The Hot Topics in Child Health conference on June 12 brought together leading professionals from across Europe to share their expertise and research in the area of ‘transgender and gender diverse children and adolescents.’ Given the recent publication of rising child referral figures from the Tavistock clinic this year, this was a timely and important event.
Professional knowledge, evidence and research formed the basis of a conference which, although focused on clinical and medical expertise, did not shirk examination of the more complex ethical and political aspects of childhood transition. In fact the overriding theme of the day was perhaps the point at which social and political change meets clinical care of children, and the ethical considerations this engenders. Tavistock Consultant Clinical Psychologist Dr Bernadette Wren’s thoughtful talk in the afternoon was an examination of the clinician’s ethical responsibilities in an area where recent developments, such as social transition of progressively younger children and the ‘affirmation’ approach, are new ideas driven by social change rather than by evidence.
The question lies specifically in how far these social changes help or harm children and adolescents who are ‘gender diverse’ and those whose ‘trans’ identities may not be permanent. The question of how social transition and puberty suppression influence the outcome for gender dysphoric children came up in several presentations, as did concerns about the closing down of options such as fertility preservation for those who progress to cross-sex hormones.
There were also questions about the huge jump in referrals of teenage girls to the Tavistock, the group most likely to both suffer associated mental health problems and to progress to adult services. Absent an agreed etiology for ‘gender dysphoria,’ the question implicitly raised about these young people is: are they really ‘trans’ or are they simply non-conforming young people who have been presented with a new way to conceptualise their problems and a new tribe to join which provides them with acceptance and approval?
The issue was inadvertently touched on by Professor Stephen Whittle of the Manchester Law School, showing slides of young people with slashed arms and commenting that this “didn’t happen in my day because it wasn’t presented as a possibility” and that “now kids learn quickly from social media.” It is only political sensitivities which prevent us from considering the same explanation for the sudden unprecedented number of teenage girls who bind their breasts and identify as boys.
Professor Katherine Johnson, Reader in Psychology at Brighton University, showed slides of interviews with young people which were revealing of what a ‘trans’ identity means for teenagers: “Cis people think you should conform” said one interviewee. The binary of ‘cisgender’ and ‘transgender’ has come to represent ‘conformity’ v ‘non-conformity’ in the minds of young people: is a trans identity now the only way for teens to distinguish themselves as not conforming? In which case, what self-respecting teenager would want to identify as ‘cis’?
To debate these issues openly is crucial. Teenagers can potentially go straight onto an invasive medical treatment pathway which is so new that the long-term effects are unknown and which leaves them with permanent body changes even if they change their minds later and decide to stop treatment. Very few younger children diverge from the pathway once they are on it and we don’t yet know how puberty suppression affects cognitive development, nor the physical or psychological effects of a cross-sex puberty.
The professionals with decades of experience working in the field were consistent in their emphasis on how much we still don’t know, as well as very informative in their presentations of facts, statistics and clinical experiences. What came across most clearly was their desire to help genuinely gender dysphoric children whilst at the same time bearing the enormous responsibility to judge whether to medically intervene in the cases of children who are gender non-conforming but may grow up to regret serious body alterations which they cannot reverse: caught ‘between affirming and gate keeping’ as Director of the Gender Identity Development Service Dr Polly Carmichael put it.
Two speakers mid-morning took us into the actual nuts and bolts of those body alterations and what it actually means to physically transition. These were both valuable presentations of the reality that children face in the future if encouraged onto a path of medical transition. First off, Dr Kelly Tilleman of Ghent University Hospital, in her talk ‘Fertility Preservation,’ gave us a run-through of the options for storing gametes (not often taken up) and tissue transplants (possible with ovarian tissue but not (yet) with testicular tissue) with a nod to surrogacy and the potential uterus transplants of the future.
This talk was followed by Dr Mark Bram Bouman, Plastic Surgeon at the VU University Medical Centre, Amsterdam, who gave a factual account of penile inversion (with and without skin grafting), intestinal vaginoplasty for the patient whose penis has not grown after puberty blockers (“the material is not there”), phalloplasty (forearm flap, thigh flap, groin flap or double flap) and mastectomy. Graphic videos were shown of genital surgeries which although perhaps nausea-inducing for adults would probably not be for most teenagers with their higher threshold of tolerance for shock and gore. In fact, these videos would probably do very well on YouTube in the ‘medical transition’ niche.
In the absence of any ethical considerations, the factual and matter-of-fact presentation of both speakers created a sense of normalcy which exacerbated the feeling of emerging from an alternative universe when it was all over. There are probably not many people who would truly wish to see this invasive surgery, previously reserved for a tiny minority of transsexual adults, become a normal means to ‘confirm’ a young person’s identity, nor feel a lack of concern regarding the loss of fertility for these young people.
Peter Tatchell’s human rights rallying call after lunch felt incongruent after we had seen the sobering reality of what is actually done to the bodies of young people who ‘persist’ in gender dysphoric feelings. It was out of place in an event specifically about children and which was otherwise encouraging of alternative viewpoints. Who would dare raise any objections to the ‘affirmation’ approach after his tirade against ‘transphobia’?
The presentation by Mrs Terry Reed, Trustee of the Gender Identity Research and Education Society (GIRES) in the morning similarly jarred in its certainty that transgenderism has a biological cause, during an event where professionals consistently emphasised the uncertainty in both the explanation for, and the treatment of, gender dysphoric youth.
