A report on the BAGIS Scientific Symposium in Durham, October 3 – 4 2019
by Susan Matthews
‘My musings on my last thread really reminded me of how angry I really am at my old therapist. No real encouragement to stop dissociating from reality. No real encouragement to accept who/what I am. As long as I can *pass* & *look* convincing it’s all good and a success, right?’
(Tweet from a detrans woman, 08.10.2019)
The need to pass & look convincing could have been the motto of the 2019 British Association of Gender Identity Specialists (BAGIS) Scientific Symposium which I attended. The conference opened with an address from outgoing president James Barrett, lead clinician at the London NHS Gender Identity Clinic, whose plan for the future of the UK gender profession involved looking ‘official’, ‘established’, ‘normal’ and professional:
You might expect that a professional organisation would be official, established, normal and professional. But this symposium was titled ‘Navigating the Seas of Change’ and Barrett was acutely aware of an increasingly critical social context. The ‘Plan ?’ (according to a not very professional slide) was to occupy a position bang in the centre of the Overton window – a term coined to describe the range of opinions within which politicians can plausibly advocate within any society.
‘A Professional Association’, Barrett insisted, ‘needs to not look like a campaigning organisation’. Odd then that the ‘Overton window’ is a term from the world of politics. 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.
Of course navigating the seas of change is bound to be tricky and the recent meteoric rise in referrals had changed the context. Barrett’s own views on incidence have clearly also altered. In 2011 he wrote that ‘the incidence of transsexualism is very roughly 1 in 60 000 males and 1 in 100 000 females, and it seems to have remained constant’ but now he believes that referrals have reached a ‘natural and finite ceiling’. Whereas provision was in the past offered on the basis of exceptionalism, he suggested, now gender services were
‘on the brink of becoming routine NHS business. And that brings with it security and scrutiny. That brings with it limitations and scrutiny.’
Scrutiny, according to Barrett is ‘not necessarily a bad thing.’ (That ‘necessarily’ is telling.) In this new climate, Barrett believes that the profession needs to play safe: ‘All it would take is an inauspicious prime minister and minister for health and we could end up with no more child and adolescent service and a severely curtailed adult service’. Barrett warned that ‘a strident approach’ would not be ‘that productive’. He counselled against pushing the envelope of acceptability and said that practice guidelines must reflect the limits of the possible in current UK society. (I almost expected Barrett to announce that it was time for a bit of ‘Real Life Experience’ for the gender professional).
Through the two-day conference, the lack of evidence in the field of gender medicine was a recurrent theme. A presentation on ‘Global standards for assisting with Gender Diversity’ by Professor Christine Richards (head of psychology at the GIC) argued that in the absence of evidence, protocols needed to be based on expert opinion and negotiated in terms of different cultures and levels of social acceptance across the world. So what is expert opinion?
Leighton Seal, speaking on ‘New professional training pathways in the UK’ noted that training involves handing on clinical wisdom from one generation to the next. The Royal College of Physicians course that is being developed will be delivered by gender clinicians with years of experience who will be ‘grandparented’ in to train a new generation. Gender medicine is dominated in the UK by a relatively small band, several of whom are now approaching retirement. This was the familiar problem of ‘succession’. (Odd how reproductive metaphors dominated this discussion given that gender medical interventions often privilege identity over fertility).
Although resistance to medical intervention has focused on treatment of children and adolescents, this controversial area of practice was not foregrounded. According to Seal, the Royal College of Physicians had only agreed to host the postgraduate diploma in gender on condition that treatment of under 18s was excluded: this condition had been non-negotiable.
A workshop on ‘Diverging Models of Care for Children and Adolescents’ run by Polly Carmichael and Claudia Zitz from the NHS Gender Identity Development Service (GIDS) invited participants to imagine what an ideal service for children and young people should look like. The session opened by asking participants to consider ‘Who should decide whether a twelve year old gets early intervention?’ We were told not to get ‘too hung up’ on the nature of the physical intervention but instead to place ourselves on an imaginary line stretching between those who felt the decision should be led by the child and family and those who believed it was a decision for professionals.
When I said I wasn’t keen on early intervention, Polly replied ‘Be creative!’ – refusing medication in the current context required a bold flight of fancy. And when I took up a position slightly to one side of the professional end she smiled and said ‘You’re quite close!’ Already I was part of the team, wrestling with the ethically taxing work of the GIDS as part of a band of concerned clinicians. In tune with Barrett’s ‘Plan ?’, the session sought to locate the GIDS at the mid point of the Overton window.
It’s clear from this conference that the gender critical position is now – perhaps only in the last twelve months – within the Overton window. Professionals know that concern about the irreversible medication of children is widespread. So the GIDS workshop offered slides on two positions which it implied represented two extremes: the affirmative approach of the US West Coast contingent led by Diane Ehrensaft which Carmichael correctly identified as representing gender essentialism and in the next slide, the gender critical position.
This accurately represented the key concerns (change of sex ratio, role of trauma, sexual orientation and bullying, social contagion, autism) and I was invited to explain what critics meant when they said that the ‘Transgender Child’ was an invention. I was struck that for the most part the workshop members voiced more affirmative positions than Carmichael. One spoke of the right of a child to self-determination, one thought that becoming pregnant was a more significant life choice than changing gender, another felt that definitive evidence would always be elusive. After all we can never know whether our life decisions are correct for we have no point of comparison.
After an apparently neutral account of the gender critical position, GIDS professionals rallied to the support of the current approach. The workshop explored the feelings of participants, our sense of social acceptability. It rested on the assumption that the medication of twelve year olds was a done deal and constructed the current approach as a cautious middle way. This was an exercise in building consensus.
