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by Shelley Charlesworth

Are the current adult gender clinics serving their patients well? Are their links with trans activist groups influencing treatments? More detransitioners are now coming forward to say they were rushed through gender services without adequate attention paid to the complexity behind their gender dysphoria. A majority of these are young women.

There is an assumption that more gender services are needed to deal with long waiting lists. But if the model of gender care at the existing clinics is faulty, will more clinics simply lead to more bad outcomes? An important new study into a UK gender clinic suggests this could be the case.

The Exeter gender clinic study

The first piece of research into outcomes at one of the 7 adult gender clinics has just been published, throwing much needed light on their results. Its significance is that nothing similar has been undertaken before. Indeed, it’s hard to think of another branch of medicine that has had so little scrutiny as to outcomes.  The authors write:

“There are limited data published by adult UK GICs and to date there has been no requirement for services to collate or report on either access to treatment or outcomes. As such, it is unknown how many UK service users complete their transition as planned or have unmet needs, and the impact this may have on them. It is also unclear how many disengage from services, discontinue treatment or revert to their previous gender role.”

The research looked at the records of 175 patients at West of England gender clinic in Exeter which offers treatment to people over the age of 17. The authors found that the patient profile mirrored the change in presentation to the Tavistock’s service for children which has seen an increase in trans identifying girls. They note that the adult service was designed for older male-to-female and not younger female-to-male transitioners. Because they found high rates of neurodevelopmental disorders such as autism and those with adverse childhood experiences [ACEs] like physical abuse, sexual abuse, bereavement or domestic violence, the authors call for more attention to be paid to these factors during assessment. The report contains some revealing statistical data; of the natal women under 25 who were treated at the clinic, 89.4% had an adverse childhood experience, 23.4% had a neurodevelopment disorder.

The figures for mental health conditions show higher rates than those of the general population. 3 males committed suicide during the course of their treatment. 72.4% of the clinic’s users were found to have a previously diagnosed mental health condition. The authors had to collate this information themselves from other medical records saying “As the GIC does not itself diagnose concurrent mental or physical health issues, we relied on the documentation of diagnoses made elsewhere, meaning our background characteristics data may be underestimates.”

It is hard to believe that a service which prescribes cross-sex hormones and refers patients for irreversible surgery to remove healthy body parts is so cavalier about making basic investigations into their patients’ history and mental and physical health.

Importantly, the research lays to rest the idea that detransition rates are negligible. The authors found that 6.9% of 175 patients detransitioned, adding that a further “Six cases did not strictly meet the criteria for detransitioning but showed some overlap of experience.” They conclude that their detransition figures may be an underestimate. 

The overall picture is of a service that does not keep adequate medical records or investigate the background to the gender dysphoria diagnosis of their patients.

It has become commonplace to say there is a need for gender clinics. The Equalities Minister Liz Truss said in September 2020 that three pilot gender clinics were being opened, citing long waiting lists and acknowledging that this was causing distress.

Recently on Twitter, Nancy Kelley, Stonewall CEO, asked “Perhaps now we can turn our energy towards investing in trans healthcare? We should be focused on how we can provide high quality, person-centred care close to home for both trans adults and trans children and young people.”

But the Exeter study shows there are problems with the existing model which must be addressed before expanding the network of clinics. The research points to fundamental faults built into the current stream-lined service which are the likely result of the change in 2019 to service specifications for treating gender dysphoric adults.

Earlier service guidelines from 2013 were more cautious. For instance, patients had 2-4 assessment consultations, they were required to live for 12-24 months in their new gender role before any surgery and there was a requirement that “Regular psychotherapy and counselling should be available throughout the patient’s individualised gender dysphoria care pathway.”

The 2019 service specifications in contrast stipulate just 2 assessment sessions, the requirement for living in a gender role is now set at 12 months and it says there is no need “for the individual to conform to externally imposed or arbitrary preconceptions about gender identity and presentation.” The age of referral to adult clinics is lowered from 18 to 17 and the requirement for regular psychotherapy has been dropped. This is the stream-lined service that the NHS gender clinics now offer.

