gender guidelines were resolutely “affirmative” and minimised the importance of co-morbid mental health concerns. Sutton, meanwhile, bats the complaints upstairs, confident that he will be supported.

Nowhere is this clearer than in the magazine’s promotion of the online clinic GenderGP. Run by Helen Webberley along with her husband Mike Webberley, the controversial service regularly prescribed puberty blockers to children with only minimal consultation. Helen was suspended for two months by a tribunal after putting three patients at “unwarranted risk of harm”, and Michael was struck off by the General Medical Council following a “catalogue of failings” and serious misconduct. When Harvey contacted Richard Stephens, at the time chair of the BPS’s editorial board, and now chair of its research strategy board, to complain about The Psychologist promoting GenderGP, he told her that the magazine’s advisory committee did “not propose to advise amending the article”.

“[Stephens] wrote that the day after the final Cass report was published,” Harvey says. “Doctors had been told that they should not prescribe puberty blockers or cross-sex hormones on the advice of GenderGP as it does ‘not provide physiological or psychological support to patients’. This clearly indicated that they should amend the entry or remove it.” Eventually, they took it down. Others have submitted similar complaints about being silenced and curtailed from doing their jobs effectively to no avail. One said that he was called a bigot for questioning the “trapped in the wrong body” narrative and told he shouldn’t be practising as a psychologist. Sutton, says Leslie Jones*, is “ideologically signed up” to trans ideology. “He said explicitly to me and several other people that he’s not actually going to produce any questioning or critical content relating to trans stuff, it’s all going to be affirmative because ‘trans people are the most marginalised and oppressed’.”

For Harvey, all this runs counter to the very purpose of psychology. “Psychology is supposed to be there to help people navigate their way through difficulties in their mental health, and understand how they became unwell,” she insists. It does not exist, “to validate social justice causes.” However, this is what happened to the BPS. And without the supportive oversight of the body purporting to protect its members, any psychologist exercising critical thoughts — essentially practising according to their training — is left at the mercy of activists.

Trans rights activists these days wield a lot of power when making complaints about “transphobic” clinicians. The Trans Safety Network (TSN), formed in 2020, extensively scrutinises the work of healthcare professionals, in particular clinical psychologists and those working in gender-identity services. Its stated mission is that it will “record evidence to understand the timelines and escalation of organised harm against trans people in the UK.” It looks into institutions to ascertain whether or not they are “transphobic”, and reports on alleged misdemeanours. “Trans people are not required to transition in particular ways, experience particular feelings, or obtain medical approval in order to be considered trans,” reads its values section.

In 2021, TSN was successful in its efforts to cancel a conference for trainee psychiatrists, hosted by Great Ormond Street Hospital, claiming that attendees would feel “unsafe” because two “trans sceptical” speakers would be attending. “There is no possible way in which this event can be a ‘safe environment’ for LGBTQ+ and especially trans participants,” they wrote. Health Education England agreed to cancel the event. The TSN has also devoted considerable time and resources trying to discredit the Cass Report. It has opposed Wes Streeting’s decision to ban puberty blockers; and it has poured scorn on the NHS for failing to immediately validate “trans children” and offer instant access to “gender affirming” drugs. The TSN also takes aim at the Royal College of Psychiatry, criticising anyone who suggests that puberty blockers and cross-sex hormones may not be good for children.

For his part, TSN’s director, Mallory Moore, has invested a great deal of time harassing clinical psychologists, and making numerous complaints to regulators and management. In an article published in 2023, Moore wrote: “I’ve been reporting conversion therapists to professional medical and therapeutic bodies in the UK for over two years, facilitating survivors to make complaints”. It’s worth remembering, here, what Hilary Cass said about clinicians worried about the affirmative approach: “The majority of [their] patient presentations were extremely complex, with a mix of trauma, abuse, mental health diagnoses, past forensic history, ASD and ADHD, and therefore this limited assessment was inadequate. These other clinical issues were not addressed or considered in decisions to prescribe masculinising or feminising hormones.”

