Last year GIDS (UK Children’s Gender Identity Service) published two poor cisnormative and pathologising research articles. One was reviewed in detail here.

This week a new article came out:

‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties’ by Anna Churcher Clarke and Anastassis Spiliadis in ‘Clinical Child Psychology and Psychiatry’.

In this review I’ll start with the reference list as that is a good indication of what the authors are reading and see worthy of citing.

References

Here I look through all the references cited by this GIDS paper.

The Unacceptable Transphobic Worst

The reference list includes three separate citations of the same non-peer reviewed paid-to-publish book, H. Brunskell-Evans & M. Moore (Eds.), Transgender children and young people: Born in your own body’. The first of these, a chapter ‘The transgender experiment on children’ by Stephanie Davies-Arai, the “founder” of Transgender Trend. An anti trans lobby group formed by a Davies-Ara, a sculptor with no real life or clinical experience of transgender children has been extensively criticized for its lack of rigour and transphobic bias. As Rachel Pain revealed, “of 57 sources cited in Stephanie Davies-Arai’s chapter, only seven are peer-reviewed research and these are cherry-picked and distort the wider medical and sociological evidence”.

Marchiano, L. (2018), is another chapter from the same publication, ‘The language of the psyche: Symptoms as Symbols’. We may question why GIDS clinicians working for the evidence based NHS are referencing such overt propaganda. In combination with the positive review of this same by another GIDS clinician, Midgen (2018) this begins to look like a organised attempt  to provide a veneer of respectability to an un-evidenced anti-trans-children agenda. I wonder if this is the intention of the multiple inclusions, to legitimise the illegitimate.

The known to be flawed research cited without critique

Also cited is the ‘Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood’ an article we have previously reviewed in detail and exposed as flawed in both methodology and presentation of the evidence base on “desistance”. Desistance in itself is a problematic concept which refers to children who were gender non-conforming and who do not express a transgender identity in adolescence. This is not the first time GIDS clinicians have cited this article to shore up their desistance theories that are rejected by evidence-based professional elsewhere. The flaws in this specific paper are multiple as discussed in this blog two years ago.

In 2018, since writing the critique, three peer reviewed academic journal articles (by Elhrensaft, Pyne and Temple Newhook and others) have been published, analysing and exposing the failings in Steensma’s work on desistance. A response article by Steensma himself in 2018  outlined that he felt his own work had been misinterpreted and misapplied by others (“We have clearly described the characteristics of the included children (clinically referred and fulfilling childhood DSM criteria) and did not draw conclusions beyond this group, as has wrongly been done by others”).

None of these 2018 articles criticizing the very foundations of the flawed prior research on desistance  are cited in this GIDS paper. This ignorance of the current literature is a common theme in GIDS publications (see Butler et a 2018, and our review of the Evidence section of GIDS website)

Another reference in the new GIDS paper is Giovanardi, G. (2017) a former GIDS clinican,’Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents’. This is another paper frequently cited by GIDS clinicians, and one of the few publications distributed to families, despite the multiple failings in this paper which we addressed at length in our 2017 blog.

As noted, this paper, published in a new, un-ranked journal that has since folded. The paper lacks academic rigour. Several of the references it cites are distorted including a critical paper by Simona Giordano, as she told us in interview:

“My work has been misrepresented”.

Another reference in the new GIDS paper is another extremely flawed article by Steensma, This claims kids attending gender clinics almost all end up cis and gay ‘Desisting and persisting… (2011)’. Again, we have highlighted the multiple flaws in this document previously in another 2017 blog.

GIDS relies on these same few flawed papers time and again, ignoring the criticism of these papers.

Steensma’s work is cited two more times, ‘Gender transitioning before puberty’ from 2011, and ‘more than two developmental pathways’ from 2015. Both of these publications suffer from the same flawed methodological approaches as the above.

One other reference, a 2011 Cohen Kettenis article on ‘Puberty suppression in gender identity disorder’ outlines the approach in place in the early 2000s in the Netherlands. In a field that has moved on significantly in the past decade, a paper outlining best practices ten years ago, is hardly salient.

The citation of GIDS colleagues

Three are papers from the former head of GIDS (Di Ceglie, D), articles published from 1998 to 2009 based on older data. This field has moved on a great deal in the past twenty years.

Two are articles by GIDS second in charge Wren, both focused on uncertainty.

One is by current head of GIDS Carmichael (on rise of referrals of kids assigned female at birth). One is a 2009 description of the GIDS service.