The Established Gender Dysphoria Clinics

There are 7 adult Gender Dysphoria Clinics [GDCs], run by the NHS in England, primarily under the management of mental health trusts. They are based in London, Sheffield, Leeds, Newcastle, Daventry in Northamptonshire, Nottingham and Exeter. [Tavistock GIDS for children and young people is based in London with a satellite service in Leeds.] The adult gender clinics offer surgical and non-surgical treatments. Surgery is carried out at 11 different hospitals, 7 of which are private and under contract to the NHS for the treatments. These hospitals also carry out surgery for patients referred from Scotland which has no surgical provision of its own.

The first adult gender clinics were set up in the 1970s by psychiatrists who had an interest in treating transsexuals with physical interventions rather than the then more usual psychoanalytic approach. James Barrett, lead clinician at the Charing Cross Gender Identity Clinic, speaking of the treatments in the early 80s said “the patients…they weren’t very psychiatric but needed medical things doing.”

From the late 1990s activists began to push for more services, taking their cue from Holland where the Amsterdam clinic first used puberty blockers to treat gender dysphoric children. Mermaids, Press for Change and GIRES were early and enthusiastic supporters of these drug treatments. They were helped by the growing NHS trend to engage service users in planning treatment and provision, giving them a platform as groups which represented those with ‘lived experience’. But engagement with trans rights groups is crucially different to other NHS service user consultations. These groups brought an ideology and belief in gender identity into the provision of healthcare. Mermaids, Gendered Intelligence and Press for Change have wider political and social goals such as bringing in gender self ID and changing the Equality Act to remove single-sex exceptions, and take their gender identity beliefs into health service management, schools, university and government departments. They are not comparable to the MS Society or Cystic Fibrosis Trust.   

In response to an increased demand on gender services a consultation took place in 2017 which resulted in 2019 in the current guidelines for adult services. The results of the consultation show the pressure the NHS faced from trans rights groups wanting to weaken checks and balances on the clinics and to de-medicalise the process of transitioning. (Our response to the public consultation can be viewed here).

GIRES wanted to see “fundamental changes in the model of care, for instance shifting assessment into primary care.”

The Trans Equality Legal Initiative claimed “..overall there has been a missed opportunity to remove all of the barriers and inequalities Trans and non-binary people face when accessing services.”

Press for Change were opposed to the idea that only specialist gender clinics should refer patients for surgery. “This proposal will force trans people who are seeking NHS services to sublimate their own preferences, and choices, to the standard choices as offered by the few existing clinics, effectively destroying the core patient rights to choice..”

Action for Trans Health were dismissive of the specialism of endocrinology. “While we appreciate GPs may not have specific knowledge around endocrinology, hormone treatment (after being guided by a specialist) is not unusually complicated and does not require unusual amounts of expertise over and above that of normal GP training.”

The belief that anyone can diagnose and treat gender dysphoria is a common thread running through all trans health activism. Mermaids CEO Susie Green takes this to its absurd conclusion. Her answer to the question “how did you know your child was trans?” is “there’s no easy answer because it’s not about me knowing; it’s about the child knowing for themselves.”

The NHS chose not to include the more extreme demands of trans groups. The activist bind is that their desire to remove all medical gatekeeping will always be incompatible with the need for drugs and surgery to masculinise or feminise their bodies. Gatekeeping will always be necessary in a publicly funded health service and doctors will always have to work within the law and professional rules.

Despite this, the 2019 service specifications prove that the Overton window has moved. A good example is the downgrading of talking therapies. “Psychological interventions will not be offered routinely or considered mandatory, but instead with the consent of the individual and focussed on specific psychological needs.”  Other non-surgical treatments are Hormone Therapy, Facial Hair Reduction, Voice and Communication and Lived Experience.