*** 

Audrey Taylor* has worked with gender-distressed children and young people for her whole career. “I became known as the one that parents struggling to talk to their kids about sexual identity, or the difficulties they were having approaching puberty, would come to, because they trusted me. I’m a bit gender-unconforming myself, and I know how both boys and girls internalise punishing rules about how they should behave.” Initially, Taylor, who qualified in clinical psychology in the early Nineties, suggests that the kids who came to her would more often than not turn out to be lesbian and gay — or simply not fit the traditional mould of boys and girls. But, as she tells it: “Things got much more confusing once we got into the 2010s and beyond. Kids started telling their parents what to think, and the tables were turned.”

“Parents were being dictated to by their children who told them that they had no idea what it was like to be trans,” Taylor continues, “and that they knew exactly what the issues were, and that they didn’t need a psychologist to work it out for them. They diagnosed themselves.” She adds: “And the parents, this later cohort, appeared to be frightened of their own children.”

Taylor recalls that parents would initially make contact and tell her that their child was suffering from gender dysmorphia, or simply that they were transgender. “I’d never had patients or their parents self-diagnosing. I wasn’t sure what my role was anymore. I would try to scrutinise what the issues were, but I was usually shut down as soon as I started exploring other issues, such as trauma, potential neurodiversity, or some kind of mental health condition.”

Indeed, it’s hard for parents to know how to manage gender confused children, who may get kudos from their peers for identifying as trans, and validation from schools and social services. Given the ever-lengthening waiting lists for psychological help from the NHS, and the explosion in anxiety and autism among children, many desperate parents will seek help elsewhere — and private psychologists are happy to help. “If they are going through difficult times, for all kinds of reasons, they’ll just put all their eggs in one basket and say: ‘We’ve got a gender incongruent child’.” Private clinics will then give them instant validation. “Then the problems really begin.”

By this she means medication. Despite the warnings in the Cass Report about the weak evidence base for prescribing puberty blockers to treat gender dysphoria, this is an increasing problem. Not counting those who are in private treatment, today, more than 250 primary age children, some as young as four, are in line for “gender care” treatment at NHS clinics. What this care actually consists of is unclear. Although the use of puberty blockers has been banned, Cass has thrown a crumb to the activists, who may be able to access medication via clinical trials; Cass believes that otherwise, children will procure drugs from “unregulated and dangerous routes”.

In the meantime, with the explosion in mental health problems among the young, NHS waiting lists are growing ever longer, and private providers are thriving. In 2024, a private clinic called Gender Plus Hormones, for “gender questioning” young people, became the first service of its kind in the UK to receive approval from the Care Quality Commission (CQC). Part of the provider Gender Plus, it offers hormone treatment to those over the age of 16 following psychological assessment “by a team of clinical psychologists across a minimum of six sessions”. Its CEO is Aidan Kelly, who in 2024 wrote in The Guardian that clinicians should be the only ones deciding whether or not to ban puberty blockers, not politicians. He points out that puberty blockers can be helpful for a “carefully selected minority of transgender youth who have a clear and consistent understanding of their gender identity”. The trouble is, if these children have been affirmed in that identity without challenge from a young age, as seems to be the case within the profession now, how are they to know that this is truly what they want?

Currently, Gender Plus Hormones is unable to prescribe puberty blockers, but they have commissioned what they’re calling “an independent review” to assess the evidence behind the decision to ban them for children. Dr Gideon Meyerowitz-Katz has been commissioned to write it: he has referred to the Cass ban as a “moral panic”. So while a few clinical psychologists are battling to discuss whether their young patients have underlying trauma, others are applying to gender dysphoria the same logic that they might apply to preventative dental work, i.e., the earlier we get in there, the better.

This tortured debate over puberty blockers raises a serious question for psychologists: how are the effects of transition actually measured in the young? And this is something David Freedman, a retired social science researcher, has studied in depth. In 1998, he co-edited a book by the founder and former director of Tavistock’s Gender Identity Development Service (GIDS), Domenico DiCegli, called Stranger in My Own Body: Atypical Gender Identity Development and Mental Health. “At that time,” Freedman tells me, “there were relatively tiny numbers of people who claimed to be trapped in the wrong body.”

