We attended a seminar at Cambridge University entitled ‘Gender Non-Conforming Children: Treatment Dilemmas In Puberty Suppression’ presented by Bernadette Wren, Head of Psychology, Gender Identity Development Service, Tavistock & Portman NHS Foundation Trust. This post attempts to sum up her presentation, with our comments added under each section. There is much more to say, so we will be referencing some of these points more fully in future posts. There was unfortunately not enough time to ask all the questions we wanted to ask: the information given in this seminar raises more questions than answers.

Introduction

The staff at the Tavistock and Portman clinic feel that they are on the frontline of a social revolution and they get it from all sides. The issues they are dealing with are ethical as well as medical and psychological. There is tension between Tavistock and some trans advocacy groups especially in their use of the “suicide narrative” and promotion of personal stories based on memory – kids are being influenced by fearful stories about their futures, scaring them into making decisions. There is also great pressure from ‘parental advocacy groups’ for pre-pubertal blockers and treatment on demand based on self-determination.

We suspect that Mermaids is one of these pressure groups, given their rhetoric, and the obvious tension between Bernadette Wren and Susie Green of Mermaids at the Government trans inquiry. Tavistock has a good relationship with other trans advocacy groups and has worked with Gendered Intelligence, a fact we questioned, pointing out that G.I. go into schools and essentially normalise the idea to children that they can be the opposite sex and that they have a fixed ‘gender identity.’ We were pleased that the “suicide narrative” was acknowledged as we feel that ‘support groups’ threatening parents with their child’s possible suicide if they don’t transition is a particularly cruel form of manipulation and bullying of parents into putting a child onto the trans path through fear.

Facts and Statistics

Children aged 5-18 are referred to the clinic, the number of younger kids is increasing, including pre-school children. Referrals have doubled since July 2015. 110 children are currently referred every month.

There are increasingly more psychological difficulties as a background to gender dysphoria and the treatment pathway for trans doesn’t make those problems go away. 18% of children visiting clinic are autistic spectrum (50/50 male/female) compared to 1% general world & UK population.

A large proportion of children coming in have traumatic backgrounds – self-harm, suicidal ideas. Treatment for gender dysphoria won’t eliminate psychological problems. When children arrive at the clinic they have often made a serious attempt on their lives, have often been bullied because of being ‘gender non-conforming.’

Children are not offered irreversible treatment (cross-sex hormones) until the age of 16, there is great pressure to lower that age. Until that point children are put on puberty blockers which stop development and is seen as a way of “buying time” and removing the stress of pubertal development eg menstruation.

In 1997 blockers were available to over-16’s only but from the 2000’s blockers became available from 12 years old and currently Tavistock has 132 under 16’s and 5 children under 12 on blockers.

Children are diagnosed and a treatment pathway devised after 4 assessments.

12- 27% of ‘gender variant’ children persist in gender dysphoria; that percentage rises to 40% amongst those who visit gender clinics.

Long-term research results are very unclear. Effects of blockers are being questioned: eg. how they affect cognitive function & mood. Sex characteristics don’t develop and in the case of boys this may mean there is insufficient skin development to later construct a ‘vagina.’ Putting 8, 9 and 10 year-old girls on blockers results in sterility if puberty is not resumed later, as there is no production of eggs. Clinicians talk to children about what losses treatment might result in, including loss of fertility.

There is uncertainty about gender identity development and there is no way of distinguishing the ‘persistors’ from the ‘desistors.’

The early suppression of puberty influences the development of gender identity – children on blockers almost inevitably go on to transition.

This information presents a very clear picture of the clinical path the trans lobby are pushing for and the results of their media presence and political lobbying so far in the huge rise in child referrals. Vulnerable children who previously may have accessed mental health/children’s services are now increasingly presenting to gender clinics, their problems re-interpreted with one simple explanation and solution. Despite the lack of research or knowledge of the full effects of puberty blockers on a child’s brain, the known result of sterility if a child continues on to cross-sex hormones, and the impossibility of knowing how an individual child’s ‘identity’ may develop, the trans lobby advocates a clear halt to that development with puberty blockers administered as early as possible. The ‘reversibility’ of blockers is called into question here. Attending a gender clinic significantly increases the probability that a child will go on to transition, and once on puberty blockers, that outcome is all but assured. After just four assessments, a child under the age of twelve may be made a medical patient for life.

