As I ponder the MoU and its rationale among the counselling authorities, I am reminded that the  basic philosophy about gender identity comes from a subtle reframing of what it is to be human according to our Society “social justice” perspectives. Contemporary gender ideology increasingly treats the physical body as incidental and something to be overridden by internal identity rather than integrated and accepted. This shift is not just philosophical. It is reflected in concrete practices such as  medical interventions and the intractable imposition of the MoU over gender “therapy”.

The “De-pathologisation” model that the MoU is designed to impose, relies on moving Gender Incongruence to a sexual health chapter, confirmed by  the recent WHO Pivot on Gender “treatment”. This is not a scientific shift, it is a total ideological pivot, replacing a Clinical Map for a Social Justice Map, that has given rise to unfairness to women in sport and invasion of women’s spaces by men.

The BACP and BPS current stance operates on a logic that, if gender incongruence is not a “disorder” they argue that diagnosis is a form of gatekeeping and oppression. Therefore any psychotherapist who insists on a “differential diagnosis” (such as looking for autism or trauma) is framed as being obstructive or harmful.

The Principle of Respect means accepting the person’s internal “identity” as a supreme truth. The body, or a malfunctioning brain or physical malfunction are secondary or even irrelevant.  The Association position is: if we do not provide immediate medical and social affirmation, this population is at an extreme, unique risk of suicide and catastrophic emotional harm.

So, I have asked, if gender incongruence is not a mental health condition, why are we told that failure to accede to medical transition will “lead to risks of suicide or emotional harm?” Clearly – by claiming that medical intervention is the only way to prevent suicide, they are implicitly treating the condition as a critical mental health emergency while explicitly labelling it as “not a mental health problem.” So, they get round this conflict of logic in this way:

The Minority Stress Argument.
To bridge this gap, they use the concept of Minority Stress proposing that risk of emotional harm in gender-questioning people is not caused by THEIR issues or sex identity. It is caused by “transphobia” and the “lack of affirmation” from society and clinicians. That is one reason why we SHOULD use their pronouns.

The Clinical Counter-Argument: There is no high-quality, long-term evidence (as noted in the Cass Review) proving that medical affirmation is the primary or most effective way to reduce emotional risk. In fact, many other populations suffer “minority stress” without clinicians being told that “failure to affirm” constitutes a harm risk. The research we have suggests that medical transition may not “make people happier.” (see stats at the bottom of this piece).
If the BPS/BACP argues that bodies must be changed to prevent emotional harm, they are essentially endorsing “Crisis Affirmation.”
In addition, you cannot reduce minority stress via medical intervention. A trans women will still in most cases look male and will be obliged (at the risk of sexual assault) to declare their natal sex to a romantic partner.

The legal risks
Reliance on mitigating minority stress has legal risks.  Under the Montgomery Duty (2015), a clinician cannot be coerced into a “crisis” decision that ignores other “material risks” (like the “starving brain” or autism). If you affirm a patient based on the “reducing minority stress argument” and ignore possible underlying comorbidities, you will be vulnerable to a malpractice claim if, years later, the client regrets transition and suffers harms to health.  The court will ask: “Why did you bypass a standard psychiatric, psychological and physical assessment for a ‘normal variation’?”

The Law on Material Risk
The insistence on affirmation and using someone’s chosen pronouns conflicts with our common law understanding on sex. It  is a deliberate deflection to avoid confronting real clinical issues. The Montgomery (2015) Ruling doesn’t care if the WHO or the BACP thinks gender identity is “normal.”  If a treatment or a treatment approach carries a material risk – such as making or ignoring a physical or emotional illness or leads to permanent medicalisation – the clinician MUST disclose it.  If BPS/BACP Guidance tells us not to do this because it is “bad manners” or causes “minority stress” due to “disrespect,” they are telling you to violate the Duty to Do No Harm. Ideology is not a defence for negligence.
If a therapist follows the current BACP/BPS Guidance and the patient later sues for damages you will be investigated for a breach of clinical standards, not your ideology.  The Therapy Authorities will be seen as having induced a Tort of Negligence by providing guidance that explicitly discourages your permission to investigate mental issues that will lead to assaults on physical health and future risks to it. But you will face the penalty – not your Counselling Authority.

Regarding the MoU, and current guidance on the use of pronouns
The affirmation, anti-conversion thinking is that the failure to use a client’s chosen pronouns breaches good manners, increases minority stress and fails to show unconditional positive regard to the patient. The BPS has even uncovered an old 2018 document on the effects of “misgendering”.

