NHS Public Consultation on Gender Identity Development Service

We were recently informed of the NHS public consultation on Gender Identity Development Service (GIDS) for children and adolescents.

The consultation ends on April 20th.

There are two new documents open to public consultation: a Policy Proposition which concludes that cross-sex hormones should not be prescribed to children under the age of sixteen, and a Service Specification which makes no major changes to the way treatment is provided at gender clinics.

Both documents can be viewed on this page (scroll right down for the cross-sex hormones doc) and you can click on the Online Survey at the bottom of the page to respond. Or you can go straight to the consultation hub here.

We read through all the NHS supporting documents carefully and wrote a response to the Service Specification. This is a long read but please do take some points from this and submit your own response.

7. Does the impact assessment fairly reflect the likely activity, budget and service impact? No

“Growth rates are predicted to continue to rise, although the figure is likely to be less than the on average rise (50% per annum since 2009 to 2014/15 and 100% in 2015/16) as it is expected to level off. A flat figure of 20% over the next ten years is estimated.”

This statement does not differentiate between the percentage rise between girls and boys, specifically teenage girls. On BBC Woman’s Hour recently Dr Polly Carmichael of the Tavistock clinic described the rise in the number of teenage girls referred to the clinic over the past year as “phenomenal and unexpected.”

Body dysmorphia is common in teenage girls and has previously been related to a highly sexualised culture and impossible body ideals. The APA Task Force on the Sexualisation of Girls, published in 2007, detailed the effects on girls in terms of mental health problems, eating disorders, low self-esteem, depression and the undermining of “confidence in and comfort with one’s own body, leading to a host of negative emotional consequences, such as shame, anxiety, and even self-disgust.” Since 2007, mainstream culture has become more visibly sexualised and pornified and girls’ methods of dealing with distress have expanded into cutting and self-harm. http://www.apa.org/pi/women/programs/girls/report.aspx

Girls are now being encouraged through online trans forums to reinterpret their body dysmorphia as gender dysphoria. It may be that the number of teenage girls presenting to gender clinics will continue to rise at “phenomenal and unexpected” rates if these factors are not taken into account.

Do the NHS projected figures take into account the following variables:

The increased presence of transgender activist groups working with children in schools, as the government recommends, which will lead to more and more children interpreting their non-conformity to sex stereotypes as proof that they are really the opposite sex.

The increased training of teachers in the social transition of children (not recommended by the Dutch study, but again recommended in the government’s transgender inquiry report), which will condition more and more children who are still at the stage of magical thinking, into believing that they really are the opposite sex.

The continued and increasing transgender activism in online forums, on social media and in colleges and universities, presented as social justice activism, but operating like a cult which allows no dissent or questioning, which will continue to silence people, including health professionals who already fear for their jobs if they speak out.

The power of a highly organised and funded political lobby group to control public discourse through the mainstream media (with not one, but two organisations already regulating the press: Press For Change and Trans Media Watch), which will influence more and more parents, teachers and professionals who are prevented from hearing open debate.

The proliferation of “trans support groups” across the country for both parents and children, which allow no questioning of a “trans” identity but work only to reinforce it, including by use of the “suicide narrative” which has no evidence base, but which is used to scare parents and establish in children’s minds a “transition or die” mentality.

8. Does the document describe the key standards of care and quality standards you would expect for this service? If you selected ‘No’, what is missing or should be amended?

There is some confusion around the eligibility criteria for cross-sex hormones. The K4.2.2 Criteria for referral to the Paediatric Endocrine Liaison Team for hormone blockers in the early stages of puberty and/or under the age of fifteen lists this point: “The adolescent presents as relatively stable psychologically as evaluated through clinical observation and questionnaires.”

Section K1.2 states: ” To be in scope for cross sex hormones from 16 years plus or minus two months, clients need to have: f) been assessed as having the competency and autonomy to consent to the treatment.”

However, it is acknowledged in K2.2 that “a significant proportion of clients” have features of Autistic Spectrum Disorder (ASD) or who have a diagnosis of ASD or Asperger Syndrome, and the K4.2.3 Criteria for prescribing cross-sex hormones includes this point: “associated difficulties such as self-harm are not escalating or are being actively monitored and managed by local healthcare professionals.”

This raises questions: 1. How is the suitability of “gender reassignment” treatment for children on the autistic spectrum assessed, without further investigation into why this group is over-represented at gender clinics? and 2. To what extent can an adolescent who is self-harming or has other associated difficulties be described as “psychologically stable” or have the competency and autonomy to consent to unnecessary invasive treatments on a healthy body, with some irreversible life-long effects including possible sterility?

