by Susan Matthews, academic and contributor to the book Transgender Children and Young People: Born in Your Own Body and the follow-up book Inventing Transgender Children and Young People, available to pre-order now. Susan Matthews writes on gender ideology and campaigns for better NHS treatment for young people with gender dysphoria.
Does Tavistock GIDS fast-track 16 + referrals of adolescents with gender dysphoria?
‘We do not limit or curtail assessments because of pressure to move swiftly to medical interventions. With complex cases, rather than truncating assessments, we will often extend the time given to trying understand what may be going on.’
In a private email that has been shared with us, Paul Jenkins, CEO of the Tavistock, wrote to some concerned parents and explained that the Leeds branch of GIDS did offer a pathway for older adolescents but denied that this could be described as ‘fast-tracking’:
In Leeds referrals of older adolescents are carefully screened; some attend a one-off group session. Others who are not considered suitable– usually on the basis of the complexity of their presentation – are not offered this. This approach offers young people who have been on our waiting list a chance to think with us about their options from a balanced GIDS perspective: it is not fast-tracking. (Email 2/10/2018)
This reply left us with more questions that it answered. What does ‘carefully screened’ mean in practice? Can a desire to be the other sex ever be straightforward? We got in touch with a clinician who had worked at the Leeds clinic. Their view is that: ‘The service did not have agreed criteria for how to rate the complexity of a case (despite the intake form requiring clinicians to pick a severity rating).’
Writing from their own experience, this clinician described the process as a ‘fast-track assessment’ which ‘encapsulates well what GIDS assessments often are: an extended information-giving process so that the NHS can say that the young person provided informed consent to physical intervention.’
A different clinician who also worked at Leeds GIDS, Dr Kirsty Entwistle, has written of her concerns at the lack of differential diagnosis:
‘I think there are others, like me, who went to work at GIDS expecting to do complex assessments and differential diagnosis but the reality is that you run the risk of being called transphobic if you propose that, say, a child might have Body Dysmorphia rather than Gender Dysphoria.’
We feel that the situation of older adolescents and young adults is particularly dangerous. This is the age group amongst which gender dysphoria has soared. The years from 17 to 25 are also an age group in which mental health problems can appear for the first time.
This post is an attempt to work out just what an adolescent on the 16 + pathway at Leeds GIDS might experience in terms of assessment. It draws on three sources:
- a 2017 presentation to the Belgrade EPATH conference by two GIDS clinicians, Laura Charlton and Jo Charsley.
- a video diary (four short Youtube videos) by a 17-year-old natal female who attended the Leeds adolescent pathway and was then referred on to the Nottingham GIC. These are no longer available on the web but have been archived.
- comments from a clinician (not Dr Entwistle) who was previously employed at GIDS Leeds. All quotations that follow, unless specifically attributed to Dr Entwistle are authorised quotations from this clinician.
We are very grateful to the clinician who has shared their experience with us.
The rationale for the pathway
According to the EPATH presentation, the pathway was designed to deal with the 11% of the referrals aged between 16 years 9 months and 18 for whom there was a ‘limited time to complete a standard assessment’ in the context of the sudden increase in referrals evident in the graph shown.
Time was clearly of the essence – as the next slide revealed.
The view of the Leeds clinician was that ‘GIDS were trying to find a way to get older teenagers through the service quickly.’ This was partly a funding issue, ‘an artefact of an NHS England decision not to fund any sessions at GIDS beyond the age of 18, even by one day. The endocrine clinic at Leeds General Infirmary was also unhappy if older adolescents were referred for the blocker as it meant they would have to hold on to them until the adult service took over clinical responsibility.’ The drivers for the new pathway were financial and organisational, it seems.
The pathway involved three elements: a questionnaire sent to the young person to complete at home, a group meeting for young people and their parents or carers, and a single one to one meeting with a clinician (though further meetings were available if requested). The clinician commented: ‘In my experience as a clinician, important information often only started to emerge after a number of sessions. It takes time to build a relationship with someone so they feel able to share more difficult or complicated feelings, or to trust telling a professional about experiences of abuse. It would therefore not be contained in a GP referral and not captured by this fast-track assessment.’
According to the conference presentation, the questionnaire is ‘An efficient way of gathering rich, client-centred, contemporaneous information as an adjunct to referral information’ which also ‘Saves face-to face clinician time’. It allows ‘Co-construction of gender narrative using client’s own words which they can complete in the comfort of their own homes and at their own pace’. We can get a glimpse of a young person’s response to this questionnaire from the online video diary. The young person complains that the questions were ‘quite triggering’ because they used biological terms for the female body like ‘breasts’. She believes that her body is not female (‘I was like, really no it is not female’). The assessment process offers no resistance to this belief apart from the questionnaire.
The Leeds clinic, it seems, reinforces this belief which is common in youth online culture. In Trans (2018), Psychiatrist Az Hakeem argues that trans people are generally not delusional because they don’t believe they are ‘already the preferred gender’. (183) ‘They believe that they should be, or would like to be the preferred gender.’ This young person manifests the stronger claim now common in online communities: that breasts and vagina do not define a body as female. The GIDS questionnaire challenges this belief but this challenge can be handled ‘in the comfort of their own homes and at their own pace.’
The Group meeting
The second element is the group meeting. The young person describes a presentation for about 15 seventeen-year olds and their parents and carers on ‘gender identity, gender expression, sexual and romantic attraction’ which outlines the NHS pathway for transition: ‘To be honest the presentation was basically for the parents – it was stuff we all know’. This is an opportunity for the clinicians to demonstrate that they understand online trans culture. After a mini break, parents and carers go off into a room where ‘they just sat round in a circle and told their stories, everyone went round, a couple of people were crying and all that.’ The separate group session for the ‘kids’ was ‘funny’: the convenor talked ‘about the ‘stress bucket’, what stresses us, how we deal with dysphoria. What upsets us.’ ‘It was a bit awkward, only about three people spoke’. At the break the young people were given appointments if they wanted them.
