UK: Treatment Dilemmas in Puberty Suppression Seminar

We attended a seminar at Cambridge University entitled ‘Gender Non-Conforming Children: Treatment Dilemmas In Puberty Suppression’ presented by Bernadette Wren, Head of Psychology, Gender Identity Development Service, Tavistock & Portman NHS Foundation Trust. This post attempts to sum up her presentation, with our comments added under each section. There is much more to say, so we will be referencing some of these points more fully in future posts. There was unfortunately not enough time to ask all the questions we wanted to ask: the information given in this seminar raises more questions than answers.

Introduction

The staff at the Tavistock and Portman clinic feel that they are on the frontline of a social revolution and they get it from all sides. The issues they are dealing with are ethical as well as medical and psychological. There is tension between Tavistock and some trans advocacy groups especially in their use of the “suicide narrative” and promotion of personal stories based on memory – kids are being influenced by fearful stories about their futures, scaring them into making decisions. There is also great pressure from ‘parental advocacy groups’ for pre-pubertal blockers and treatment on demand based on self-determination.

We suspect that Mermaids is one of these pressure groups, given their rhetoric, and the obvious tension between Bernadette Wren and Susie Green of Mermaids at the Government trans inquiry. Tavistock has a good relationship with other trans advocacy groups and has worked with Gendered Intelligence, a fact we questioned, pointing out that G.I. go into schools and essentially normalise the idea to children that they can be the opposite sex and that they have a fixed ‘gender identity.’ We were pleased that the “suicide narrative” was acknowledged as we feel that ‘support groups’ threatening parents with their child’s possible suicide if they don’t transition is a particularly cruel form of manipulation and bullying of parents into putting a child onto the trans path through fear.

Facts and Statistics

Children aged 5-18 are referred to the clinic, the number of younger kids is increasing, including pre-school children. Referrals have doubled since July 2015. 110 children are currently referred every month.

There are increasingly more psychological difficulties as a background to gender dysphoria and the treatment pathway for trans doesn’t make those problems go away. 18% of children visiting clinic are autistic spectrum (50/50 male/female) compared to 1% general world & UK population.

A large proportion of children coming in have traumatic backgrounds – self-harm, suicidal ideas. Treatment for gender dysphoria won’t eliminate psychological problems. When children arrive at the clinic they have often made a serious attempt on their lives, have often been bullied because of being ‘gender non-conforming.’

Children are not offered irreversible treatment (cross-sex hormones) until the age of 16, there is great pressure to lower that age. Until that point children are put on puberty blockers which stop development and is seen as a way of “buying time” and removing the stress of pubertal development eg menstruation.

In 1997 blockers were available to over-16’s only but from the 2000’s blockers became available from 12 years old and currently Tavistock has 132 under 16’s and 5 children under 12 on blockers.

Children are diagnosed and a treatment pathway devised after 4 assessments.

12- 27% of ‘gender variant’ children persist in gender dysphoria; that percentage rises to 40% amongst those who visit gender clinics.

Long-term research results are very unclear. Effects of blockers are being questioned: eg. how they affect cognitive function & mood. Sex characteristics don’t develop and in the case of boys this may mean there is insufficient skin development to later construct a ‘vagina.’ Putting 8, 9 and 10 year-old girls on blockers results in sterility if puberty is not resumed later, as there is no production of eggs. Clinicians talk to children about what losses treatment might result in, including loss of fertility.

There is uncertainty about gender identity development and there is no way of distinguishing the ‘persistors’ from the ‘desistors.’

The early suppression of puberty influences the development of gender identity –  children on blockers almost inevitably go on to transition.