In fact, how can any adolescent be assumed to have Gillick competence to make an informed decision given that, as stated in the Service Specification:

“the evidence for making treatment recommendations is very limited”
“The research base for the effectiveness of any particular treatment offered is small”
” the long-term effects regarding bone health and cardiovascular risks are still unknown”
“The current context of treatment decisions about cross sex hormones in adolescence is that there is limited scientific evidence for the long-term benefits versus disadvantages of this intervention, and great uncertainty about both the causes of significant GD and the early identification of those young people who will persist in their trans identity and feel content in the long term with the early treatment choices they made”

The teenage brain is risk-taking and incapable of really understanding long-term consequences of irreversible treatments; in this case not even the professionals know the long-term health effects so surely this decision needs to be left until full adult maturity is reached at around age 25?

The Aims and Objectives state:

“The clinical work that supports identity exploration involves conversations which are focused on increasing understanding and insight” and “Such conversations might also touch on the impact of living in a social world where negative attitudes towards gender variance are widespread and how these forces may be contested.”

This is to be welcomed; however, it is also stated:

“It may also be relevant to promote a sense of the range of possibilities of varied trans identities in order to encourage thinking about notions of masculinity and femininity and to tolerate uncertainty” and “All aspects of the care pathways are offered to clients who present with other gender identifications, including non-binary.”

This suggests that “gender variance” has been accepted as “trans identity” rather than being viewed as completely normal, and that “non-binary” is a special category (again, rather than being completely normal – in fact no-one is either 100% “masculine” or 100% “feminine”). I would hope that young people are given the facts, ie. that biological sex is a reality (we are born male or female) and “gender” is a social construct: we can completely reject “femininity” and still be a girl, and we can reject “masculinity” and still be a boy. No child needs to define his or her personality in terms of “gender”- behaviours and interests are not exclusive to one sex or the other.

I would also hope that, as part of the discussion, homophobia would be explored as a reason for society’s rejection of “girly” boys and “butch” girls, and support given to young people (and their parents) to consider gay or lesbian sexual orientation as a possible reason for their feelings of difference.

Teenagers with no previous history of “gender” problems typically find their information from online transgender activist sources, where they will be pushed by other young people to adopt a “trans” identity, coached in what to say at the gender clinic in order to get hormone treatment, and encouraged to view any parents who don’t fully support them as “transphobic” (In fact, anyone who questions transgender ideology is called transphobic and ostracised from the group). Do NHS clinicians factor this in to discussions with young people and their parents? Are teenagers given information and support regarding social contagion, groupthink and brainwashing techniques?

9. Please provide any comments that you may have about the potential impact on equality and health inequalities which might arise as a result of the proposed changes that we have described?

In the case of children with underlying co-morbidities (autistic spectrum, psychological problems, depression, anxiety, self-harming, troubled background etc) a ‘gender reassignment’ path will not be a ‘cure’ for these issues, but a distraction from them. Although there is some research which suggests psychologically positive outcomes in the short-term (but only amongst cohorts of children who are already psychologically stable) there is increasing research and anecdotal evidence of high levels of suicidality in the long term, after the honeymoon period is over. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043071/

There are increasing numbers of blogs, websites and online support forums for young people who, on reaching the age of full maturity at around 25, regret transitioning and are left with irreversible effects on their bodies (typically, girls will have deeper hoarser voices and increased body hair, possibly no breasts and infertile). https://thirdwaytrans.com/     http://twentythreetimes.tumblr.com/detransition_support_forum http://redressalert.tumblr.com/      http://retransition.org/      http://www.greenwomanstore.com/blood-and-visions.html

Gay, lesbian, troubled and non-conforming children will be denied equality of treatment if their problems are reinterpreted as evidence of transsexuality and they are subsequently set on the wrong treatment path. Children will be denied equality of care with other children presenting to CAMHS clinics with exactly the same psychological issues and behaviours, but who do not frame their problems as “transgender identity.” Similarly, gay and lesbian young people who think they are trans because a trans identity is more acceptable amongst their peer group will not receive equality of care with gay and lesbian teenagers with similar psychological difficulties who present to other mental health services.

It is therefore crucial that clinicians do not jump to “affirm” a child or adolescent’s self-declared transgender identity and replace normal exploratory therapies with social justice therapy.