 

The citation of Zucker – disgraced former clinician who compares respecting a trans child to feeding a delusional child dog food.

Two are by Zucker, including the hyper offensive ‘psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism’.

Another is by Steensma, Blanchard and Zucker ‘Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria’. Blanchard, is a deeply divisive figure, with no clinical experience working with children or young people, with an attitude to trans people widely regarded as deeply offensive.

Why is a modern service continuing to cite material by offensive outdated former clinicians with deeply transphobic views? Why continue to centre the work of authors whose body of work is deeply problematic and pathologising.

 

The citation of other non-mainstream gender services that are systematically cisnormative and pathologising

One is a paper from the outdated service in Finland (Kaltiala-Heino et al 2015 ‘Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development’. It is deeply troubling that GIDS is benchmarking its approach to youth gender care with the state health service of Finland, a country which still requires sterilisation before recognising a change of legal gender.

The irrelevant:

Two references are on psychoanalysis. One is on psychotherapy. Five references are on family therapy.  Two are on speech communication or role playing. One is on attachment narratives in psychotherapeutic interventions. One is a psychoanalytical account of one family’s experience (Marcus et al 2015). One is a paper I’ve not yet read from Norway (Roen, 2015) – it has been cited three times before (apart from self-citation).

Several are older books with titles like ‘Mind-body problems in family therapy’ from 1990, ‘Identity: Youth and crisis’ from 1968, ‘Development and validation of ego-identity status; from 1966. One’s on ‘Masculinity as Homophobia’ from 2004. One is a 2009 article on ‘Internalized homophobia’. One is the 2004 book by Judith Butler ‘Undoing Gender’.

Six are on gender variance and autism (these are references may well be worth following up but are beyond the scope of this particular blog).

Gender affirmative body of literature

The body of literature from Gender Affirmative professionals and researchers across USA, Canada, Australia and elsewhere is a large and growing body of literature..

This GIDS article contains two references that include authors and experts who support a gender affirmative approach.

One is an article on research priorities (Olson-Kennedy, J., Cohen-Kettenis, P. T., Kreukels, B. P., Meyer-Bahlburg, H. F., Garofalo, R., Meyer, W., & Rosenthal, S. M. (2016). Research priorities for gender nonconforming/transgender youth). This is cited purely for the statement “Longitudinal data examining the impact of social transition are sparse”.

And one is an article by Leibowitz, S., & de Vries, A. L. (2016). ‘Gender dysphoria in adolescence’. This is a 2016 literature review of research conducted prior to 2016 (including stacks of older pathologising literature). When I looked closely at the statements in the GIDS paper for which this is the citation, I saw that the reference is referring to the part of Leibowitz’s literature review where they cite work by Zucker (again), as well as an extraordinarily pathologising 2010 literature review by Lawrence a proponent of Blanchard, and author of books including the 2013 “Men trapped in men’s bodies: narratives of autogynephillic transsexualism”.  This reference may at a glance appear to be from the more affirmative Leibowitz, but is in fact yet more references to old pathologising research. Yet more Zucker.

Neither of these in any way represent the evidence from the substantial body of evidence coming from professionals who support trans kids and trans positive researchers who work respectfully with trans children and adolescents, in USA, Canada, Australia. Why is none of this sizeable body of literature cited? Have GIDS still not read it or is this a deliberate choice to completely ignore the existence of literature from a gender affirmative or trans-positive body of work in favour of promoting obsolete and fringe theories, described as non-evidence based by WPATH, the world authority on transgender health.

Summary of references 

The literature selected for inclusion in the bibliography is extremely biased, ignoring all gender affirmative literature published since 2016. It is dated, citing a number of older, discredited works and ignores up to date research. This is completely unacceptable in a field where older research has extreme cisnormative biases and flaws. It tends towards a clique of pathologising researchers such as Zucker, Blanchard and Steensma, it quotes material from journals and books that are not peer reviewed, it quotes material that is known to be flawed without mentioning the peer reviewed critiques of such work. Of most concern is that it includes work that is extraordinarily transphobic, written by anti-trans-children activists with zero clinical or lived experience, outright propaganda that lacks any academic credibility. Even a cursory review of the material reveals its flaws and lack of scholarship. The decision to include this here, is deeply troubling, at best this demonstrates that the authors lack ability to discern good from bad, or far more frightening, evidence that the UK Gender Children’s Service is listening to, and providing credibility to, anti trans lobby groups.

