A few years before the Covid pandemic, the Irish state television network (RTÉ) asked me to appear in a documentary about the sudden increase of transsexualism in the Western world. Why me, I asked? I had written nothing on the subject and was neither an expert on, nor particularly interested in, the whole question. I soon learned that I was not their first choice. In fact, they were desperate for someone to voice an opinion different from what had become an orthodoxy, at least in public: that transsexualism (I prefer this more accurate, older term to “transgenderism”) was both a medical condition and a perfectly good way to be in the world and that, having experienced oppression through the ages, transsexuals should now be added to the growing list of certified victims.
I was reluctant. I dislike going on television and am no good at it, and since we live in a golden age of monomania and monomaniacs, I thought that I might become an object of persecution if I appeared. But the RTÉ crew were persuasive and made it sound almost as if it were my duty. They had, they said, requested many doctors and academics, all extremely opposed to transgender ideology, but none was willing to put his head above the parapet. They all feared for their reputations, and even their jobs; surely, I was not like them. Finally, I agreed.
Between the time I said yes and the time they filmed me, I reflected on my knowledge and experience of transsexualism, which was not extensive. I must have read the chapter in Ismond Rosen’s textbook, Sexual Deviation, but I remembered nothing of it. I had read Conundrum, published in 1974, the memoir of Jan, formerly James, Morris. A soldier, derring-do journalist, travel writer, and father of five, Morris had felt from the age of three that he had been born into the wrong sex and duly changed gender in midlife, remaining the companion of his wife—a story that struck me as so extraordinary that it could scarcely be of general application or relevance.
During my 15 years as a doctor in a male prison, we had two transsexual inmates in mid-transition, as it were. The staff held long discussions about what to do with them, the main concern being their safety (whatever else one can say about prisoners, they are not progressives). Was it the right of the transsexual prisoners to dress as women, or should they have to wear male garb? After all, the more conspicuous they were, the harder it became to protect them. Some staff thought that the inmates should be sent to a women’s prison—this was before any male prisoners who “identified” as female had been incarcerated in women’s prisons and committed rape there—but the prison department ruled against this well-meaning solution. Fortunately, the two prisoners’ sentences were short, but while they lasted, a sense of unease persisted among the staff.
Once, in what might be called the pre-ideology days of transsexualism, a young male-to-female transsexual was admitted to my hospital ward after taking an overdose following a quarrel with a boyfriend. The boyfriend turned up for a reconciliation; he was a female-to-male transsexual. Not even Joseph Stalin, no slouch in altering historical records, would have thought of changing a person’s sex on his birth certificate years later, as is now possible in Britain.
None of this qualified me to speak on television about the subject. The question that the interviewers wanted me most to focus on was the sudden rise in the prevalence of gender dysphoria, especially among children. My suggestion was that it was a social contagion, almost a fashion, and that the history of Chanel or Balenciaga might be more illuminating than, say, endocrinology in supplying an answer.
Fashions run through psychopathology: we rarely see hysterical paralyses these days, for example, though they once were common, not least during and after World War I. In the 1980s and 1990s, multiple personality disorder (as in The Three Faces of Eve) was suddenly prominent, with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association quoting a community survey concluding that one in 60 adults suffered from it. That diagnosis is now deeply unfashionable.
The suddenness with which an infrequent diagnosis became first common, and then the object of an entire ideology and social cause, is astonishing and surely requires an explanation. When I think of the rapid increase in gender dysphoria and trans identification, a line from Rudyard Kipling’s “The Road to Mandalay” comes to mind: “An’ the dawn comes up like thunder outer China ’crost the Bay!”
Who would have foreseen the dawn of such a worldview coming up like thunder—such that people are denounced and attacked for suggesting in public that a person’s sex is immutable, and that neither surgery nor hormonal treatment and neither voice and deportment training nor makeup and other externals, will turn a man into a woman? Who would have foreseen that a political party in Western Europe, the Scottish Greens, would expel 13 of its prominent members for stating publicly that “sex is a biological reality,” because to do so supposedly threatens the safety of transsexuals? Who would have thought that the world’s most financially successful author, J. K. Rowling, could now “paper her walls,” as she put it, with the death threats she has received (the anonymous death threat having become, alas, the highest form of argument) after she said something that only a few years ago would not have been thought worth saying—namely, that a female is born, not made?
Who would have thought that a democratically elected Scottish government would pass a law (since struck down) stipulating that anyone over 16 could change legal “gender” (a stand-in for sex) more or less at will? And who would have believed that, according to one poll, a third of Britons would agree with the proposition that transgender women are women (that is to say, women in all senses of the word)—the same proportion as those disagreeing (the other third not knowing)?