This information presents a very clear picture of the clinical path the trans lobby are pushing for and the results of their media presence and political lobbying so far in the huge rise in child referrals. Vulnerable children who previously may have accessed mental health/children’s services are now increasingly presenting to gender clinics, their problems re-interpreted with one simple explanation and solution. Despite the lack of research or knowledge of the full effects of puberty blockers on a child’s brain, the known result of sterility if a child continues on to cross-sex hormones, and the impossibility of knowing how an individual child’s ‘identity’ may develop, the trans lobby advocates a clear halt to that development with puberty blockers administered as early as possible. The ‘reversibility’ of blockers is called into question here. Attending a gender clinic significantly increases the probability that a child will go on to transition, and once on puberty blockers, that outcome is all but assured. After just four assessments, a child under the age of twelve may be made a medical patient for life. 

Ethical Issues and Influences on Identity Development

The ethical issues include the consideration of autonomy: the ‘freedom to choose,’ and the political ideal of non-interference; self-determination as a right. “The autonomous choosing self” idea of who someone is says that some things are not up for choice or change, some things are a given. However,  the evidence for a biomedical account of gender dysphoria is very flimsy (ie ‘female’ brain in a male body).

“Children are autonomous decision makers” – is it possible for them to make medical decisions free from influence?

The sense of self is built on other factors such as your perspective, your views, and influences – your sense of self stabilises over time & this developmental achievement is determined by multiple influences. “Gender identity” choices develop against a background: seeing yourself as non-conformist, being different, being a rebel, (even being infertile may be seen as a rebellious, non-conforming choice). These children believe the world should adapt to them rather than them adapt to the world. Children are making choices before these factors have a chance to evolve.

There has been an expansion of gender possibilities since the Seventies, from a binary choice of boy or girl to fluid, shifting, trans – there are now many identities to choose from. Kids accounts are highly influenced by what they hear.

Parents want a simple account. From parents there is a catostrophising outcome of not transitioning; parents want clarity, not change. Is it reasonable for parents to accept uncertainty in their child? Parents put pressure on clinicians. Transition can be a rearticulation of very rigid norms.

The transgender theory of an innate, fixed ‘gendered’ brain is unsupported by evidence. The diagnosis of transgender is dependent on a view of children and adolescents as autonomous agents capable of making their own decisions and choices in a bubble outside of any form of parental or cultural influences, and that the choice to define themselves as transgender is unrelated to any other personal beliefs, level of understanding, influences, experiences or psychological states. This is contrary to all knowledge of child and adolescent development and psychology. Parents have clearly been made fearful by the “suicide narrative” of trans advocacy groups and are typically intolerant of uncertainty, wanting a clear diagnosis which supports their own fixed beliefs of ‘normality.’ 

Conclusions

There is no chance to build a therapeutic relationship with a child if that child is fast-tracked.

When children are 18 they transfer to adult services and their protected characteristic means there is no way to follow their progress (this is prevented by law), there are no past studies or assessments done on veracity of treatments or on treatment choices, although a cohort study has begun and is now underway.

Gender non-conformity is a normal variant.

Tavistock believes in the need to be pragmatic: is being gender-conforming helpful, will transition resolve the problem? Then why not do it?

But clinics can act as an ‘invitation.’

Child and adult services are totally separate, so outcomes have not previously been tracked; the initiation of a cohort study is welcome, but long overdue. The status of children on the transition path will be raised to ‘guinea pigs’ whereas previously they weren’t even that. Given that ‘gender non-conformity’ is normal, it seems that the ‘problem’ has been created by cultural conditioning and parental investment in gender stereotypes, pressure on children to conform to those stereotypes, bullying of children who resist that pressure, and a concerted campaign by trans activists to convince everyone that those children who do not conform must be the opposite sex, a ‘solution’ which just reinforces the prejudices of the bullies. The idea that we should halt a child’s development, fill him or her with hormones and later surgically alter his or her body in order to meet society’s expectations of conformity, is chilling. We totally agree that ‘gender clinics’ – along with ‘trans support groups’ – are a strong invitation to parents, children and adolescents to frame non-conformity as a ‘gender’ issue which needs fixing.

