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Artillery Row

A question of ideology

Psychiatrists must be free to challenge dogma

I wrote about the serious schisms within the Royal College of Psychiatrists (RCPsych) and its members over the fraught issue of gender dysphoria in January. Those divisions were explicit during recent elections. Dr Lenny Cornwall is a consultant adult psychiatrist with an impressive career history. He recently tweeted: “Someone said anyone who voted for me was a bigot (so that’s 1593 of us.) It would be nice if @rcpsych made a statement now to refute that.” 

In March Dr Cornwall stood for election to the RCPsych Board of Trustees on a platform that made explicit his commitment to “provide evidence-based rather than ideological leadership”. He pledged to “seek to end RCPsych’s partnership with Stonewall”. His manifesto elicited accusations of bigotry on social media, the automatic activist response to anyone who deviates from the gender orthodoxy ascendant across apex institutions including the Royal College of Psychiatrists. The closely contested election highlights dissent from members who are increasingly concerned about the influence of Stonewall and the lack of open debate on gender dysphoria and its treatment. On 20 April 20, the results were announced. Dr Cornwall lost by 111 votes on a familiar split of 48 per cent to 52 per cent. 

When I spoke to him, he was magnanimous and congratulated Dr Billy Boland on his win. Dr Cornwall’s manifesto had been scrutinised and approved according to College protocol, but RCPsych didn’t defend its legitimacy when he was being denounced as a bigot during the campaign. He explained: “Things work very nicely when a consensus is easily achieved, but if someone stands on a platform which dissents from the establishment position? The College isn’t prepared to defend your stance.” He is concerned this silence will have a chilling effect on future candidates. “It will be a deterrent. It’s obviously a divided position amongst members, but there needs to be a mechanism for encouraging debate and discussion.”

What does conversion therapy mean in the context of healthcare?

The absence of a forum for debate and the top-down imposition of ideological orthodoxy on gender and trans healthcare has been vividly described to me by the psychiatrists I’ve interviewed since my article in January. It is striking that all of the female psychiatrists I spoke to requested anonymity because they are fearful of repercussions if they speak openly. What does that say about the glacial climate for free speech within the profession? Phoebe* is a consultant adult psychiatrist with decades of experience and a sharp analytical mind. She is scathing about the dominant influence of Stonewall and EDI on the issue of gender dysphoria. She tells me: “The agenda for EDI has become paramount. EDI dictates are unquestionable, and there is an atmosphere of fear which makes discussion impossible. You are made to feel like a fascist if you criticise the affirmative approach.” Phoebe says ideological perspectives are inhibiting debate, and people are denounced for asking questions. 

That was explicit during a fraught webinar on Gender Identity at RCPsych last November which I wrote about here. One of the presenters, Dr Jo Hartland, who is Deputy Ed Director for EDI at Bristol Medical School, claimed that 45 questions from RCP members were “80 per cent transphobic”. The College said it was “appalled by the treatment of presenters” and would investigate. The outcome of RCPsych’s investigation has never been made public. Psychiatrists who asked to see it were rebuffed. Alice* was in the audience at the Gender Identity webinar, and she was concerned about the use of unscientific activist terminology such as “cisgender” and “people with testes”. She was dismayed by the accusations of bigotry. “Lots of people had asked questions. We were all characterised as transphobic, hateful. There is an atmosphere where you can’t speak. This is not upholding the values of the College, the values of the profession, the values of the average psychiatrist.” She describes how the College has adopted a dogmatic position and doesn’t listen to its members. “EDI primacy is unchallenged. There is a chilling effect on anyone who wanted to raise questions.”

A consultant adult psychiatrist who I will call Cassandra* has a wealth of clinical experience. Her compassion for her patients is clear. She describes how aggressive activism is having a distorting impact. She is critical of the affirmative approach particularly if a young woman presents with a constellation of issues, including a background of sexual abuse. Cassandra used to deliver annual lectures to junior doctors to pass on her clinical knowledge and expertise, but she has stopped out of concern that she will be reported for failing to adhere to the orthodoxy on gender dysphoria. She has no confidence her trust would support her if that happened. Medical education is becoming increasingly ideological. “We’ll look back at this like we look on lobotomising patients.”

Dr Adrian James is the current President of the RCPsych. His tenure ends in July. His commitment to EDI has been explicit. In a blog to celebrate Pride in 2021, he announced RCPsych was signing up to both Stonewall’s Workplace Equality Index and its Diversity Champions programme. He wrote: “When I announced I was running for President in 2019, I made Equality and Diversity one of my four key priorities. When I did that, supporting the LGBTQ+ community was central to what I wanted to achieve.” When RCPsych won a Stonewall Gold Award in February after complying with “80 per cent per cent of the measures which were consistent with our values”, Dr James was “delighted”. Are these clinical or political priorities? Dr James has also affirmed RCPsych’s commitment to a ban on “so called conversion therapy”. What does conversion therapy mean in the context of trans identified patients seeking healthcare? Will a ban mandate affirmative care? Will it criminalise clinicians who adopt a holistic, exploratory approach? What about the young women encouraged by the medical profession to embark on a pharmaceutical and surgical voyage that leads not to euphoria, but regret? 

Science is being subverted by the influence of activist political forces

Dr Hilary Cass has written an article that appears in the current edition of RCPsych’s Insight magazine. Insight also features articles by Dr Elinor Hynes and Dr Stephen Westgarth, which reflect divergent views within psychiatry on this contentious issue. It is the first time in years that RCPsych has openly acknowledged there is dissent within its ranks on this subject. Dr Adrian James clarifies that RCPsych’s official position hasn’t changed, and that it is in line with the International Statistical Classification of Diseases (ICD11). “As a College, we have a clear position … when an individual’s gender identity or role is different to the sex they had at birth, that is not a mental illness, but rather a condition related to sexual health.” In her article, Dr Cass writes: “We have to ensure that professionals feel safe to ask questions in an open, curious and non-directive way.” She also says: “The planned conversion therapy bill needs to provide clarity on what conversion therapy is and what it is not.”

Dr Cornwall hopes the current edition of Insight signals a departure from RCPsych’s silence on dissent amongst psychiatrists and a new trajectory of free debate and discussion. He is concerned that science is being subverted by the influence of activist political forces. He says: “This article cannot be published, this piece of research cannot be commissioned. It is restricting scientific investigation. What does the evidence show? Let’s try to make sense of that. We need a forum where we can highlight clinical questions. Psychiatrists have to be able to raise questions. We have to be free to speak. Ideology is trumping science.” He recently tweeted: “It is very worrying that standing for a RCPsych election and stating your views is considered brave.” 

What precisely is happening within apex institutions across the medical sphere? This picture of an icy inhibiting environment, in which psychiatrists are frightened to speak or question gender orthodoxy, does not bode well. If the freedom to debate, challenge, explore is lost, where does that leave science and medicine? 

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