The utter confusion that gender ideology has sown is reflected by the fact that more than 60 percent of people, when polled about whether “transgender” women should be allowed to participate in women’s competitive sports, say that they should not. Why not, though, if they were truly women? But a sign of the rapid success of the ideology is that 22 percent say that transgender women should be allowed to play, answering in the affirmative a question that a few years ago would have led people to doubt the sanity of the person asking it.
Further illustrating the confusion: no one asks whether transgender men—women who have changed into the simulacra of men—should be allowed to compete in men’s sports. The question doesn’t arise for obvious reasons, but that the reasons are obvious is itself a powerful indictment of the strange state of mind of those who excoriate and threaten the likes of Rowling, a state of mind in which they furiously defend something that they know is false.
Future historians, if we have any and if they enjoy sufficient freedom to do so, will wonder at this extraordinary efflorescence of intellectual absurdity and seek the reasons for it. This sexual tulipomania would be worthy of a new chapter of Charles Mackay’s book of 1843, Memoirs of Extraordinary Popular Delusions and the Madness of Crowds. “Whatever got into them?” the historians will ask. No definitive answer will be forthcoming.
Faint signs of resistance have emerged, however, to the advance of the transgender ideology—in Britain, of all somnolent, pusillanimous countries. In the wake of revelations about the careless, almost cavalier way in which the Tavistock Clinic, the country’s premier clinic for transgenderism, treated children and adolescents, often under the bullying of transgender pressure groups, the country’s centralized National Health Service commissioned a report from independent pediatrician Hilary Cass about the treatment of gender-dysphoric children and adolescents, which, though it strained to be open-minded and evenhanded, sounded a tocsin. Thousands of children and adolescents were being treated in life-changing ways in the absence of evidence about the long-term effects of that treatment.
The Cass Review, no literary masterpiece, tackled the vital question of why the number of children and adolescents suffering from uncertainty about their gender has increased so dramatically. The figures are startling. A Gender Identity Development Service for the country was founded in 1989, initially seeing fewer than ten young patients yearly. From 2009, the numbers exploded. In that year, 15 adolescent females and two female children were referred to the service, along with 24 adolescent males and ten male children. In 2016, the figures were, respectively, 1,071 and 426, and 138 and 131. Between 2014 and 2015 alone, the numbers more than doubled, from 314 to 689 for female adolescents and from 125 to 293 for female children. Incidentally, these rises were paralleled in other Western countries. By 2023, 3,115 or more children and adolescents were being referred annually to the gender identity clinics in Britain.
What accounted for this vertiginous rise? Cass’s report tries to answer it with scrupulous care. One possible explanation is that no real rise in incidence occurred, only in recognition and ascertainment. This, however, is unlikely, for we can chart a similar rise in all other manifestations of child and adolescent distress. I was startled to read in the report, for example, that between 2017 and 2021, the incidence of eating disorders among young women aged 17 to 19 rose from 1.6 percent to 20.8 percent and among men from 0 percent to 5.1 percent. Figures for other conditions are similar.
Transsexualism is not new, but it has been rare; where it occurred, it was overwhelmingly of the male-to-female variety, whereas the reverse is now the case. Cass considers the possible biological contribution to the condition, finding no evidence of genetic predisposition, though in a few cases, hormonal influences in the womb may have played a part. It is extremely unlikely, though, that any biological change took place in the population between 2000 and 2023 that accounts for the rise in prevalence.
Other figures given in the report paint a horrific picture of childhood and adolescence in modern Britain, and no doubt in other countries, too. For example, 27 percent of 11-year-olds have been exposed to pornography on the Internet; for the 16–21 age group, 42 percent of females and 58 percent of males actively seek it out. Forty-seven percent of adolescents (both sexes) believe that women expect to be slapped or strangled during sexual intercourse. This might, I suppose, help to explain why transsexualism has changed from being predominantly male-to-female to being predominantly female-to-male. It is more blessed to strangle than to be strangled.
Cass avoids attributing the increase in gender dysphoria to social contagion, but this, it seems to me, must be the greater part of the explanation. She mentions a survey in the United States of Generation Z, those born after 1997, showing that the proportion of members who believe that more than two genders exist rose from 39 percent in late 2019 to 51 percent by late 2021 or early 2022. This suggests considerable effort at indoctrination of young people, be it formal or informal and spontaneous, whether by what is found on the Internet and social media or by conversations held among themselves.
Cass illustrates the power of social media. She takes the case of “Functional Tic-Like Behaviours,” that is, tics with no organic basis. These “are found to occur in young females with complex, disabling and tic-lookalike patterns, usually triggered by videos portraying tic-like behaviour on social media.” According to one survey, 41 percent of people with these tics have gender dysphoria. A conference of specialists on Tourette syndrome who had noticed a great increase in such tics during the Covid pandemic reported:
Over the past few years, tics and tic-like symptoms have gained visibility, especially on social media. Young people who watch others with tic-like symptoms on social media may develop symptoms similar to those in the video. Social distancing during Covid-19 has increased time spent on social media, which has greatly exposed people to this content on a global scale.