You may have a personal dislike of describing a client as what they are not (in law) , using a recognised form of common language. In other words, you have the right not to call a biological “he” a “she”.
Here is how you may protect your rights and freedom of belief. In a therapy setting, the therapist’s role is to maintain a “neutral” space for exploration. A psychotherapist has a primary duty to explore the patient’s internal world, their beliefs and feelings, without pre-emptively validating or cementing a specific identity before a full holistic assessment (including physical co-morbidities) is complete. In other words, if a patent were to insist that they are a hat, you have the right to explore that belief and what may have given rise to it, without pre-emptively agreeing with the patient that they may sit on your head.

Using “preferred” pronouns is a clinical intervention that signals a conclusion has already been reached. If you use the client’s pronouns before any underlying morbidities are ruled out, you would be  prematurely “affirming” a state that may be a symptom, not an identity.

In other words, using the clients preferred pronouns because you are forced to, is a symbolic affirmation. If a psychologist uses the client’s he/she/they/ zie or it,  before a full differential diagnosis is complete, they have “collapsed the space” for exploration. They are no longer a neutral observer; they have become a participant in the patient’s internal narrative.

The legal arguments against pronoun coercion

1             Montgomery” and “Consent” Justification. Under the Montgomery Ruling (2015), you are legally obliged to avoid any action that creates a “false sense of security” or bypasses the disclosure of material risks. Compelled use of preferred pronouns in a clinical assessment of a minor, or vulnerable adult with, say,  an eating disorder, can be viewed as Diagnostic Overshadowing. It reinforces a detachment from the biological body at a time “when the patient is clinically ‘untethered’ from reality.”   By refusing to use their pronouns, you are upholding your duty to keep the patient focused on their biological vulnerability.

2. The “Equality Act” Justification (The Forstater/Mackereth Precedent)

Under the Equality Act 2010, gender-realist beliefs (that sex is biological and immutable) are a protected characteristic. Any organisation that compels you to use language that contradicts this belief-particularly when it conflicts with your clinical observation of a patient’s physical health, constitutes Harassment and Compelled Speech under the Equality Act. While we are told to respect the client, Respect goes both ways. The BPS/BACP cannot force a therapist to lie about biological reality if it violates their professional and protected beliefs.
The BACP may rely on the need to give the client unconditional positive regard. This does not require colluding with their system of beliefs, no matter how intense. The current position on gender “therapy” could be regarded as a Breach of Fiduciary Duty: Charity resources are used to promote a guidance that creates potentially uninsured financial risk for its members. As things stand, ideology is not a defence against Negligence – as evidenced by emerging cases of compensation against affirming psychotherapists in the USA and UK with severe financial penalties.

3 The Human Rights Act Article 9 and Article 10

Under the Human Rights Act and the Equality Act 2010, you have protection against compelled speech. Whatever reasons your authority give you , they may not violate your freedom of Conscience (Article 9) and Freedom of Expression (Article 10). Furthermore, as a clinician, you may claim that you cannot ethically use language that you believe to be clinically harmful or factually inaccurate regarding a patient’s sex-based physical risks. I have known of several therapists working in the NHS who have been belittled and sanctioned for refusing to use a client’s personal pronouns that conflict with their sex. In all cases the therapist has succeeded with harassment law.

THE SOLUTION
You have the right to decline without sanction, to work with a gender questioning client. Or, preferably, be clear about your position on pronouns, and use a neutrality approach. To be respectful and polite you may say to a client that you will use their name rather than a label while you find out what is best for their physical and mental wellbeing.
Be aware of what is really going on in the counselling world. The following table makes the position clear

Issue	BACP/BPS “Respect” Model	“Lawful” Model
Pronouns	Mandated as “Affirmation.”	Viewed as a Clinical Intervention requiring caution.
Justification	Reducing “Minority Stress.”	Maintaining Diagnostic Integrity and Montgomery Compliance.
Conflict	View as “Transphobic/Conduct.”	Viewed as Protection against Negligence/Tort.

How to deal with the “minority stress” argument: The Gender Minority Stress Model (GMS) posits that the mental health disparities seen in gender-questioning people (anxiety, depression, suicidality) are not caused by internal pathology, but by a hostile social environment. By centring “Minority Stress” as the primary clinical concern, the BACP/BPS achieves three things that are legally and clinically dangerous:

First They Presume the Identity: To have “Minority Stress,” the person must first be a “Minority.” By applying this model immediately, the clinician is presuming the child or adult’s gender identity is a fixed fact, rather than a phenomenon that requires differential diagnosis. Then, it asks us to replace Diagnosis with Advocacy: If the “problem” is external (society’s reaction), the therapist’s role shifts from a clinician who assesses the mind/body to an activist who “affirms” the identity to reduce that stress. Finally, it creates a hostile environment trap for you. If you insist on investigating the reasons for this identity position, the BACP/BPS  guidance frames the therapist themself as a source of Minority Stress.