10. Are there any changes or additions you think need to be made to this document, and why?

Some of the language is misleading, especially the conflation of the terms “sex” and “gender.” Although “gender dysphoria” has become the accepted term, “sex dysphoria” or “body dysphoria” would be more accurate, as the body discomfort is rooted in biological sex, not “gender” which is just a concept. Likewise, “gender reassignment” is difficult to understand in place of “sex-change.” “Transsexual” is mentioned once: this was previously understood as an adult psychological/psychiatric condition and I would like to know the rationale behind the change of word to “transgender,” which has the same treatment pathway but is applied to children.

This language seems to reflect a view of children’s problems which is already rooted in acceptance of transgender theory that “gender identity” is fixed and innate, and a stronger reality than biological sex, for which the biomedical evidence is very flimsy. Some of the language used comes straight from gender identity and queer politics, which is incoherent and confusing.

Some examples:

“Gender identity is an individual’s personal experience of their own gender. Gender Dysphoria (GD) is where a person feels that they identify emotionally and psychologically as a different gender to the biological sex they were assigned at birth based on physical sex characteristics.”

Many people do not “identify” as the “gender” stereotype for their sex, they accept that they are men or women but do not identify with society’s ideas of “masculinity” or “femininity.” It is false information to teach children that everyone has a “gender identity.” Many people reject “gender” altogether as a harmful and limiting social construct. Gender dysphoria, taken literally, must mean identification with behaviours/interests more commonly associated with (and imposed on) the opposite sex, to such an extent that you feel you would be happier living as the opposite sex.

“Gender identification is diversifying. A person may identify as the opposite gender to their biological (natal) gender or may identify by another descriptor such as nonbinary or gender queer. Binary implies that an individual identifies exclusively as a man or a woman. However there is a growing recognition that many people do not regard themselves as conforming to the binary male/female classification.”

There is no such thing as “biological gender” but biological sex. Sex is a binary, male or female, whereas “gender” is a fluid concept which differs from culture to culture. People do not “conform” to biological sex, but to society’s expectations of gendered behaviour/interests etc. “Opposite gender” here implies that normal people are 100% masculine or 100% feminine, a binary which nobody fits. Everyone is “non-binary” in terms of gender and binary in terms of sex (except for the tiny percentage of people who are intersex).

“Many children experience incongruence between their experienced and their assigned gender early in life. They may not identify with the assigned gender, show behaviours and preferences not stereotypical for the gender they were assigned to at birth, and sometimes strongly dislike their physical sex characteristics.”

We are not “assigned” anything at birth, we are correctly classified as male or female; our biological sex is noted. This would be more accurate: “Many children experience distress because their personality does not fit the gender stereotype that society expects them to enact based on their biological sex. They show behaviours and preferences which are not stereotypical for the sex they were born”

“…the range of possibilities of varied trans identities” should be changed to “identities,” as feeling relatively “masculine” or “feminine” is not necessarily related to being transgender, it is perfectly normal to NOT identify with some, many, or most aspects of masculinity or femininity.

“The Paediatric Endocrine Liaison Team will consider with clients and their family or carers the prescribing cross-sex hormone therapy to adolescents in whom the gender identity is settled inconsistently with the sex assigned at birth” – this should be “the sex they were born.” No adolescent’s identity is settled or fixed, the development of one’s identity is constantly changing throughout adolescence and only settles to a certain extent at full maturity in the mid twenties, although self-identity continues to develop and change throughout a lifetime.

I would like to see the language used by the NHS to be clear and factual, and not misleading, confusing or based on current constantly changing political theories of “gender.” From the language indicated here, I am not confident that the NHS is presenting children with alternative models of understanding and thinking, outside of a transgender ideology which many people feel is harmful for young people in its positioning of “gender” as a fixed internal reality.

What is the medical rationale for accepting a transgender and queer theory of gender, and how has this been assessed in comparison with other models, such as a feminist critique of gender?

I would like to see evidence in this document that the NHS is aware of other theories of gender, in order to feel reassured that gender clinicians are not merely reinforcing further to children the only theory which is currently “acceptable” throughout society.

This Post Has 4 Comments

  1. radicchio

    It is embarrassing to see the factual errors that the government engages in and propagates. This is as usual brilliantly surmised and critiqued! Thank you for your excellent work on this important subject.

  2. Una Hodgkins

    I have submitted a response based on your very helpful comments and guidance. Thank you.

  3. Andy Morris

    My partner (a mental health professional) and myself submitted a repose expressing concern that services need to offer a more balanced perspective (watchful waiting, without hormonal or surgical information). We have also recommended that further stud is required to identify the causes of the increased referral rates and develop treatment protocols based on evidence.

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