Ronald Reagan famously said the most frightening eight words in the English language were: ‘I’m from the Government; I’m here to help’. Times change. Today, I’d argue the (ten) apposite words are: ‘I’m from Social Services; I’m here to do an assessment’. Fifty years ago this past February, I joined the editorial team of a new magazine, set up in the wake of the Seebohm Report (or the Seebohm Report on Local Authority and Allied Personal Social Services).
This was the report of a committee reviewing the organisation and work of social services in the United Kingdom. It recommended that separate local authority health departments such as children's' mental health, social welfare, and home help, should be condensed into a single department of social service. It was implemented but the new local authority social service departments never (big surprise) got the requisite funding.
Young, enthusiastic, idealistic, we all believed the future was in community-based social work, hence the title of the magazine, Community Care. It was the most financially successful ever launch of an IPC journal and we basked in its success, both financial and editorial. I rapidly became the mental health correspondent, a job I loved and relished.
One unintended consequence of the Seebohm Report was that long-term mental health patients, hitherto confined to dreary hospital back-wards, or dismal Victorian piles of brick, set in a ring around London, were free to leave. Which they did, only to find themselves adrift in an uncaring society, often to be found sleeping rough. The origins of todays’ rough sleeping crisis may be located in that enlightened decision. Be careful what you wish for.
The Victorian model was matriarchal, based on Christianity, top-down, do-goodery, middle-class with some upper-class icing on the cake of kindness. William Wilberforce, Lord Shaftesbury, a host of followers (Quakers were in the forefront: Cadburys, Rowntrees, for example) trying to alleviate some of the damage inflicted by uncontrolled Capitalism and the growth of slums, child-labour, oppressed workers. One of the finest early examples of exposing the ghastliness of mid-century life for the poorest, still a masterpiece of ethnographic empirical research is Engels, Condition of the Working Class in England in 1844.
Well into the 20th century, social work was largely the domain of charities. Then along came the Welfare State and Government intervention. With the onset of academic research into society, and the new discipline of sociology, one of its greatest early exponents was John Madge, who brought rigour to the chaotic nature of humanity’s culture. His brother, Charles who, with Tom Harrison, founded Mass Observation in the late 1930s, took another step in understanding human behaviour in the field. Its greatest triumph is to be found in their work in the Second World War, examining what ordinary people thought of the conflict (less enthusiastic, more sceptical than expected through the rhetoric of one Winston Churchill as they battled with wartime austerity).
The social scientific approach was always bound to lead to the social work equivalent of nursing’s ‘too posh to wash’ syndrome, manifest by the 1990s and with us today in hospitals and social care. With a shift from just helping to trying to understand the root causes of poverty, unable to affect the onward rush of late Capitalism, social work drifted towards neo-Freudian psychobabble.
I well recall being told of a disabled woman, wheel-chair bound, who had a leaking roof she urgently needed to be fixed. The social worker she dealt with in her home, after hearing of her plight, leaned confidentially forward and asked, no doubt in a faux concerned voice, perhaps patting the woman’s hand, ‘but what’s the real problem?’
From there is an easy jump from doing the mundane, tedious task of calling in a builder, to busy-body interference in peoples’ lives. Remember the moral panic about Satanic cults in the 1980s, using children as pawns in some twisted pseudo-scientific game, ripping children from their homes, insisting on the clearly deranged idea that such cults existed. It turned out the whole confected nonsense derived from fundamentalist Christian ideas out of the USA.
It was compounded, made infinitely worse, by a rogue doctor, subsequently struck off the register by the GMC, but not before he had ruined countless lives and made good parents fearful that their own children would be torn from their loving embrace. Meanwhile, small children in real danger were regularly overlooked, killed by parents who the system casually overlooked, social workers insisting that the children were safe, with ‘safeguards’ in place. It’s happened again, in recent weeks; it is happening as I write these words.