You can deal with this by asserting that minority stress is a subjective construct. It relies on the patient’s perception of hostility. This perception itself may be a symptom of an underlying condition, not a  reflection of reality. It is your clinical duty to determine what ELSE is causing their distress. This could be an eating disorder or high levels of autism. Using the term “minority stress” as a catch-all explanation for distress is diagnostic overshadowing by another name.

A personal word.
I have questioned my own Professional Authority on their current gender guidance. They gave me no evidence of the safety of the application of the MoU. I have had no guidance regarding risk assessment for transition regret.  Because of this, I have alerted my Insurers that their guidance currently places me at risk of malpractice if I follow the Society Guidance. Or the risk of a conduct hearing if I do not. This puts therapists in an impossible bind.

When I have presented this “conflict” to the BPS they have suggested that I use my own “judgement” to work with gender questioning people.  It means that the MoU may be functionally meaningless in law.

The Summary:  Our Association’s current position is logically incoherent and clinically dangerous. They claim gender incongruence is a ‘normal variation’ to avoid the ‘stigma’ of diagnosis, yet they simultaneously weaponise suicide or emotional harm statistics to coerce clinicians into bypassing the Montgomery Duty of Care. If a condition is truly a ‘normal variation,’ it should not require a therapist to surrender their clinical judgement under the threat of patient self-harm. Forcing us to bypass the investigation of physical and mental co-morbidities is a breach of safeguarding and a failure of professional ethics.”

******Some Facts for your Knowledge on Transition Regret or Failure*******

While many activist organisations point to short-term observational studies to support “gender-affirming” pathways, major systemic reviews conducted between 2024 and 2026 have found these “foundations” to be scientifically unstable. The most comprehensive review to date, led by Dr Hilary Cass, 2024 concluded that the evidence for medical interventions (puberty blockers and cross-sex hormones) is “remarkably weak.” The review found no high-quality evidence that medical transition improves gender dysphoria or mental health outcomes in the long term for children and young people. Because of this lack of evidence for wellbeing, NHS England moved to restrict the routine use of puberty blockers, citing that the benefits do not clearly outweigh the risks.

The “Quality of Evidence” Problem; Systemic reviews from the University of York and recent 2025/2026 reports have identified a persistent pattern in the literature used to support the MoU’s ideological position: Many studies that show “positive outcomes” suffer from high rates of “loss to follow-up” (up to 36% or more). This means we often only hear from the people who stayed in treatment and were happy, while those who desisted or detransitioned, simply disappeared from the data.

The Cochrane-style reviews often rate the certainty of evidence for “improved wellbeing” as Very Low. In evidence-based medicine, “Very Low” means the true effect may be markedly different from the estimated effect.

Latest Findings: New research (2024–2026) has begun to look at Desistance and Detransition, which directly contradicts the “wellbeing” narrative: The “Wait and See” Outcome: Historically, studies (such as those from the Dutch clinics) showed that a large percentage of gender-distressed children would desist (return to their birth sex) if not put on a medical path. A 2024 study of 237 detransitioners found that 70% realised their dysphoria was actually related to other issues (trauma, autism, or eating disorders). This proves that for many, medical transition was a misdiagnosis, not a wellbeing intervention.

The Long-Term Reality: 10-Year Lag: A significant data point is the Time-to-Regret. Most studies used by the BPS/BACP only follow patients for 1–2 years. Using 12-month data to justify a lifelong medical path is a Failure of Duty under the Montgomery Act, which requires the disclosure of long-term material risks. Research indicates that “regret” or the realisation that transition did not solve the underlying distress often takes 8 to 11 years to emerge.

Precise Definition: The MoU on Conversion Therapy

The Memorandum of Understanding (MoU) on Conversion Therapy (Version 2, 2017/Updated 2021) is a voluntary, non-statutory agreement between over 25 UK health and therapy organisations (including the BPS). The Scope: It defines “conversion therapy” as any model or viewpoint that assumes one sexual orientation or gender identity is “preferable” to another and seeks to change or suppress it. The “Exploratory” Clause: Crucially, Paragraph 5 states that the MoU is not intended to prevent exploratory therapy. It claims to support therapists in helping clients “explore” and “clarify their sense of themselves.”

