Kids on the Edge: The Gender Clinic was a documentary on the work of the Tavistock and Portman gender clinic in London, aired on Channel 4 on November 16th. The programme was devastating and heartbreaking in equal measure, not least because of the statistic that half the number of children being referred to the Tavistock show autistic traits. Is this alarming statistic being investigated? There was no indication that it was, or will be. Is that it then, for ASD kids, no further investigation needed?
Two themes emerged as the backdrop to the stories of two distressed children, Ash aged 8 (a natal boy), and Matt aged 11 (a natal ASD girl), and they are interrelated. The first was the defining distinction between boys and girls as cultural (“gender”) rather than biological (“sex”), with all the attendant confusion that causes. We see gender stereotypes of behaviour and appearance unconsciously and unquestioningly reinforced by adults throughout the programme: what would happen if these kids were encouraged to challenge them?
The second was the reversal of roles in the adult-child relationship; the adults occupying a child’s fantasy world of magical thinking as reality (specific examples include references to becoming a “real boy” through hormone treatment and the question put to a natal boy by the narrator “Do you think you’ll be a girl forever?”), while the children occupy the role of fully autonomous mini-adults, capable of making mature decisions on complex issues. These are both recent broad cultural changes, not specific to the people involved in this documentary; the idea that children can choose their “gender” has followed on naturally from a child-led parenting culture in which children are seen to be the authority on themselves, given choice and responsibility and deferred to by the adults.
It was hard not to reach the conclusion from watching this programme that we are prolonging the agony of these families by holding out a possibility which does not really exist and certainly not in the way it appears to the children. Ash got a taste of the reality of future life when attending a new school in “stealth” as a girl, only to find that “she” was still hiding the secret of who she really is: a boy. Reality is hard, but do we try to equip children to find their resilience to cope with it or do we try to change the world to fit them? Holding out a promise to children which involves such a level of cognitive dissonance and suspension of reality for everyone is a shaky foundation on which to build a therapeutic relationship.
What would dedicated services for these children look like if the adults started off from a position of “this is the reality: now let’s look at ways we can help you deal with it.” Perhaps this is the “certainty” that everyone is looking for, as Polly Carmichael comments:
“We don’t really know whether this is the right treatment for everyone, whether there are long-term implications for this treatment, but for families and young people it can be very difficult because they are seeking certainty. But the reality is that at the moment we don’t have that certainty.”
“Certainty” about identity is something we can never possess when we are talking about children or adolescents whose development is not complete and whose identities are not yet formed. We can only ever know if an immature childhood identity is long-term once a child has grown up and matured into an adult. The problem with a diagnosis of “gender dysphoria” is that the treatment itself, from social transition to blockers to hormones, will influence the outcome. This is the dilemma parents face when presented with a treatment which may alleviate a child’s distress short-term but fix a child in an identity they otherwise may have grown out of during the course of adolescence.
A one-hour documentary obviously can’t give us the full picture, either about the Tavistock or the children and families involved, so we can only make observations based on a tiny snippet of the story. From this snapshot, all players in the drama were sympathetic characters; the Tavistock clinicians were careful and cautious and the parents came across as typical parents caught up in, and struggling with, a very atypical scenario. Any parent with a very distressed child would understand their confusion, the desire to fix things and make it right for their child, and their guilt (“Was it something I did? Did I make her like this?”)
Our observations about details of these personal stories are not intended to be critical of the parents, with whom we have great sympathy, but only as indicators of the wider cultural factors which were not examined in the programme (we don’t suggest that the Tavistock has not addressed them, just that there was no evidence of this in this documentary).
Dr Polly Carmichael of the Tavistock summed up the problem for parents in this comment:
“Awareness has raised exponentially over the last year and in some senses culture and society are moving faster in terms of what they think they understand about it and what they think we should do about it than the evidence base.”
The way that culture and society have been moving has been in the adoption of a new hypothesis of gender, from understanding it as a culturally constructed idea about how girls and boys “should” behave according to stereotypes of masculinity and femininity, to the idea that it is an innate and fixed part of our identities. We have also applied this hypothesis to children for the first time and developed “treatments” to fix it, placing “gender” as the immutable reality and biological sex as changeable. We have begun to do this in the absence of any evidence that there is anything “wrong” with these children biologically or neurologically and with no long-term evidence base that the treatment is effective.
To be in the position of having to make this decision is an unenviable one for parents but it’s especially worrying when the decision is handed over to the child. Of course, a child needs to be informed and their view ascertained before any treatment, but really how can a child begin to understand the complexity of this issue, the life-long effects of treatment which even the adults don’t know, and the reality of life as a transsexual adult?
There was a telling interchange between Polly Carmichael and Ash which demonstrated this autonomy afforded children, of which Ash is fully aware and knows the script:
Polly Carmichael: “It’s your life, your body..”
Ash: “My decisions!”
Polly Carmichael: “And your decisions. Absolutely.”