The bibliography as a whole makes me despair. These people are either extraordinarily poor at keeping up to date with modern evidence and research, or are mired in bias and committed to defending their (institutionally transphobic) positions. Or, I fear, both. These are clinicians working in the monopoly service for children and families like mine. We have no alternative but to force our children spend their time with these people – people who hold damaging outdated views about our children, or we need to go outside of the NHS. Even before the age of puberty – when there is no requirement for medical interventions, there is pressure from schools, GPs, family members, social services, to reassure them that our children are registered in the NHS service. A service that causes harm.

The institutional transphobia in children gender identity services in England and Wales should be a national scandal. But due to wider transphobia, skepticism, ignorance and cisnormativity, no one gives a damn about the harm caused to our children.

That was just the bibliography. Now to the paper.

First sentence:

“Young people presenting to the United Kingdom’s Tavistock & Portman’s Gender Identity Development Service (GIDS) are a diverse group and present requesting help with distress experienced as arising from a felt incongruence between their gender identity and their biological sex”.

Straight away they are using outdated language. The 2018 Endocrine Society Guidelines (which later in the paper they claim GIDS works to) states that ‘the terms biological sex and biological male or female are imprecise and should be avoided’. This can only be read as a a direct challenge to the international guidelines from a pathologising UK children’s service.

Second sentence:

“many meet the criteria for gender dysphoria (GD). The extent to which this can be understood as a normal variation of gender expression, a social construct, or a ‘pathology’ is a matter of ongoing debate”

Last year the World Health Organisation formally recognised that being trans is not a mental illness, GIDS meanwhile think that there is still debate on whether it is a normal part of human diversity or a pathology. This view while outdated, is not surprising GIDS is founding in psychiatry rather than medicine.

“While broadly similar discussions could be had about the nature of any psychiatric diagnosis, the question about what is at stake – in the different ways we might describe or seek to make sense of this embodied distress – takes on a unique salience in a domain where young people, their families and clinicians, are facing complex decisions around possible medical interventions in physically healthy and developing bodies.

This is indistinguishable from the anti-trans rhetoric the paper later quotes. The  emphasis on psychiatric diagnosis is astonishing given the WHO removal of in-congruent gender identity from categorisation as a mental health condition.

“prospective follow-up studies have shown that childhood GD is strongly associated with a lesbian, gay or bisexual outcome in adulthood and while estimates vary, the majority of participants in these studies did not seek out medical interventions for GD; the assumption being that gender dysphoric feelings requiring medical intervention receded around or after puberty (Ristori & Steensma, 2016).”

This is a failed understanding of the evidence base which focused on children diagnosed with Gender Identity Disorder (which included gender non-conformity) not on children diagnosed with Gender Dysphoria. The categorically false claim that gender dysphoric kids are likely to end up ‘cis and gay’ is critiqued here and the work cited to evidence this claim is falsely applied (Ristori & Steensma, 2016) as argued in detail here

“Factors contributing to persistence and desistence of childhood GD are still largely unknown,; however, it seems that in some cases a period of questioning and exploring sexual identity may be the key (Steensma & Cohen-Kettenis, 2015)”

There is no acknowledgement that the concept of desistance is deeply offensive and pathologising. There is no mention of the approach elsewhere which prioritises ensuring a child’s well-being and self-worth in the present, without fixation on prediction of future identity. The claim here that exploring sexual identity is key to resolving gender identity is a conflation of gender identity and sexual orientation, based on the same methodologically flawed Steensma study debunked here.

“Adult studies indicate that later onset GD, as well as biological maleness and sexual attraction to individuals of a different gender from the adolescent’s biological sex, may predict a more challenging treatment course and outcome, and historically more late-presenting adolescents have been male (Leibowitz & de Vries, 2016).”

This misrepresents Leibowitz paper which is not evidence, but rather an overview of older literature.

The statement about the majority of late presenting adolescents being ‘male’ (assigned males), is instead a reference to a Zucker 2012 study. If GIDS are yet again citing Zucker they should state so rather than hiding it with a reference to the more progressive Leibowitz. Also in the Leibowitz paper the term ‘natal male’ is used which the GIDS clinicians have chosen to alter for ‘male’ (not to infer ‘natal male’ is good, but ‘male’ alone is worse). The context of the quote is vital, and here missed, in the very next sentence of the Leibowitz paper they state that other studies find more assigned females in adolesence, something the GIDS paper omits to mention.

The first part of the Leibowitz citation, appears in the original Leibowitz paper as:

The relevance of sex ratio, age of onset, and sexual orientation lies in the fact that adult studies have revealed that natal maleness, late onset GD, and a sexual attraction to individuals of a different gender from the adolescent’s natal sex may predict a more challenging treatment course and outcome (Lawrence, 2010; Smith et al., 2005a; Smith, van Goozen, Kuiper, & CohenKettenis, 2005b).