Some years later, as he saw growing disquiet within the profession with regard to children presenting with gender distress, Freedman came out of retirement to examine an early intervention study by GIDS and University College Hospital. The study involved 44 children aged between 12 and 15 recruited over three years. It concluded that the puberty blockers brought “no changes in psychological function”.

The methodology included information compiled from questionnaires from both parents and children about feelings, relationships and depression. Yet when Freedman, along with Professor Susan McPherson of the University of Essex, re-analysed the data, they found a huge range in the outcomes in terms of mental health. While just 29% had improved, 37% showed no change, and 34% had deteriorated. Their 2024 paper on the topic caused consternation among transactivists who had previously argued that puberty blockers do not cause harm.

“I felt children were actually being abused,” says Freedman, “and that they were being entrusted to a service that was not offering the best possible treatment to them.” “Puberty is crucial,” he continues, “children build bone mass and [the drugs] suppress growth spurt and skeletal strength. We don’t know yet exactly what effect it has on the brain, but we know it can and does affect functioning. This is unforgivable abuse.” 

Nonetheless, following the closure of the GIDS and a growing call for the puberty blocker trial to be cancelled, Cass told the British Medical Journal that she still considered it justified. “Her own review found that the evidence for puberty blockers is extremely weak, that there is no demonstrated benefit, and states that the longer-term risks are unknown,” says Lianne Smith. “And now Cass is a staunch defender of conducting a trial involving 250 child guinea pigs…”

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Could there be another motivation behind the push for blockers? Joanne Hall*, who worked with young adults in a gender service, believes there might be. She says she discovered the limits of her freedom when she began questioning whether patients’ wider psychological needs were being adequately addressed. “Of the patients that come to the clinic, there is high rates of autism, of complex trauma, of abuse. Those things are clearly relevant, but I was called transphobic for saying it.” Hall says she took her concerns to senior managers, but was eventually pushed out of her role. She recalls confronting one manager: “I said, ‘We’re castrating people as a treatment option when this is about trauma and autism.’ He said, ‘I agree with everything you’re saying. The thing you don’t understand is that the gender service bankrolls the mental health service in this city.’” Her account raises a question that is arguably bigger than the dispute over gender medicine per se: what happens when someone’s clinical judgement comes into conflict with the priorities of the institution employing them?

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Today, Parliament will hear the first oral evidence on the Conversion Practices Bill. Which way will it go? And will the outcome be indicative of whether this bitter battle is lost or, finally, won? It is worth remembering Cass’s emphasis, in her review, that young people experiencing gender distress should receive comprehensive, evidence-based mental-health support, just like any other child with similar psychological or neurodevelopmental needs. But that would require psychologists to be brave and robust enough to stand up and say that their profession doesn’t advocate for this approach any more. It would also require their regulatory body to support them.

Will the BPS do that? The jury is out. I contacted them, offering a right of reply regarding the numerous complaints made by members and former members. And I also asked what they had to say about Sallie Baxendale’s shortlisting for the Maddox Prize, following her research into the effects of puberty blockers on brain development. The prestigious prize is awarded to scientists “whose courage and persistence in promoting or defending evidence despite facing obstacles have had significant real-world impact”. And, as Baxendale pointed out: “It is a sign that something has gone very wrong when ordinary clinical enquiry and following the evidence needs to be recognised as an act of courage.” “The BPS should have been the strongest advocate of the concerned clinicians at the Tavistock,” she says, “and should now be celebrating them as examples of the very best of us.”

But while the BPS declined to respond, there is a glimmer of hope. A number of psychologists have gravitated over to the Association of Clinical Psychologists (ACP-UK), which does take a firm stand against the instant affirmation model. What will this rupture do to the practice and integrity of clinical psychology? Today’s parliamentary hearing will give an early indication of how this battle might play out. But amid all the furore, a more important point risks being forgotten. Those who have the most to lose from this struggle aren’t the psychologists or the credibility of their discipline; the greatest price will be paid by the vulnerable people it exists to help.

* Names have been changed.