If, in addition, an active, vocal, and ideologically motivated pressure group was advocating for tic-dom, one could well imagine the result.
One unidentified person interviewed for the report said, “A lot of trans people make YouTube videos which I think is a major informational source for a lot of people, and that’s mainly where I get my information from.” One anonymous informant does not make an encyclopedia, but it is hard to believe that he was the only one of his ilk. And what he, and others, see on YouTube is probably an encouragement of, and propagandistic for, transsexualism.
Cass explains the more than doubling of referrals to the Tavistock Clinic for gender dysphoria between 2014 and 2015 by the fact that, in 2014, the clinic uncritically adopted the so-called Dutch Protocol. This was based on a single experiment conducted by Dutch pediatricians on 70 youngsters, of an initial sample of 111, who had suffered long-term gender dysphoria and were free of confounding serious mental conditions and had family support. They were given puberty-blocking drugs and supposedly felt better as a result, though the study was of very poor quality: only participants who had “positive” experiences with the drug were selected to participate; there were no controls (not even by the 41 excluded from the sample); psychologists carefully attended the patients while they were taking the drugs; and the follow-up was far from complete.
In fact, with an almost criminal frivolity, the Tavistock Clinic had begun handing out puberty blockers as routine care before the results of its own experimental study, begun in 2011, were in. Word soon got around. Even if Cass is mistaken in thinking that this accounts for the sudden surge in dysphoria referrals (the increase over the years actually fits an exponential curve), it reminds me of the start of the epidemic of deaths from opioids in the United States, which began with the willful misinterpretation of research published in The New England Journal of Medicine. The research had found that those given strong analgesics in the hospital did not become addicts; from this correct observation, doctors, heavily influenced by drug-company propaganda, thoughtlessly concluded that it was safe to give strong analgesics to anybody with any kind of pain at any time. A million deaths later, we now know differently.
Cass’s attempt, which cannot be definitive, to explain the rise of transsexualism has the merit of making it impossible to view the condition in a purely medical, or even psychopathological, light. But she also examines (with the help of a team) the evidence that the use of puberty blockers is justified in the treatment of gender dysphoria of pubertal children, as well as the justifications for use of masculinizing or feminizing hormones in adolescents with gender dysphoria.
The evidence favoring puberty blockers is lacking, and therefore the use of them is unethical. Moreover, the so-called Dutch Protocol was admittedly experimental, and the ethical propriety of experimenting on pubertal children with potentially life-changing drugs thus should be questioned. Indeed, it recalls, admittedly on a much smaller scale and with much less malign intentions, the experiments conducted on children by Josef Mengele. Not only is the evidence lacking; it should remain lacking and should not be gathered or gatherable in the first place. The condition is variable, changeable, and nonfatal; it is by no means simply a medical one. In fact, Cass asks the ethical question as to how far doctors should go in treating with medication and later with surgery a condition that is only marginally medical:
The nature and causes of gender dysphoria/incongruence are complex and poorly understood, and there is very limited understanding of the currently presenting population of predominantly birth-registered adolescent females. Each individual will have a different mix of biopsychosocial factors, but if potentially dynamic psychosocial or sociocultural factors predominate in a significant proportion of people, one of the most challenging ethical questions is whether and/or when medical intervention is the correct response.
Furthermore:
The University of York’s systematic reviews [of the evidence concerning treatment, the University of York being one of the world’s centers for examining the quality of medical evidence] demonstrated poor study design, inadequate follow-up periods and a lack of objectivity in reporting of results. As a result, the evidence for the indicated uses of puberty blockers and masculinising/feminising hormones in adolescents [is] unproven and benefits/harms are unknown.
The problems are legion:
Once on puberty blockers, they [young patients] will enter a period when peers are developing physically and sexually whilst they will not be, and they may be experiencing the side effects of the blocker. There are no good studies on the psychological, psychosexual and developmental impact of this period of divergence from peers.
No informed consent to treatment can be given, either—first, because the children involved are not capable of giving it; and second, because the information necessary for informed consent is lacking anyway, and probably will remain so.
The Cass Review, which doubtless has its defects, has nonetheless played a role in effecting significant change, at least in the U.K. Parliament has banned puberty blockers from private clinics, the National Health Service has decommissioned them, and Scotland has paused their prescription. In the United States, however, such treatments are going ahead unchecked, at least for the time being. The entire phenomenon over the last decade or so should lead us to two large questions: Have we gone mad? And what, as a society, are we doing to children?
Photo: Pediatrician Hilary Cass, who led an independent review of gender-identity services for children (PA Images/Alamy Stock Photo)