GIDS have made the decision to amend the language from Leibowitz’s ‘natal maleness’ to the deprecated ‘biological maleness’. Also note the references underpinning this claim are from older studies published in 2010, 2005 and 2005. Using a 2016 reference to cite findings published in 2005 is misleading – especially given how different to world was for trans youth healthcare 15 years ago.

Looking at the most recent of these studies – the 2010 Lawrence paper. It turns out this is itself a literature review of older work, an overview of studies from as far back as 1974. The paper itself is extraordinarily pathologising and dated. Is this the best we can expect from our NHS in 2019?

However, current referral patterns to child and adolescent gender identity clinics in the western world demonstrate a shift in the sex ratio, with many more female-bodied young people referred, especially in adolescence, in the context of an overall increase in the number, diversity and mental health complexity of referrals, including the observation that many young people seeking help from gender clinics are also neurodiverse and/or meet criteria for a diagnosis of an autism spectrum condition

Again, ‘female-bodied’. Clinicians in other countries successfully write about gender diverse children and adolescents without mis-gendering them. It is not hard to do. This is lazy, cisnormative and disrespectful.

“Tentative hypotheses which emphasise primarily biological, social or psychological processes have been proposed to make sense of why young people with ASC may be at higher risk of GD, although they have rarely been tested (see Van Der Miesen, Hurley, & De Vries, 2016)”

‘Higher risk of GD’. This use of “risk” pathologises trans identities and reinforces the false and harmful concept that  a child being trans is, in and of itself, a bad outcome.

In a retrospective chart review of referrals to Finnish clinic over a 2-year period (n=47), Kaltiala-Heino et al. (2015) found that 65% presented with adolescent onset GD, defined as age 12 and above, and most (n=41) were female-bodied. The authors identified five distinct groups; the largest group developed gender identity development difficulties in the context of confused identity more broadly, with histories of social exclusion and persistent bullying when younger. In adolescence, they presented with social anxiety and depression, most often with self-harm and suicidal ideation (if not attempts); were socially and/or academically marginalised and had very high expectations that medical interventions for GD would solve their difficulties. A comparable profile – of young people with adolescent onset GD, significant psychological difficulties (histories of trauma, psychosis, body dysmorphic disorder and severe depression) and expressions of certainty about medical interventions being the only solution – has been observed in the gender identity clinic at the Toronto Centre for Addiction and Mental Health (Zucker et al., 2012). A retrospective chart review of referrals to GIDS 2009–2016 (n=4148) showed that the vast majority of referrals were adolescents, with the sex ratio favouring female-bodied young people (1:2.1) in this age group (Carmichael, 2018). There was a sharp increase in referrals, with referrals for male-bodied adolescents increasing by 55% on average each year and for female-bodied adolescents by 105% over this 7-year period (Carmichael, 2018).

That the authors choose to cite studies from only the trans sterilising Finland, and from the utterly discredited Zucker reveals the inherent bias of the paper. There is no citation of the evidence base of the children who are thriving with a gender affirmative environment. No mention of the known link between minority stress / family rejection / transphobia and poor levels of well-being amongst trans youth. Again the language is outdated. It is interesting that a recent critique by the Guardian’s US staff rejected the the transphobia  of the UK head office, highlighted that the language of ‘female-bodied’ was unacceptable. Through the use of this language of stigma, the UK Children’s Gender Service is codifying and giving authority to systemic transphobia.

A significant proportion of young people in GIDS are also neurodiverse and may present with traits of ASC and/or a diagnosis. Between April 2011 and August 2018, 48% of children and young people who were seen in GIDS and whose parents completed the social responsiveness scale (SRS), a quantitative measure of autistic behaviours in children and young people, scored in the mild to severe range (n = 2073). Ten per cent of female-bodied young people scored in the severe range, as did 7% of male-bodied young people.

As GIDS service users we have grave concerns as to the validity of these findings. We have multiple first hand reports of GIDS forms being destroyed or never returned by parents and youth. One of the stated reasons for this is their deeply pathologising language. It would be useful to have data on completion rates before giving any credence to these figures.