It’s worth thinking, though, what the workshop omitted. When I mentioned the launch of the detransition advocacy network I was told first that we would be covering this topic later and then that this was a hugely complicated issue that needed a session all to itself. The question of the evidence base came up several times. ‘We have looked at the evidence base’, Carmichael reassured us. But she also admitted that the numbers don’t exist for ‘calculations which have much power’. GIDS would certainly be mindful of emerging evidence but ‘don’t have research base predictors of which pathways people might take’.
GIDS recognizes that ‘hormone treatment can be a process of exploration’ but may also be ‘a foreclosure of future possibilities’. The ‘idea of the blocker was around alleviating […] distress in order to create a place for further exploration’ but ‘the truth is there is a lack of an evidence base that this is always reliably achieved through speedy intervention’. It sounds great that the work of GIDs ‘can be characterized as curious and exploratory’ until you reflect that some young people will be living with the unknown outcomes of this curiosity for the rest of their lives. The line between a frank avowal of known unknowns and straightforward negligence may be a narrow one.
BAGIS was founded in 2014 to promote ‘clinical research and exchange of knowledge of gender dysphoria and transgender health’. The homepage is packed with reassuring references to ‘clinical research’, ‘clinical practice’, ‘excellence’ ‘best available evidence’ and ‘evidence based clinical practice.’ The problem, as evidenced by the 2019 BAGIS ‘Scientific Symposium’ at Durham, is that these claims are hard to substantiate.
There were certainly valuable presentations. Kate Nambiar’s paper on ‘Cervical screening cytology in transgender and non-binary patients compared to cisgender women’ revealed that young people who deny the sexed nature of their bodies often avoid the HPV vaccine as well as smear tests. This can harm health leading to levels of cervical abnormality higher than in other women.
But for a two-day conference, this one was light on content. Over a hundred NHS and private surgeons, gender clinicians, researchers, nurse practitioners, counsellors, trainees and famous trans pioneers had signed up. Many attended in groups: the Tavistock and Portman GIC was out in force with 26 delegates. From GenderCare we had Stuart Lorimer (loved by young trans men and celebrated by tattoo on the neck of one). Christopher Inglefield was there from the private London Transgender Clinic. But this was more of an occasion for networking, boosting morale and refining strategy than for sharing research. After the non-binary cabaret, disco and pay bar at the end of the first day, speakers regaled the company with jokes about hangovers. A brave band of pioneers needs to let its hair down.
I arrived with a mental bingo card of words (ROGD, detransition, regret, randomized controlled trial, Littman) and left with my card for the most part unmarked. The rise in referrals was presented by Polly Carmichael as a sign of decreasing stigma, of the commendable willingness of young people to explore gender identity and of the sterling work of support groups. There were no presentations on long-term outcomes. It was taken for granted by the assembled company that therapy is both inappropriate and ineffective for gender dysphoria. ROGD was mentioned to collective hilarity by Christine Burns.
When I asked a speaker to compare the methodology of her convenience study of 15 supportive partners of transitioners (conducted with a counsellor from Gendered Intelligence) with the Littman study the response ignored the word Littman. The study of supportive partners was valid because it was telling a story which wasn’t often covered – which to me sounds more like supportive journalism than an academic study. I did not hear the phrase ‘randomized controlled trial’.
The finding that around 4% of the trans masculine patients accessing mastectomies at Parkside hospital were diagnosed with (treated) schizophrenia elicited no comment: in the UK the lifetime prevalence of schizophrenia and schizophrenia-related disorders is more like 1%. What was important, we learned, was that the private Parkside does not need to compete for resources with breast cancer patients and is conveniently located for Tavistock GIDS patients. I didn’t really need to know that one surgeon held the record for the weight of breast tissue removed (5 kilos).
Trans veteran Christine Burns ended her talk with a rousing call to the assembled clinicians to stand with trans people: ‘Please, we need your help. Stand up for us.’ BAGIS clearly is a ‘campaigning organisation’ committed to standing up for trans people. It’s understandable that clinicians have an interest in protecting both their clients and their own reputations. But this commitment runs counter to scientific openness and requires the silencing of detransitioners, of skeptical parents, and critical medical colleagues. The Overton window has shifted through the work of parents, feminists, therapists and detransitioners and is likely to shift further as more is known about long-term outcomes. This, then, was a conference playing catch up.
The session on trans in sport (which opened the second day) was a response to Fair Play for Women’s campaign to preserve female sports. The voices of Martina Navratilova, Sharron Davies and Paula Radcliffe haunted a presentation by a trans-feminine football player who described how female opponents avoided contact on the playing field. The coach of the opposing team rebuked female players with the words: ‘She’s not that frightening’.
Nor could Sunday Times coverage of the controversy over physical interventions for children be easily forgotten: Christine Burns asked the conference to consider ‘how to reform and take forward the profession without necessarily making us all vulnerable to another headline in the Sunday Times because we have enough of those’.
This was a conference constrained by a central belief system. Because a ‘cis’ clinician can only echo the terms and the conclusions of ‘trans’ people (no ‘cis’ person, we have to believe, has ever experienced ‘dysphoria’) a cisgender professional risks forgetting not only their training but their shared humanity when they become a ‘gender specialist’. Maybe this was why it seemed the most intellectually incurious conference that I have ever attended. Several presentations elicited no questions. Discussions focused instead on such technical issues as whether to remove all gland duct in a mastectomy.
Yet attendees must know that not all outcomes are positive. Plastic surgeon Christopher Inglefield is on record just last year as recognizing ‘The sad reality […]that some people will have regretted that decision [to transition] so much that they may end up taking their own lives and that’s a very very sad outcome but that does happen.’ (7.32) Over the door of the ex-Catholic college that hosted the event there might as well have been the words: ‘Abandon questions all ye who enter here’.