Ethical Issues and Influences on Identity Development

The ethical issues include the consideration of autonomy: the ‘freedom to choose,’ and the political ideal of non-interference; self-determination as a right. “The autonomous choosing self” idea of who someone is says that some things are not up for choice or change, some things are a given. However, the evidence for a biomedical account of gender dysphoria is very flimsy (ie ‘female’ brain in a male body).

“Children are autonomous decision makers” – is it possible for them to make medical decisions free from influence?

The sense of self is built on other factors such as your perspective, your views, and influences – your sense of self stabilises over time & this developmental achievement is determined by multiple influences. “Gender identity” choices develop against a background: seeing yourself as non-conformist, being different, being a rebel, (even being infertile may be seen as a rebellious, non-conforming choice). These children believe the world should adapt to them rather than them adapt to the world. Children are making choices before these factors have a chance to evolve.

There has been an expansion of gender possibilities since the Seventies, from a binary choice of boy or girl to fluid, shifting, trans – there are now many identities to choose from. Kids accounts are highly influenced by what they hear.

Parents want a simple account. From parents there is a catostrophising outcome of not transitioning; parents want clarity, not change. Is it reasonable for parents to accept uncertainty in their child? Parents put pressure on clinicians. Transition can be a rearticulation of very rigid norms.

The transgender theory of an innate, fixed ‘gendered’ brain is unsupported by evidence. The diagnosis of transgender is dependent on a view of children and adolescents as autonomous agents capable of making their own decisions and choices in a bubble outside of any form of parental or cultural influences, and that the choice to define themselves as transgender is unrelated to any other personal beliefs, level of understanding, influences, experiences or psychological states. This is contrary to all knowledge of child and adolescent development and psychology. Parents have clearly been made fearful by the “suicide narrative” of trans advocacy groups and are typically intolerant of uncertainty, wanting a clear diagnosis which supports their own fixed beliefs of ‘normality.’

Conclusions

There is no chance to build a therapeutic relationship with a child if that child is fast-tracked.

When children are 18 they transfer to adult services and their protected characteristic means there is no way to follow their progress (this is prevented by law), there are no past studies or assessments done on veracity of treatments or on treatment choices, although a cohort study has begun and is now underway.

Gender non-conformity is a normal variant.

Tavistock believes in the need to be pragmatic: is being gender-conforming helpful, will transition resolve the problem? Then why not do it?

But clinics can act as an ‘invitation.’

Child and adult services are totally separate, so outcomes have not previously been tracked; the initiation of a cohort study is welcome, but long overdue. The status of children on the transition path will be raised to ‘guinea pigs’ whereas previously they weren’t even that. Given that ‘gender non-conformity’ is normal, it seems that the ‘problem’ has been created by cultural conditioning and parental investment in gender stereotypes, pressure on children to conform to those stereotypes, bullying of children who resist that pressure, and a concerted campaign by trans activists to convince everyone that those children who do not conform must be the opposite sex, a ‘solution’ which just reinforces the prejudices of the bullies. The idea that we should halt a child’s development, fill him or her with hormones and later surgically alter his or her body in order to meet society’s expectations of conformity, is chilling. We totally agree that ‘gender clinics’ – along with ‘trans support groups’ – are a strong invitation to parents, children and adolescents to frame non-conformity as a ‘gender’ issue which needs fixing.

Overall Bernadette Wren came across as cautious and very careful in her choice of words; Tavistock is clearly under extreme pressure to capitulate to all the demands of trans advocacy groups and, like everyone, clinicians lay themselves open to the charge of transphobia if they put a foot wrong. We feel there is no place for such a highly-charged political agenda to hold any sway in the diagnosis and treatment of children and adolescents who need time to develop their identities, and that much more attention should be given both to protecting parents and children from this untested and incoherent hypothesis of gender and to presenting them with a different model to counter it.

With thanks to our supporter in Cambridge who drew our attention to this seminar and helped by writing comprehensive notes.

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