“The dilemmas around how and when to respond to requests for medical intervention come alive in particular ways when working with these young people. These are inherently ethical questions, as well as medical and psychological ones and views are often polarised (Wren, in press). A number of concerned parent groups characterise the willingness to provide such intervention to young people as the medicalisation of psychological and social ills. In relation to female adolescents, this is constructed as simply confirming an identity conceptualised as often the only viable escape route from the oppressive gender and sex-role stereotypes society applies to girls and women (DaviesArai, 2018). A competing discourse, also represented by parent groups, promotes young people’s rights to medical treatment and can be characterised in terms of its emphasis on the ‘privileged access’ they have to their own bodily experience; this arising in part from the contexts of a health care system and broader sociocultural milieu in which trans people have historically been pathologised and dismissed (Wren, 2014). The GIDS clinician has to navigate through these competing forms of knowledge and justice claims, always ‘working at the edge’ of the boundary between 4 Clinical Child Psychology and Psychiatry 00(0) mind and body. In doing so, there is an attempt to preserve a space for thinking and to hold a balanced view, which attends to complexity (Di Ceglie, 2008, 2009)”

Here GIDS clinicians are stating that they are listening to and take note of the views of organisations like Transgender Trend, a group of anti-trans lobbyists who actively campaign against trans rights, especially trans children’s right. This “group” has only had two named members (the founder DaviesArai is cited above for a non-peer reviewed book chapter). Neither of the two named members of Transgender Trend are current GIDS service users or have ever had children within GIDS. This group share materials claiming that trans identities are deluded and should be treated with conversion therapy. There is no evidence they represent any significant numbers of parents of current GIDS service users. By referring to these anti trans lobbyists as ‘parent groups’, and by citing them in the bibliography – GIDS are engaged here (not for the first time) in legitimising one of the UKs most prominent anti trans campaign groups. This legitimacy is extremely harmful – the Transgender Trend resource pack for schools, if followed by a school, not only would break law as per the Equality Act, but would cause significant harm to LGBT pupils which may include GIDS service users. The group was forced to apologise and withdraw a sticker campaign which encouraged students to bully trans pupils. Yet here are GIDS clinicians giving legitimacy to this hate campaign.

In this paper, GIDS contrast the view of groups like Transgender Trend with the view of parents like myself, who want their child to have evidence based, modern, respectful, trans-positive healthcare.

They position GIDS and themselves as half-way between parents like myself and Transgender Trend. Halfway between accepting trans children as a part of natural diversity to be loved and supported, and denying the mere existence of trans children and considering such children deluded and psychologically ill. These two ‘positions’ are not equally valid. They are not equally supported by evidence or experience. Positioning GIDS as halfway between the two, considering either as equally valid, risks causing significant harm.

Educating parents

One important issue that is not mentioned in the paper, is the role of GIDS in educating parents. The vast majority of cis parents, raised in a cisnormative and transphobic UK, educated under section 28 (UK law forbidding school education about LGBT people), start out highly ignorant about trans children. In other countries’ children’s gender services, educating parents, and educating wider media, schools and society about gender diversity is a top priority for gender clinicians. In the UK GIDS does not perform this role (sometimes doing the exact opposite, and giving credence to un-evidenced groups like Transgender Trend, failing to publicly distance themselves from fringe theories around ‘social contagion’ and failing to even condemn anti-trans publications like the Transgender Trend resource pack for schools).

We know from speaking to senior GIDS staff, that the majority of kids arriving in their service as adolescents (ie the cohort in this new GIDS paper) are not supported by their parents. This topic is not mentioned in the paper. It is unclear whether any of the youth who have not yet been approved for medical intervention in this data set, are being held back by lack of parental approval.

There is zero acknowledgement in this paper of the critical role GIDS staff should be playing in educating parents and society on gender diversity. There is zero acknowledgement of the harm caused when parents fail to support their trans adolescent.

Back to the new GIDS paper

“Following psychosocial assessment and provided that a young person is in established puberty and can give informed consent, they may be referred to the paediatric endocrinology clinic to undergo a brief medical assessment with a view to commencing hormone blocking treatment.”

Puberty blockers are reversible. Some trans kids start puberty at age 8. Puberty blockers are regularly given to cis kids in precocious puberty at age 5 or 6. Informed consent from a child is not required for puberty blockers. Consent from a parent on behalf of a child is sufficient. I worry that they are moving towards claiming Gillick competency is needed before blockers, which will deny timely care to kids who start puberty early (which is likely to discriminate especially against kids who are not white who are more likely to start puberty at an earlier than average age), and kids who are considered less able to be Gillick competent at say age 11 or 12 (which I’m guessing is likely to discriminate against kids who are neurodiverse). Restriction on timely access to blockers are also likely to discriminate against trans masculine kids (who on average start puberty at an earlier age than trans feminine kids). This is not considered in the paper.