The 1:1 assessment
There is just one ‘1:1 assessment session’ and that’s it. The young person reports being complimented on how well she passes. Then they talk through the answers on the questionnaire in more detail. But then ‘Something just hit me, I felt myself welling up. I was gone, absolutely gone.’ The teenager breaks down and cries but time is up (the sessions, apparently, run exactly to time). She has talked in some detail about self-harm and worries this might slow the process but the clinicians reassure her that she fits all the criteria and can now choose which adult clinic to be referred to. Another appointment is offered but the young person does not want any more potentially embarrassing conversation and instead confirms by phone.
That this assessment session provides little scope for a differential diagnosis is not surprising given the comment from the clinician that: ‘There are staff at GIDS who believe that even suggesting that a gender presentation may be an expression of other difficulties is tantamount to transphobia. Those staff believe that any difficulties are almost always the result of gender dysphoria and transphobia and that therefore the answer is to remove barriers to both social and physical transition.’
From the point of view of GIDS, the pathway is a success. Feedback from the young people reported in the EPATH presentation is positive. ‘Having all my questions answered so I could make more important decisions’, said one. ‘Being able to meet more trans people’ said another. The trans youtuber likes it because there is as little embarrassing contact with professionals as possible.
It’s interesting to compare what this self-harming 17-year-old might have encountered had they accessed dialectical behaviour therapy (DBT) on the NHS at the Maudsley in London. In June 2019, Dr Troy Tranah described the experience of using DBT with a ‘small group of young people […] who identify as transgender’ (ACAMH Jack Tizard lecture 14th June 2019). The group were ‘not referred in relation to transgender but generally due to a combination of self-harm, aggression, trauma and CSE’. Nevertheless, ‘several were on the waiting list for Gender Identity Development Service.’ The difference in provision is striking: DBT practitioners work with around six patients whereas GIDS clinicians may have up to 120 patients at any one time (and according to the Bell report have reported difficulty in remembering individual cases).
Before a young person is accepted onto the Maudsley DBT course they must undertake up to six individual pre DBT sessions to ‘orientate them to DBT, assess and strengthen motivation, clarify goals of treatment and for the young person to decide whether they wish to commit to engaging in DBT.’ They will then be asked to sign a contract before entering a year of therapy which requires weekly individual therapy sessions plus for the first six months, a compulsory skills training group. Telephone skills support and crisis management are available if needed. Their parents and carers are offered, in parallel, a six-month skills training course so that they can support their young people together with their own telephone support.
On to Adult Services
Given the sketchy nature of the GIDS brief assessment, we might assume that the real work takes place at the adult service. But this is not necessarily the case – indeed all the information we have suggests that once within adult services there is little in the way of careful psycho-social assessment. A young natal female who transferred from GIDS to the London GIC claimed at the GIDS ‘Science of Gender’ conference on Thursday 18th October 2018 that ‘Assessment at adult services felt perfunctory, like a box ticking exercise.’ She had experienced sexual abuse as a child and told how her belief that she was male came on suddenly after the abuse: ‘like a switch flicked’. She had struggled with self harm and dissociation. Nevertheless, the adult GIC required no further exploration before putting her on to testosterone and offering a mastectomy.
We know that the various NHS clinics work to different protocols and we also know that if a young person decides to use the private gender clinic GenderCare they can access hormones after a one hour assessment with a single clinician followed by a one hour endocrinology assessment some months after starting on cross sex hormones.
In the case of our trans YouTuber on the ‘Older Adolescent Pathway’, the ‘Mini assessment’ was forwarded by Tavistock GIDS to the Nottingham gender clinic with ‘a little bit of information but not too much’. The questions at the first adult appointment were ‘really easy, easiest I’ve had it so far.’ According to the teenager, they ‘really only skimmed the surface…there’s a lot deeper that I feel I go’. The adult service second appointment was a ‘kind of just a mish mash of different things, there wasn’t any huge big questions.’ It seems as if it was mostly a discussion about effects of testosterone.
In this case it appears that self-harm and distress served to speed up the process and remove the need for any deep exploration. The young person’s verdict: ‘It was really easy, honestly’. Thinking about the Older Adolescent Pathway in general, the clinician comments: ‘It isn’t a psychosocial assessment, it is a tick-box exercise to ensure that the young person has correctly learnt from the Internet about how to self-diagnose as meeting the criteria for gender dysphoria.’ In 2011, James Barrett, lead clinician at the Charing Cross GIC wrote this:
‘The least certain diagnosis is that made by the patient, made as it is without any training or objectivity. This uncertainty is not lessened by the patient’s frequently high degree of conviction. Neither does the support of others with gender dysphoria help, since conviction leads people to associate with the like-minded and to discount or fail to seek out disharmonious views.’
In place of what could be seen as the hubris of the medical professional exemplified by Barrett in 2011 we now have professionals who have given up their ability to diagnose altogether: in the case of transgender identity the patient’s word, aided by the internet, is enough. Our concern is that the ‘Older Adolescent Pathway’ fails to offer a chance to explore the complex psychosocial context in which gender dysphoria develops in this age group, effectively discouraging self-reflection and preventing differential diagnosis. The result is a complete failure in normal duty of care for those vulnerable young people who self-diagnose as transgender.