Only two assessment consultations are required before a diagnosis and treatment plan is agreed with the patient, who can in theory be given a prescription of puberty blockers after their second appointment. The Exeter study found that there was a connection between those who didn’t complete their treatment and neurodevelopment disorders, substance abuse, mental health issues and ACEs. As only 56.1% of the service users completed their treatment it would suggest that the current requirement for only 2 assessments is not working.

There are other factors which may influence the outcomes at the clinics. They all operate within an ideology that believes in innate gender identity. Some are run by clinicians who could easily be confused for activists. The writer Susan Matthews recounts attending a conference in 2019, when the lead clinician at the London gender clinic, James Barrett,  “spoke of the threat to gender medicine from an apparently organized alliance between ‘right-wing evangelical Christians, old-school therapists and some kinds of feminism.’ What Barrett did not do was consider whether the concerns voiced by critics had any basis in truth. The concern of critics, he believed, masked a desire to reintroduce “reparative therapy.” His language and reasoning could be mistaken for that of Stonewall or Gendered Intelligence who also frame gender critical views as malign.

All the clinics have website links to resources that promote ideas of innate gender identity. Not one suggests resources with a different perspective. Exeter has links to Mermaids and GIRES.

Leeds has links to Mermaids and Pink Therapy among many others. Northampton links to Mermaids and Gendered Intelligence. The front page of Newcastle’s clinic features the anti-science diagram, the Genderbread person, which promotes the idea that sex is a spectrum and that everyone has a gender identity.

Nottingham in particular has close activist links.  Gendered Intelligence run a helpline service there and at the Sheffield gender clinic. Professor Jon Arcelus, a mental health and gender specialist at the Nottingham clinic says he works ‘closely’ with Mermaids and Gendered Intelligence.

The Nottingham NHS clinic is headed by Dr Walter Bouman who gave evidence at a GMC hearing  on behalf of Dr Helen Webberley into her failure to provide good clinical care for her young trans identified patients. Dr Bouman is the outgoing president of WPATH. Notes[1] written by those following the case are revealing. At the Nottingham clinic, he said that nurses are prescribing hormones and one nurse with a Masters can also refer patients for surgery. He doesn’t like the multidisciplinary team model, calling it outdated, and doesn’t think that for 85-90% of his patients there is any need to seek a second opinion. Asked if a 12-year-old would need a full examination and diagnosis before being prescribed hormones he said psychological tests weren’t necessary as a transgender doctor knows when a person is trans.

Dr Bouman is relaxed about a lower age for starting cross-sex hormones, saying the global consensus was 14, but it was stage as well as age that is important in pubertal development and that in some cases they could start at 12. His views echo those of Jay Stewart of Gendered Intelligence who also wants to lower the age for accessing hormones and surgery.

The Nottingham clinic was awarded the contract for the East of England pilot service. It opened in Cambridge in June 2021, run by nurses and GPs with a satellite clinic in Norfolk soon. The nurses and GPs will be trained by the Nottingham gender clinic. Gendered Intelligence is running the daily helpline service there too.

Pilot gender clinics

In a move to shorten waiting lists NHS England has opened four pilot gender clinics, based in London, Manchester, Cheshire and most recently the East of England. They operate with the same guidelines as the 7 established clinics and offer non-surgical treatments. In theory, a patient can self-refer but at present the pilots are mainly taking patients from existing waiting lists. The Cheshire clinic is run by neighbouring clinical commissioning groups; Manchester by a partnership of a not-for-profit healthcare provider and the LGBT Foundation; the London clinic is run by the sexual health clinic, 56 Dean Street, which is itself part of the Chelsea and Westminster NHS Trust.

John Stewart from NHS England told MPs on the Women and Equalities Committee in May 2021 “It was very disappointing that, during that tender process [for the East of England service] we did not manage to attract any new bidders willing to provide new and additional services to support these patients.” There was no explanation for this fact.