The Study Aim

“This study aimed to develop an initial understanding of those young people who presented to GIDS with GD emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or no longer felt that their gender identity was incongruent with their biological sex, through (1) an overview from the authors’ caseloads of their demographic and shared characteristics and (2) two more detailed case examples.”

The Sample

They started with a sample of 156 cases of adolescents age 12 and older at age of first assessment whose psycho-assessment phase ended with them categorised as ‘open case’ (47 ‘male-bodied young people’; 109 ‘female-bodied young people’). The paper does not define what ‘open case’ means, but I interpret it to mean cases where the adolescent has not been approved for referral on to endocrine services (=not been approved for blockers) at the end of the assessment phase.

Four (2.5% total) dropped out after one session (no mention on if they dropped out to go private) and no acknowledgement that GIDS often does not know when kids go private.

20 (13% total) female-bodied young people intended to pursue medical interventions in adult services. 4 (2.5% total ) gave practical reasons as to why they were not seeking medical interventions at that time (two males; two females). 12 (8%) cases met criteria for GD emerging in adolescence, were actively requesting medical interventions at outset of assessment and ceased wishing to pursue medical interventions and/or no longer felt that their gender identity was incongruent with their biological sex.

Interesting that they combine ‘ceased wishing to pursue medical interventions’ with ‘no longer felt their gender identity was incongruent with their sex’ – these are very different categories and makes no sense to lump them together.

116 (75%) were still wanting to pursue medical interventions in GIDS.

The latter figure is not stated specifically, and had to be calculated by deduction. This is a strange omission.

The figures as presented here show that 2.5% dropped out after one session (no discussion on if they went private or waited to get referred direct to adult services). 13% were forced to wait for treatment in adult services. 2.5% had practical reasons for not wanting to have medical interventions at this time. 75% were still wanting and waiting for medical interventions. And 8% either no longer felt the need for medical interventions (but still trans) or decided they were not trans.

Remember these are all percentages of the youth arriving at the service at age 12+ who have not been referred for blockers at the end of their (9 month) assessment.

The 8% who no longer wanted medical interventions is presented in the paper as 12% for no given reason (It appears they exclude the first three categories to get a lower denominator to give the impression of a larger number…). I find it poor practice to exclude categories from the sample size at the analysis stage, without clear justification – it biases the statistics.

The authors (in the next section, not in the main sample data section) break this 8% up into the two categories, stating that 7 (4% total) decided they were cisgender and 5 (3%) were trans but decided they didn’t need medical intervention.

Other facts

“The mean length of the psychosocial assessment was 9.6months (range=2–14 months). The mean number of assessment sessions was 6.6 (range=2–9 sessions). The mean number of individual appointments was 1.7 (range=0–4 sessions) and the mean number of family sessions was 5 (range=1–8 sessions)”

As GIDS service users the interesting, though unspoken finding from this sample is that of these ‘open cases’, 88% (75% + 13%) are still wanting to access medical treatment, but have found their pathway to medical intervention denied (or delayed) even at the end of a 9.6 month (average length) assessment. Note the NHS service specification gives an assessment period of 3-6 sessions over 6 months – yet this group have had an average 9.6 month assessment. There is no mention of the time period of this data set, nor of the average length of wait before first appointment. For the past 2 years waiting times have always been over 10 months, and in past years have risen to over 20 months – so the amount of time waiting before a 9 month assessment is relevant information.

With 88% of these adolescents still waiting and wanting medical intervention even after a 9 month assessment, this is a service operating under an extremely cautious model. Missing from this new GIDS paper is any reflection of potential harm caused through this prolonged assessment period. There is no acknowledgement of the harm of withholding fully reversible puberty blocking medication from extremely vulnerable trans kids. The evidence base (ignored by GIDS) states that withholding puberty blockers is not a neutral option and will cause harm (Giordano, 2014) Yet the England and Wales service continues to do this.

There is no reflection of the impact on vulnerable youth (88% of this sample) of:

• waiting up to 20 months after they have finally worked up the courage to
  • a) tell their parents
  • b) persuade their parents to go to their GP
  • c) persuade their GP to give a referral to GIDS,
• to then undergo a 9.6 month assessment
• to at the end of this 9.6 month assessment still be denied any access to fully reversible medical interventions (hormone blockers).

There is no discussion of the powerlessness of being kept in a prolonged state of waiting, with no clear end in sight and no power to influence the monopoly power of GIDS gatekeepers (not to mention the kids with unsupportive parents and unsupportive GPs that can make the process longer still).