And so, we come to the Cass Report, which has exposed where this can lead to, in the case of gender dysphoria. Apart from professionals – including social workers – not doing their jobs properly, children are additionally confused by the onslaught of anti-social media. It’s too easily available to our children, making it easy to dive into toxic rabbit warrens which shout at them that their anxieties and normal unhappiness can be instantly cured by chemicals and mutilation.
Meanwhile, the medical approach is rooted in a belief that many, perhaps even most children questioning their gender will go on to have a fixed trans identity in adulthood, and that it is possible to discern them from those for whom it is a temporary phase. But studies suggest that gender dysphoria resolves itself naturally in many children. It is often associated with neurodiversity, mental health issues, childhood trauma, discomfort about puberty, particularly in girls, and children processing their emerging same-sex attraction. A large number of children referred to the Gender Identity Development Service (Gids) said that they were gay. (Disgracefully, incredibly, the clinic never collected data on those children who passed through its doors.)
Putting these children on a medical pathway does not just come with health risks, it may also take temporary distress and turn it into something permanent. The Cass Report is also clear that socially transitioning a child – treating them as though they are of the opposite sex – is a psychological intervention with potentially lasting consequences and an insufficient evidence base, that transitioning in stealth may be harmful.
There is a conundrum at the heart of the report. Cass found that a childhood diagnosis of gender dysphoria is not predictive of a lasting trans identity and clinicians told the review they are unable to determine in which children gender dysphoria will last into adulthood. If this is indeed impossible, is it ever ethical to put a young person on a life-altering medical pathway? If there are no objective diagnostic criteria, on what basis would a clinician be taking this decision other than a professional hunch?
The Cass Report recommends a total overhaul in the NHS’s approach to caring for gender-questioning children and young people: holistic, multidisciplinary services grounded in mental health that assess the root causes of that questioning in the round and take a therapeutic-first approach. Puberty blockers should only be prescribed as part of an NHS research trial and Dr Cass recommends ‘extreme caution’ in relation to cross-sex hormones for 16- to 18-year-olds; one might expect this to be contingent on it being possible to develop diagnostic criteria for gender dysphoria that will last into adulthood.
Cass’s vision is what gender-questioning children deserve: to be treated with the same level of care as everyone else, not as little projects for activists seeking validation for their own adult identities and belief systems. But it is going to be immensely challenging for the NHS to realise, and not just because of the parlous underfunding of child mental health services. There will be resistance among captured clinicians wedded to quasi-religious beliefs.
It is astounding that six out of seven adult clinics refused to cooperate with the review on a study to shed more light on those the NHS treated as children. A senior NHS researcher at one trust told me the opposition to taking part in an uncontroversial methodology to inform better outcomes came not from the board but from some clinicians in their service, and this was unheard of in other parts of the NHS.
Cass has also commented on the intense toxicity of the debate. The fact that she says medical professionals were scared of being called transphobic, or accused of practising conversion therapy, if they took a more cautious approach in a climate where activists and charities like Stonewall were quick to level accusations of bigotry at people flagging concerns, and that NHS whistle-blowers were vilified by their employer, has not only prolonged the avoidable harm that will have been caused to some young people but will make it difficult to recruit clinicians, or grounded social workers to any new service.
The Cass Report is an immense achievement. It has stripped some of the heat out of one of the most contested arenas of modern medicine (and, ergo, social work) and restored the role of evidence back to its rightful place. But there is a long way to go yet in unpicking the influence of a contested and controversial – yet in some cases, deeply embedded – adult ideology about sex and gender.
Social workers, entangled in this web of deceit and outright lies should take heed and back off from ill-judged, ill-informed, ideologically driven, wild ideas. To paraphrase, ‘social workers, leave those kids alone; all in all, it’s just another brick in the wall’.
This week: Tim finished watching the excellent Nordic Murders series on the Channel Four catch-up streaming service. There are a large number of episodes, all set on the Baltic island of Usedom, close to the German-Polish border. Good cast, twisty plots, all help keep the viewer intrigued and entertained; highly recommended.