THE BPS AND THE BACP The central tension, which I have identified in their Guidance (and the stance of the Public Affairs Board) effectively treats any exploration that doesn’t end in “affirmation” as “conversion practices.”

In fact, the BACP’s position is often seen as more “ideologically locked” because their Ethical Framework is frequently interpreted as a mandate for validation over investigation. Their guidance on the MoU version 2 has threatened therapist autonomy, by suggesting that any therapist who does not affirm a client’s self-identified gender may be practising “conversion therapy.” This is the same “chilling effect” as with the BPS.

In their view, gender misalignment is a normal variation of human experience, not a mental disorder. They explicitly align themselves with the WHO’s ICD-11, which moved “Gender Incongruence” out of the mental health chapter and into a chapter on sexual health.

The Logic of the Therapy Organisations promotes De-Pathologising of Trans Yearnings and Respect as the Primary Goals
The Council of Europe aligns with the therapy organisations in assuming that if a phenomenon like thinking or wishing to be the sex you are not, is “normal” (like being gay), the primary role of the therapist is not to “treat” or “diagnose” it, but to: Affirm: Support the individual’s self-identification as a matter of human rights. AND Mitigate Minority Stress: Focus on the distress caused by society’s reaction to the person, rather than any internal pathology. FINALLY : Remove Barriers: Ensure that the path to transition is as smooth and “respectful” as possible which involves medical and surgical transition.

THE THERAPIST MANDATE
We must surrender the goal of getting a gender questioning person to accept their body/sex, even where we are convinced that sex is binary and immutable, a Protected View supported by the Supreme Court Ruling on Sex and Sex Based Rights. There are other requirements, such as we must accept their “gender identity” if it differs from their biological sex, as valid- as explained above under the Code of Respect. When a male says he is female, (or vice versa) we must accept this as a normal variant of human identity, in the same way as accepting gay and lesbian identity as NOT pathology.

YOU MUST USE THEIR PRONOUNS?
The  Guidance requiring us to use the person’s chosen pronouns is for good manners and any departure would be harming the patient (misgendering) and affirming, via pronoun use, is the necessary clinical intervention to reduce “minority stress.” You may not be forced to do this, see the legal comments below.

DO NOT PATHOLOGISE OR EXPLAIN?
The Guidances issued by the Therapy Associations suggest that if we try to link their identity to a mental health condition such as autism, or childhood trauma, as a way to “disprove” the “flawed” identity, the BACP/BPS will likely view this as “reparative” logic. It may become a conduct issue or reframed as “conversion therapy”. You can argue against this, as I explain below.

THE FAILURE OF LOGIC
The Supreme Court Ruling puts gender puts therapists in conflict with the MoU and with the Ethics Codes of their Associations.

The Code of Respect ; Respect goes both ways and it may be unlawful if a therapist is coerced against their choice to use common language that defines biological sex (calling he “she”) and is then forced to agree that a client is what they are not, in the Law. Coercion is a breach of your Association’s Public Sector Equality Duty. And may be unlawful.

The Code of Do No Harm ; Certain conditions give rise to problems with embodiment and identity. Anorexia is a good example. One way to avoid present and future harm is to rely on “capacity” to understand the considerable risks, socially, emotionally and physically of transition.
Where eating disorders are comorbid with gender questioning, this BOTH affects capacity to make life-changing decisions, AND magnifies physical risk. Capacity in eating disorders is affected by pre-existing neurological confounders (cognitive inhibition, set shifting difficulties/ rigidity). These neural factors are worsened where there is dietary chaos.

The risk of harm is strong if strong hormones are given to a person already compromised by malnutrition. This is again a strategy that has not been tested. This clearly asks for extreme caution for the eating disorder patient at any age , and suggests that their capacity to understand the risks of transition may be impaired and that medical interventions will add to existing harms.

DUTY OF CARE AND TRANSITION REGRET
Capacity, physiology and Transition Regret intersect with failure to do holistic, evidence-based evaluations – none of which are proposed by our Professional Bodies. The current malpractice cases such as Fox Varian in the USA and R Herron in the UK, make this need for clarity compelling.

Other conditions that may affect capacity to assess present and future risks of medical interventions, include Mitochondrial Disease, which “mimics” autism. Therapists wishing to protect themselves from malpractice charges, as well as to protect a vulnerable client, have a Duty of Care to do extended and holistic assessment. Our Duty of Care requires us to consider all adverse or social experiences that have culminated in gender incongruence. A therapist’s first duty is to the Law of Consent, not your Association’s Guidance. Should your Association be insisting that you must ignore a “material risk” (like the impact of starvation on the brain or neurological “impairments”), they are telling you to commit a TORT* OF NEGLIGENCE. In other words they could be forcing you to act outside the law.