He explained “assessments will usually comprise two appointments; an emphasis on shared decision-making with the patient; and a real focus on preventing unnecessary intrusive physical examinations… clinicians should not expect, from a patient self-referring, an inappropriate, unnecessary amount of detail.”

Leigh Chislett, the Clinical Manager at 56 Dean Street at the same hearing told MPs “we have seen 177 people for a first assessment and 163 for a second. We have referred 37 people for gender-affirming surgery and 78 for epilation, which is a service we have set up from Dean Street as well. Thirty people are currently having psychological input that they have chosen, and 76 are having speech and language therapy.”

Chislett described the Dean Street service as an “extremely lean model.” After the initial appointment with a nurse, “Two to three weeks later, should they wish to proceed, which most do, they will see our medical doctor or one of our psychologists, and that is where they can get their gender dysphoria confirmed… At Dean Street, if the gender dysphoria is confirmed between the client and the doctor, they get their hormones on that day.”

Unfortunately, the MPs didn’t ask for the breakdown by sex of those accessing the Dean Street service. The figures for the take-up of epilation and speech therapy suggest trans women are significant users of the service.

Leigh Chislett told MPs the feedback so far has been positive. This is hardly surprising as the pilot clinics, like the 7 older clinics, operate within an affirmative framework not a diagnostic one. Patients arrive at all these clinics with a diagnosis as ‘trans’ either by GP or self-referral. This is of particular concern as we will see below because the age at which patients can be seen is 17. With just 2 assessments required by the treatment pathway and the pressure to deliver a lean, one-stop shop it is likely that many co-morbidities and background circumstances will not be explored.

The Cheshire and Merseyside Adult Gender Identity Collaborative, CMAGIC, currently employs the trans activist GP, Dr Adrian Harrop. He told Vice News “I have well over 100 people who I supervise the medical treatment of, including gender affirming hormone therapy.” It’s not known if Dr Harrop has had any specialist training in psychotherapy or endocrinology for this role. Like the other pilot clinics, they prescribe hormones on the second appointment.

There is a growing discourse against the use of any talking therapies for gender dysphoria. Simona Giordano, a medical ethicist at speaking on a webinar organised by the Institute of Medical Ethics in September 2021 asserted that therapy was known to be “unhelpful” or “damaging.”

Lisa Littman speaking at a webinar on October 7^th explained the logic that might lead to such assertions. Those who believe in innate gender identity, as gender clinicians must do, believe in “one cause and one treatment” that the biosocial context is unimportant, and therefore psychological issues are likewise unimportant.

The “psychological input” referenced by Leigh Chislett above should not be confused with open-ended neutral therapeutic investigation. Once in the system at a gender clinic it is a one-way street, treating and affirming the idea of transition. Psychological input is most likely to be help with being trans rather than an exploration of mental health issues. Some activists say any therapy as harmful, recasting it as conversion therapy.

The push to primary care 

There has been a constant demand from gender healthcare activists for GPs to take over the role of specialists at gender clinics. The Royal College of GPs is cautious about such a move. The pilot gender clinics have fewer specialists on their teams than the established gender clinics. While the Exeter clinic employs 3 genitourinary consultants among many others in its multi-disciplinary team, the 56 Dean Street has a titular clinical lead and just one medical consultant. The move to make primary care take responsibility for hormone prescriptions and referrals for surgery will see a further dilution of specialist care. It’s hard to see busy GP practices picking up these complex cases and getting better outcomes than the admittedly poor results of the GDCs.

GPs are also being targeted by trans activist groups in other ways. As part of the government’s LGBT action plan the Pride in Practice programme was rolled out in Manchester under the management of the LGBT Foundation. A further pilot scheme began in London in 2019. It works as a “quality assurance and social prescribing programme that strengthens and develops primary care services’ relationships with their lesbian, gay, bisexual and trans (LGBT) patients.”  The LGBT Foundation claims it’s reached 2.1 million patients who are registered in Pride in Practice GP surgeries. According to their website, 100% of trans patients at GP practices in the scheme say that their GP was supportive of their gender identity and their medical transition.