Professor Butler, a child hormone specialist and leading endocrinologist acknowledges:
“… they have to get their head around the whole process of what it means, it’s a hard concept in any case for an 11/12 year-old to take but particularly if there are other distresses around.”
“If someone is 11 going on 12 they really need to be able to understand the concept to the level of maturity we’d expect for a nearly 12 year-old but also a knowledge about what it means by going on a journey which might end up changing their body permanently.”
Professor Butler was talking about the particular difficulties for an autistic child, but really, what nearly-12 year-old has the level of maturity to understand the implications of this pathway?
Here’s Polly Carmichael explaining blockers to Ash, who is eight:
“So what the blocker does is it jams the signal coming from your brain telling your body to turn on testosterone. It won’t make your body more female. Would you be someone at the moment who thinks they’d like to have the female hormone – is that right, is that what you’re saying?”
“And I guess that’s a really big decision because that’s taking you down a path that you can’t come fully back from.”
Ash doesn’t care. Ash is a child. Children and adolescents can have no conception of future change or regret; every child and adolescent thinks they know who they are and that this will never, ever change. Children also trust adults not to harm them; they have no ability to place themselves in the wider perspective that comes with maturity, and no ability to analyse their own influences and motivations.
There were aspects of both these cases which would have presumably rung alarm bells if the idea of “transgender kids” was not pushing out every other therapeutic analysis.
Particularly worrying was the precocious and in some part sexualised nature of Ash’s behaviour: putting on a full face of make-up, including concealer, foundation, eyebrow liner, mascara and lipstick, wanting Mum to feel the “lumps” of imagined developing breasts, kissing a boyfriend on the lips, wanting a womb transplant in order to have a baby in the future. Here is a child who “Googles everything” and has had access to online content which a child cannot distinguish between information or propaganda (what has this child learned about being transgender through Google?) The resultant behaviour is not the common behaviour of an eight year-old girl, but of a child prematurely exposed to an adult world which he cannot understand or process.
The most glaring elephant in the room though, is the boyfriend. Ash likes boys. The overwhelming likelihood is that Ash will grow up to be a very flamboyant gay man. Given that we know these statistics, why are we not concerned that affirmation and reinforcement of a “girl” identity is gay conversion therapy by another name?
The case of Matt is particularly distressing in its exposure of the bullying faced by an autistic child at school. Matt initially did not want to be labeled “girl” or “boy” which in any child’s world mean distinct gender stereotypes of behaviour and appearance. It seems clear that the most relevant factor in Matt’s development of a “boy” identity was the bullying from classmates which came out of Matt’s refusal to correctly perform a “feminine” gender role. Matt is forced to make a choice between two gender stereotypes and chooses the one that best fits. In this case, the bullies have won and they will continue to win as long as we believe that it’s gender which marks the distinction between boys and girls and not biological sex. How can we address the bullying which results from gender stereotyping if those gender stereotypes are accepted as the definition of “boys” and “girls”?
It is of huge concern that the school in question was not involved in the support of this child (as far as we were told), nor the connection made that opposite-sex identification can develop through external influences, rather than being “innate.” Polly Carmichael does allude to this possibility in the following statement:
“If we create a narrative where it’s the end of the world if you can’t fully be seen to be a particular gender, if there are things that perhaps don’t quite fit then I wonder what sort of message that is that we’re giving – how far are the physical changes one seeks motivated more around feeling that you fit in and are accepted by others?”
She also acknowledges the doubts around the role of gender clinics:
“There are sometimes dilemmas around thinking “gosh, just what are we doing?” just knowing there isn’t a right and a wrong and no-one has the answers and this is an evolving picture really with many voices contributing and all we can go on really is the young people who have taken this route that it’s been the right thing for them to do.”
Apart from the fact that there exists no research on how long children continue to believe that it was “the right thing for them to do” (it is only over the last five years that puberty blockers have been used at the Tavistock), there is an established “right and wrong way” of treating children, which is not to sterilise them unless sterilisation is an inevitable result of life-saving treatment. Blockers and hormones should be a last resort treatment, used only after extensive support and counselling of these distressed children, based on the knowledge we have that becoming a transsexual adult is the least likely outcome, not the default.
Polly Carmichael again:
“There are very strong arguments on both sides, there are people who really would like to see earlier physical interventions and there are people who feel that it’s absolutely mad to be allowing young children to change their bodies in a way that’s not fully reversible. I think in the middle we’re really cautious about what we do.”
To be clear, earlier physical interventions for children are only advocated by trans activists and transgender advocacy organisations; it is the rest of the world who feels that this is “absolutely mad.” The Tavistock is caught between the two and from the evidence of this programme they are cautious. The problem lies in the fact that they can only exhibit caution within the already-established “gender identity” belief system; they cannot step outside and throw out the whole theory.
One thing is absolutely clear: this new “treatment” for children is a complex social, political and ethical issue: children cannot be given the responsibility for making the decisions around it; that is a job for us as a society, as parents, as health professionals, as ethicists, as politicians, as adults.