And we know that the adolescents most likely to be kept in this state of prolonged denial of timely interventions, are neurodiverse adolescents (and allistic adolescents without parental support).

It is interesting that only 4% of the ‘open cases’ (the cases of kids first seen at age 12 or older which were ‘open cases’ at the end of a 9.6 month (average) assessment) were kids who seemingly decided they were cisgender.

The paper focuses on this 4% (this is not 4% of all youth, just 4% of the youth denied access to blockers after the assessment phase). The paper provides no reflection of society or familial pressure to identify as cisgender and no reflection of the known experience of gender diverse people having a number of ‘unsuccessful’ transitions before returning to a transition later in life.

It is highly significant that it is the 4% minority of ‘open cases’ which  GIDS choose to focus their publications on.

Also we have no information provided here on statistics as to how many kids aged 12 and older at first assessment are cleared for medical intervention at the end of the assessment phase. So we have no idea what percentage these 7 individuals are out of the overall caseload of kids in the GIDS service. Although we know the percentage will certainly be less than 4% of all 12+ year olds. Omitting this data, and denying us sight of what percentage of all youth aged 12+ in the service are these 7 kids, seems like misleading manipulation of the statistics.

They also note here that “the majority of the 12 cases” who were not wanting medical intervention ‘had not received a formal diagnosis of gender dysphoria’ (again they have reverted to grouping together the 5 individuals who are trans but don’t need medical intervention and the 7 who are cisgender – for no clear reason). Again this is confusing at best – why are we talking about a sample who have not been diagnosed with gender dysphoria?

Case Vignettes

Out of their 7 individuals who have seemingly decided they are cisgender, the authors pick 2 to write up a case history. The 2 individuals picked are supposedly representative of the other 5.

They had “a diagnosis of an ASC and significant risk including suicidal ideation and self-harm. In both cases, the referral was presented in such a way as to assume that medical transition would be the primary intervention required to alleviate gender-based distress; however, they had not received a formal diagnosis of GD”

Here the authors present a table of the characteristics of the 12. Again grouping the 7 who are cisgender and the 5 who are trans but decide they don’t need medical intervention. It is problematic and unhelpful to combine these two categories together and smacks of deliberate manipulation. This criticism would be avoided in part if  table (ref) was split up into the two different groups allowing comparison.

The two case histories presented are presented without acknowledgement of author weighting, or bias, and extrapolated to represent and support a narrative.

Case history one had not socially transitioned nor expressed a wish to socially transition, and chose to drop out of the service before his 8^th appointment. He had one follow up appointment at which point “he spoke openly about continuing to feel confused about his identity and was still struggling with low mood”. He had no medical intervention through GIDS, not even blockers.

Case history two was a 14 year old adolescent assigned female at birth, who had socially transitioned to male 18 months before their first appointment. At some point over the 13 month assessment she was prescribing the contraceptive pill to stop periods. At a later point she confirmed she no longer wanted to pursue any medical intervention through GIDS (ie did not want hormone blockers – though for an assigned female who is already needing to bind and has already started their period, hormone blockers are of limited usefulness anyway – this is not discussed in the article). At a later point, at age 16 (again, without having accessed any GIDS specific medical interventions) the individual moved back to female pronouns.

Analysis

“The case review yielded cases of young people who were predominantly female-bodied with high levels of social communication difficulties, suicidality and self-harm. While a sex ratio favouring female-bodied young people, higher levels of mental health complexity and neurodiversity have been observed more broadly in referral patterns in GIDS and elsewhere (Aitken et al., 2015; Carmichael, (2018); Kaltiala-Heino et al., 2015; Van Der Miesen et al., 2016), the presence of these features was particularly pronounced here.”

This may be true, but let’s check the  sparse facts as presented. 7 individuals out of 156 (4%) of the ‘open cases’ (cases aged 12+ at referral who were not referred for medical intervention after a 9 month assessment) decided they were cisgender (most of whom were never formally diagnosed with gender dysphoria). We don’t know clearly the assigned gender of these 7. We know that the 12 (including the 5 who were trans but decided they didn’t need medical intervention) included 9 assigned female at birth and 3 assigned male at birth.

Voice

Here’s a thought – there is no voice of any child or adolescent in this paper. It is meant to be a portrait of two case studies, but where is the adolescent’s own words? The focus is primarily on the clinician’s view. Secondary is the parent’s view. Absent is the adolescent’s view in their own words.

