DR Hilary Cass has said she doesn’t know how MSPs will get the "balance right” in banning conversion therapy in Scotland while simultaneously allowing therapists to have open conversations with patients about their gender identity.

During an appearance at Holyrood’s Health, Social Care and Sport Committee, Cass – who recently published a review into gender identity services provided to under-18s by NHS England – was asked by Labour MSP Carol Mochan about the Scottish Government’s plans to ban conversion practices and whether they could impact the willingness of clinicians to work in gender identity services.

While denouncing conversion therapy practices as “totally unacceptable,” Cass also expressed concerns about determining a therapist’s intent.

She said: “This one’s a big challenge and all I can say is I’m glad I’m a doctor and not a litigator because it is a really difficult problem.

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“Everyone should be protected conversion therapy it’s a totally unacceptable practice. But thinking about the legislation the issue has been about intent.

“If the therapist engages with a young person and they change their views about their gender identity during the course of that therapeutic relationship and then they subsequently say it was because the therapist had an intent to change their gender identity that puts the therapist in a difficult position because how can you legally determine intent.

“That anxiety that you may be the test case is making clinicians even more anxious potentially about working in this area and we don’t want to do anything to frighten professionals off from working in this. So, walking that path is very difficult.

“The only thing I would say is that no credible professional body would support conversion therapy so if any practitioner is deemed to be practicing conversion therapy it should in a first instance be a matter for their professional regulator before it would be legislative issue.

The National: Dr Hilary Cass with the Cass ReviewDr Hilary Cass with the Cass Review (Image: PA)

“But I don’t know how we get that balance right of protecting people from conversion therapy and not frightening therapists who are just doing their job and having an appropriate exploratory conversion with a young person.”

It comes as the Scottish Conservatives pressure the Scottish Government to fully implement the recommendations of the Cass Review.

NHS Greater Glasgow & Clyde and NHS Lothian paused the prescription of puberty blockers and hormone treatment to under-18s last month. 

However, when asked by Scottish Greens MSP Gillian Mackay if hormone treatments could be right option for some young people, Cass agreed but called for more robust research to be undertaken.

“Yes, we think that certainly masculinising and feminising hormones could be the right treatment,” she said.

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“[But] we don’t know which young people those are.”

She added: “For somebody who is going to have an enduring long-term trans identity, medical transition is a really important option and one from which many people do benefit.

“The risk is starting that transition at a time when somebody is still in the process of development is that you give the treatment to the wrong group of people.

“The reason that is a negative outcome is because medical transition doesn’t come without costs in terms of effect of sexual function, fertility, our knowns and unknowns about bone health risk, limitations of surgery.

“All of those things are cost which are well worthwhile if you have a long-term stable trans identity but it’s a high cost to pay if, in the longer term, you don’t.

The National:

“So picking that sweet point where you have a high level of certainty that you’re giving the treatment to the right people is very important and the group that we have least understanding about is the group that we are most commonly seeing now in clinics which is birth registered females who are presenting in adolescence for whom there may be a range of other factors driving their gender related distress.”

Cass also noted that the “toxic” nature of the debate surrounding gender identity was creating “fearfulness” amongst healthcare practitioners and said lengthy waiting times were pushing young people towards “higher risk actions” such as self-medicating with hormone treatment.

“I can understand that because they’re often in a situation where the care provided by the health system is failing them,” she said.

The current waiting time for a first appointment at Scotland’s only gender identity clinic for young people is around four years.