AFFIRMATION VERSUS THE MONTGOMERY DUTY 2015
The Montgomery v Lanarkshire Health Board [2015] UKSC 11 ruling – is one of the most significant Supreme Court judgments in the history of UK medical law. It mandates the investigation and disclosure of all “material risks” of any intervention. It was first applied to medical procedures but the Principle is extended to psychological practice too.

These risks include the physiological and cognitive impact of co-morbidities like Eating Disorders, comorbid mental health problems, or metabolic problems. Furthermore, by discouraging the rigorous investigation of the “starving brain’s” role in gender distress, which can also arise in cases of mild metabolic disorders,  the MoU policy places members in direct breach of their statutory obligations under the Children Act (1989/2004), where a child’s physical welfare and safeguarding must remain paramount.

 IGNORING OR NOT ASSSESSING a client FOR CURRENT AND FUTURE RISK IS THAT TORT OF NEGLIGENCE. Since the counselling authorities have as yet to provide evidence-based guidelines for assessing that risk, their ideological stance places members in direct breach of their statutory obligations under the Children Act (1989/2004), where the child’s physical welfare and safeguarding must remain paramount. As things stand now with all the Authorities aligned with the MoU under their “social justice” position, ignoring or not requiring testing for that current and future risk is a Tort of Negligence as identified above.

YOU ARE NOT COMPELLED TO AFFIRM : Being compelled to affirm is a breach of the Dignity at Work Guidance, and a breach of your Protected Beliefs if you are a gender realist. You may “affirm” that a client believes that they are a sex they are not, or “feels” like a member of the sex that they are not. But you may not be compelled to agree that they are the sex that they are not – because the legal framework for sex is enshrined in law. If you work in a professional environment where you are belittled for this position, or you are are accused of being unprofessional, you will be able to seek lawful protection against harassment or victimisation.

RISK CANNOT BE EVIDENTIALLY ASSESSED: The current “Affirmative” framework imposed upon therapists, suggests that you must support and not question clients in accessing medical interventions if they shout loudly enough for them. It is your lawful duty to firmly establish the risks. But in the absence of formal evidence-based guidance – I have asked for it, but have never received it – how is this possible? I have yet to find any Supervisor who can tell me how the risks of say – infertility- can be appraised by a person who is not at the age where these motivations become compelling. We know many young people seeking transition are at the stage where they are neurally primed to prioritise escape from emotional discomfort rather than engage in rational thought. Any external mandate from your counselling authority requesting you to follow their Guidance, effectively requires practitioners to act ultra vires (beyond or in conflict with their legal duties).  By prioritising identity validation over holistic clinical assessment, the guidance compels a practitioner to bypass the Montgomery Duty (2015).

The Montgomery Ruling mandates the investigation and disclosure of all “material risks”.  These risks including the physiological and cognitive impact of co-morbidities like Eating Disorders. Furthermore, by discouraging the rigorous investigation of the “starving brain’s” role in gender distress, which can also arise in cases of mild metabolic disorders,  the Society’s policy places members in direct breach of their statutory obligations under the Children Act (1989/2004), where the child’s physical welfare and safeguarding must remain paramount.  IGNORING OR NOT ASSSESSING FOR CURRENT AND FUTURE RISK IS THAT TORT OF NEGLIGENCE.

LEGAL CHALLENGES TO THE MoU AND RECEIVED GUIDANCE FROM OUR PROFESSIONAL OVERSEERS
Legally, a professional body should not issue guidance that overrides a clinician’s common law duty to prevent negligence to the client, put themselves at risk of financial claims for malpractice by the client,  or fail their statutory duty to protect a vulnerable person from the “impairment of health.” The time for arguing about current regulatory guidance is done. In the absence of scientific evidence, I have alerted my Insurers about these matters and may use my professional judgment, take supervision from a professional who knows the law and who is not motivated by ideology. Then I will meet my duty of care to clients and validate the protection of my indemnity insurance, in the event of any sanction.

POSTSCRIPT * In English law, a Tort is a civil wrong that causes someone else to suffer loss or harm, resulting in legal liability for the person who commits the act. Unlike criminal law (where the State punishes a person), Tort law allows an individual (the “Claimant”) to sue for compensation.