Overall Bernadette Wren came across as cautious and very careful in her choice of words; Tavistock is clearly under extreme pressure to capitulate to all the demands of trans advocacy groups and, like everyone, clinicians lay themselves open to the charge of transphobia if they put a foot wrong.  We feel there is no place for such a highly-charged political agenda to hold any sway in the diagnosis and treatment of children and adolescents who need time to develop their identities, and that much more attention should be given both to protecting parents and children from this untested and incoherent hypothesis of gender and to presenting them with a different model to counter it.   

With thanks to our supporter in Cambridge who drew our attention to this seminar and helped by writing comprehensive notes.

15 Comments

  • Petuniacat Reply

    Well, Wren acknowledged it. The purpose of this treatment is to make them “gender conforming”.

    From the post:
    “is being gender-conforming helpful, will transition resolve the problem?”

    The cat is out of the bag. This is Gender Conformity Surgery. Let’s start calling it that. Let’s stop presenting trans in the media as special snowflake/brave medical patient people. And acknowledge that this is the same thing as if you sent your sports hating son to some kind of ‘Masculinity Camp’ to brainwash him into liking sports. Or made a daughter go to the old-fashioned type of finishing school to make her into a Lady. Only they’re doing it with irreversible surgery.

    • Joseph Reply

      During the recent Academy Awards, when presenters were discussing the nominations for “The Danish Girl,” they referred to what has previously been called Sex Reassignment Surgery as “Gender Confirmation Surgery” and I was troubled by that phrasing (see link below, specifically at 0:39); but slightly changing that second word to “Conformity” makes more sense. And it horrifies me.

      • petuniacat Reply

        Thank you. “Gender confirming” surgery is their new creepy creepy name for it. Bonus creepy creepy fact: the person the Danish Girl is about died because they implanted I think it was ovaries in her abdomen just any old place. In the 1930s, 30 years before organ transplants were properly invented. Just a really nutty thing for the doctors involved to have done. Like a hideous preview of the recklessness today.☹️

  • atranswidow Reply

    I agree that Bernadette Wren, as the spokesperson for the work of the GIDS at Tavistock and Portman is in a very difficult position. It was very, very clear at the Oral Evidence Session of the Trans Inquiry that there is an awful lot of pressure from Trans Activist groups, particularly Mermaids. I got the impression that Dr Wren’s approach is as cautious as she can possibly be under the circumstances. At the Inquiry, having been asked about the lowering of the age limit on cross-sex hormones (currently 16) she had this to say……..

    ”There are issues about the range of young people coming forward and the difficulty of knowing which are the children who might do really well, unless we confine it to a vanishingly small number, which we possibly should, but that would be an issue. I am sure Susie (Susie Green Chair of Mermaids) would want us to have a flexible approach to this, so that not everybody who comes in the door at 13 or 14 would have fast access to cross‑sex hormones. I am sure Susie would want us to do a reasonable assessment of that young child and how they are presenting, so that we are making a wise clinical decision. On the other hand, once you drop that age limit it will be harder and harder for us to say, “No”.

    For Mermaids it would seem that ”No” is not an option.

    It really is important to listen to what the clinicians are saying and separate that from the voices of the activists. The government needs to urgently look at the role of trans advocacy groups in pushing vulnerable children and their parents into demanding cross-sex hormones and surgery at such early ages as if it was inevitably a matter of life and death.

    • petuniacat Reply

      Thanks for that atranswidow. Jesus that’s pathetic. It sounds to me like Bernadette Wren needs to screw her courage to the sticking place and punch Susie Green on the nose. It will help boost Wren’s self-confidence. 😉 And then as clinicians she and her colleagues can do what they know they ought to! Bloody hell.

      “Susie Green would want to have a flexible approach.” Susie Green wants you to be bad doctors, Tavistock and Portman! Buttheads. When this fad is over Susie will go on to some new fake activist job, but you MDs will get struck off.