It begged the question of the place of advocacy groups at a medical and clinical conference such as this. Three of the breakout workshops after lunch were led by such groups, GIRES, Mermaids and the Intercom Trust, all groups certain of the need to ‘affirm’ trans-identified children (although GIRES and Mermaids must be given credit for their part in the organisation of this thoughtful conference). But if those who passionately advocate for the affirmation of trans-identified kids have a platform, in the interests of balance perhaps the voices of those who equally passionately defend the rights of ‘gender diverse’ kids to remain gender diverse should also be heard.
Terry Reed’s certainty of the benefits of unquestioning affirmation and social transition was in stark contrast to the uncertainty expressed by clinicians in the field. Dr Polly Carmichael in the morning had stressed that social transition is very new and has come about through social change, not through research and evidence. Children are now socially transitioning at a much earlier age and there is no consensus amongst professionals on the rationale for giving puberty blockers. Very few children in the early intervention clinic stop treatment once they start on blockers, a point reiterated by Dr Bernadette Wren later in the afternoon and developed further with a list of reasons why we need to be cautious:
“There is increasing concern about puberty suppression and the risks and uncertain outcomes. They may affect gender identity development by increasing the likelihood of persistence. We don’t know the long-term effects on cognitive development, sex organ development and so on.”
Dr Wren pointed out that gender non-conforming behaviour, as well as a wish to be the opposite sex, is a common developmental variant and that children with confused identities nevertheless hold their beliefs with extreme conviction. Dr Wren also referenced other underlying factors in children and young people’s gender dysphoria. Of the overall figure who were tested at the Tavistock since the clinic began, 51% have clinical range autism traits.
Rapid onset gender dysphoria amongst teenage girls with associated difficulties such as ‘social disapprobation, disrupted early attachment, early abuse and neglect’ is of particular concern. Given that “The adolescent’s developing brain is generally more limited than the adult brain in its ability to weigh up the long-term consequences” are we expecting young people to make decisions “even without an extensive grasp of the possibility of future harmful regret?”
Dr Wren also raised the issue of influences on a child from people who “inevitably shape their views, select and present evidence to them and interpret their options” and wondered how we can be sure of the authenticity of any young person’s choice of treatment when “some support groups and online sources widely communicate to young people their conviction that transition is essential.” Support groups such as Mermaids, GIRES and the Intercom Trust for example?
Professor Gary Butler, Consultant in Paediatric & Adolescent Medicine and Endocrinology at UCL made clear that the biological investigation of ‘trans’ children has not revealed anything abnormal and that medically we should approach the care of young trans people as only needing to look after their general health. Endocrine tests for children referred to the Tavistock show that there is no difference between gender dysphoric children and the control population: they are physically 100% normal. He also pointed out that true gender dysphoria is still very rare.
One of the leading researchers in this area, Thomas Steensma from VU University, Amsterdam, confirmed in his afternoon presentation that there is ‘no true data’ to support an ‘affirmation’ approach above one of ‘watchful waiting’ and that only a minority of gender dysphoric children persist in those feelings: even with long-term persisters, 20% eventually desist. Social transition, he cautioned, is very difficult to come back from, citing the case of a girl who waited two years to ‘transition back.’
Dr Steensma pointed out that a recent study from the US which showed positive functioning after social transition gave no information about how these children were doing before, so the results cannot show that social transition results in improvement in psychological functioning or other variables.
The crucial period for desistance / persistence is 10 -13 years. It should be of great concern that a crucial deciding factor is the emergence of sexual orientation and that same-sex attraction is taken as confirmation of cross-sex identity by these young people. Given that persistence is more likely in both the older age group and for girls, what does this say about the level of lesbophobia in society that so many young lesbians are transitioning to a ‘straight’ identity?
Dr Steensma stressed the ‘need to be balanced and honest,’ admitted that ‘we don’t know a lot,’ advised that ‘we should keep all possibilities open’ and suggested a less prescriptive approach:
“It is OK to be ‘more boyish’ or ‘more girlish’ without labeling ‘boy’ or ‘girl.'”
Before the final summing-up by Dr Carmichael and Professor Butler, the conference concluded with Tavistock Consultant Clinical Psychologist Dr Sarah Davidson’s sensitive interviews with three brave young service users willing to talk about their different journeys, including one who had felt regrets about transition and now identifies as non-binary.
Anyone who looks out for such things may have noticed that throughout the conference there were three mentions of past sexual assault or rape of females who subsequently suffered ‘gender dysphoria,’ as well as other cases of unspecified childhood trauma and troubled backgrounds. These cases alone are reason enough not to take a ‘trans’ identity at face value in place of the normal duty of care to assess children on a case-by-case basis and make space for exploring underlying issues.
Ultimately the take-away message from this conference was the need for caution as well as more research and evidence. It was reassuring to know that in the UK clinical research is ongoing as a fundamental part of the NHS Gender Identity Development Service and to see evidence of the thoughtfulness and integrity of the clinicians involved.
Within the current climate of media-generated hyperbole, sensationalism and cheer leading on the one hand, and political silencing of debate on the other, this conference managed to create a space for thoughtful reflection where diverse views were respectfully heard. The Royal College of Paediatrics and Child Health and all the organisers of the conference are to be congratulated for this unique achievement.