The problem is not that GP surgeries are being encouraged to treat LGBT better but that the LGBT Foundation is itself a campaigning body not a healthcare provider. They actively support moves to bring in a legal ban on conversion therapy, they welcomed the Appeal Court decision in the case of Keira Bell v Tavistock saying “Puberty blockers are essential treatment for many young trans people and especially for those questioning their gender identity. They are a reversible treatment, giving young people more time to decide what is right for their wellbeing.” They are part of a group taking legal action to remove the charitable status of the LGB Alliance.  Recently they replied to the Health Secretary Sajid Javid’s factual tweet restating the biological fact that only women have cervixes, saying it was “a matter of deep concern at a time when the bodily autonomy and healthcare of trans, non-binary and gender diverse people are being undermined. It also goes against scientific fact, contrary to what Mr. Javid himself claims.”

Sajid Javid must decide for himself if Pride in Practice is something the NHS should be promoting and ask if the LGBT Foundation is a fit body to co-run the Manchester pilot gender clinic, given their views on puberty blockers and human biology.

Concerns for the 17-25 year-olds

The Exeter study found the median age for referral to the clinic for natal males was 36, but for natal females it was 20. They had been referred between 2010 and 2017 which is the period that saw the reversal of the sex ratio for referrals to the Tavistock GIDS clinic with the historically unprecedented rise in teenage girls being treated there.

Teenagers can self-refer or be referred to adult services once they reach 17. Whether they attend one of the larger clinics attached to NHS mental health units or the smaller pilot clinics, the treatment pathway will be the same: hormones after 2 visits, surgery referrals, epilation, voice coaching, and psychological support, rather than therapeutic investigation.  Trans lobby groups like Gendered Intelligence and Mermaids will be on hand to provide support.

If they attend the Exeter clinic they will be treated according to the conceptual model of innate gender identity theory. Exeter’s website states “An individual’s awareness of gender identity, and the emergence of a range of gender-typical behaviours, is usually established by the age of two to three years. The earliest features of gender incongruence may start to become apparent around this age.” This is misleading as there is no evidence for a ‘gender identity’ at that age when children do not even have the conceptual ability to understand that biological sex is constant.

The vulnerability of this cohort is already a matter of great concern, not least because it’s the age at which many young people leave home for the first time. Recent developments in neuroscience show that brains do not reach full cognitive function until around the age of 25. In addition, research on the growing number of detransitioners shows that many only decide in their early twenties that transitioning was the wrong solution to the problems they faced as teens or young adults. Both Keira Bell and Sinead Watson have spoken about the lack of psychiatric care they received before being given irreversible hormone treatment. This is precisely the group of people who are most in need of the “inappropriate, unnecessary amount of detail” dismissed so casually by John Stewart of NHS England in his evidence to the Women and Equalities Committee.

It’s unfortunate that the Exeter study does not include any data on sexual orientation, because it’s highly likely to follow the same pattern as the children’s service. Detransitioners are likely to be same-sex attracted, and likely to have suffered homophobic bullying before identifying as trans. 17-25 year olds need more time and better therapeutic help, not a one-way ticket to make permanent changes to their bodies.

Conclusion

NHS adult gender clinics need their own review similar to the Cass review which is looking at treatment pathways for gender dysphoric children. The Exeter study shows the need for more consideration to be given to the complexity of the patients, to mental ill health and drug abuse during a longer assessment process. Gender clinics should be required to keep and publish data to show their outcomes. Trans rights activists should not be contracted by the NHS to offer advice or services. Gender dysphoria should be treated like any other health condition, subject to normal oversight and free from political agendas.

Finally, detransitioners should be asked what sort of services they need to undo some of the damage caused by over hasty hormone prescribing. The NHS will have to build bridges with this group who have been harmed by a service unduly affected by political activism.

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[1] Information from the twitter account @tribunaltweets