      Sorry I got more angry as I went on with that comment. 😯

  • puzzled Reply

    It’s a key point, I think, that parents who choose this route for their kids want some kind of simple answer to hook onto. Living with a kid who chooses a gender presentation incongruent with society’s idea of how someone of that sex should look/act is not an easy thing. (Not easy for the kid, either, though these days some of them get a lot of points for being brave and edgy, and the “ally” girls, knowing they are supposed to be loving/accepting, in particular are likely to offer fierce support, if mixed with pity. At least for the natal males. Not sure they are so unconditionally accepting for masculine-presenting natal females.)

    At any rate — these parents so often get the message that this is an EMERGENCY and if they do not DO SOMETHING to circumvent puberty their kid has about a 50/50 chance of attempting suicide. (Which is a contention absolutely unsupported by science or statistics, but if all the psychs believe this — like a lot of the American ones do — it takes a good bit of parental fortitude to say “no, we’re going to let this ride until the kid is truly old enough to understand more of the consequences.”)

    Wren seems to be sensible. I hope she and the clinicians in her world stand their ground, Mermaids or no Mermaids. She is absolutely right that once you drop the age limit it is hard to say “no.” And the transactivists absolutely refuse that learning peace with your natal body is a GOOD thing, that avoiding extreme endocrine and surgical modifications is a GOOD thing. They’ve picked their “born this way” narrative and they’re not going to waver.

    thanks for this very good report.

  • TiredoftheTransAgenda Reply

    I do wish we had more sensible types in the US who bring up the unresolved issues of subjecting children to medical hell and the abuse of parents who refuse to parent them in an ethical way.

    Would you give your child a loaded gun with which to kill her-/himself?

    Then don’t listen to the trans lobby’s agenda about how your child is developing–what the hell do they know about your child anyway? Use your parental love to get that child the correct therapy she or he deserves and stop this cultural bullshit in its tracks.

  • atranswidow Reply

    @Petuniacat. When watching the video (unfortunately no longer available) of the exchanges between Bernadette Wren and Susie Green at the Trans Inquiry I have to admit that I was on the edge of my seat waiting for Dr Wren to do just that. What she did say was……..

    ” I know that Susie and Mermaids would like a fast track so that young people who are already well into puberty and feel that they know that they want to move forward into physical intervention would bypass our assessment process and move straight into physical intervention. We feel that is not an ethical way to practise, and this is a sticking point between us and Mermaids.”

    I really hoped that the committee would pick up on this, and indeed the only recommendation that was made re patients at the Tavistock and Portman is that the length of assessment at the clinic before prescribing puberty blockers and cross-sex hormones be reduced. So I do think that Dr Wren got across. However as it’s clear from this post’s excellent report the activists are continuing to keep up the pressure.

    And you are right, for what ever reason, Dr Wren will not always be at the Tavistock and Portman. Susie Green will be at Mermaids for the long haul as it is a very personal matter. (Her son’s transition did not proceed at the speed she wanted and so she took him to America at 13 to get cross-sex hormones and to Thailand to have surgery on his 16th birthday. He is now a model.)

  • had_enough Reply

    I predict that Dr. Wren is going to meet the same fate as Dr. Zucker. She’s already being called a TERF (oh the irony). The reason that there aren’t more sensible types in the medical community is that most like having jobs.

  • bobab Reply

    This link is to a Radio 4 programme about the Tavistock Clinic that is on today between 4-5pm;
    “The latest annual figures from The Tavistock Clinic, the country’s only gender identity clinic for under-18s, reveal surprising statistics. Reporter Jenny Kleeman talks to Consultant Clinical Psychologists Dr Polly Carmichael and Dr Bernadette Wren, and to Sasha, who received treatment from the Tavistock clinic in his(her) teens.”
    http://www.bbc.co.uk/programmes/b0766h2s

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