Back to the paper

“It was striking that a clear majority of the young people had either an existing diagnosis of ASC or would be likely to obtain one; a higher number than would be anticipated in the context of the already observed elevated levels of ASC in GIDS cases.”   

From the 12 (again, no information on the pertinent 7), we know that 7 had a diagnosis of an ASC prior to first appointment and 5 did not. 4 out of the 5 without a formal ASC diagnosis completed a ‘Social Responsiveness Questionnaire’ and 1 was rated a normal range and 3 severe. Discussing the meaningfulness of this questionnaire and issues around ASC is beyond the scope of this blog.

“Assessment consisted of at least six sessions in most cases – at the upper end or beyond what the existing GIDS protocol suggests – although notably there was also considerable variation in assessment length. This may be illustrative of neurodiverse children needing more clinician-facing time to convey their experience due to their progressing through gender identity development along differing timelines or frameworks than neurotypical peers (Van Schalkwyk, Klingensmith, & Volkmar, 2015). This is in line with initial clinical consensus guidelines for this population, which recommend an extended diagnostic period and the need for clinical decisions to proceed more slowly due to the myriad ‘social, adaptive, self-awareness, communication and executive function complexities’ of this population (Strang et al., 2018, p. 107). The findings suggest further research and service development is needed on this theme, including greater collaboration across services to share learning and explore whether such young people may require different or adjusted assessment protocols. Interestingly, the majority of the young people had not received a formal diagnosis of GD prior to coming to GIDS, and it may be that this contributed to their capacity to engage with an extended and exploratory assessment process through which an individualised formulation could be co-created. Furthermore, discussions between comparable gender identity services internationally could help to shed light on the function and timing of providing a diagnosis of GD”

Here the authors are arguing that extended assessment could be beneficial for youth with ASC (Autism Spectrum Conditions?). Let’s not forget, they are arguing that it is beneficial to extend the time for which neurodiverse youth are denied access to fully reversible puberty blockers. They are focusing on 7 individuals who ended up identifying as cisgender, and presuming this path needs to be applied to all neurodiverse youth. Let’s not forget, they are not considering in this study any negative impacts on the 88% of youth in this sample who have continued to be denied puberty blockers, youth who are still wanting and waiting for medical intervention even after a 9 month assessment phase. The GIDS authors also make here a rather bizarre suggestion that the lack of a formal diagnosis of Gender Dysphoria was perhaps in some way related to these 7 individuals ending up identifying as cisgender. They suggest there is a benefit in delaying or denying diagnosis for youth who are eligible for such a diagnosis. This is a spectacularly un-evidenced jump. And worrying in its implications. It is reckless to make such a jump.

“It was also the case that the majority of young people had not made a social transition. Longitudinal data examining the impact of social transition are sparse (Olson-Kennedy et al., 2016); existing studies have focused on those with childhood onset GD and drawing on limited case data, suggest that the process of re-identifying with one’s original gender role can potentially be stressful in terms of fear of teasing and feelings of shame around being ‘wrong’ (Steensma & Cohen-Kettenis, 2011).

It is unethical to state this. The Steensma 2011 study took a sample size of 2 individuals, an neither of these individuals had socially transitioned. We review this in a 2017 blog in detail (see second half of this blog). This cannot be used as evidence of the harm of social transition as is clearly inferred here

It is possible that for some of the cases identified in the case review, living in the gender role congruent with their biological sex was one factor, which facilitated the opportunity for meaningful exploration in the assessment phase as opposed to premature ‘foreclosure’ of identity (Marcia, 1966), although it was also the case that some young people who had already socially transitioned did feel able to live once again in the gender role congruent with their biological sex. For some young people (such as Louise, described above), social transition may be felt to be precisely the platform through which a meaningful exploration of different adult roles can occur and/or may in the longer-term turn out to be a necessary and sufficient means through which to live life well as a gendered person.

The GIDS clinicians recognise the potential benefits of social transition for case study number two, who had socially transitioned, and then makes a second social transition. But they also conclude that for case study one, not having socially transitioned may have been part of his becoming comfortable with a cis male identity. There is no acknowledgement of choice and autonomy here. Case study number one never wanted to socially transition. So he cannot be used as an example of the potential benefits of not supporting a social transition. A child who never wanted to socially transition, cannot be used to argue for denying the social transition of a child who desperately wants to do. It is a marked failing of this paper that GIDS do not acknowledge this distinction.

“In both the cases described here, a number of common themes can be noted, including experiences of teasing/bullying (including of a homophobic nature) prior to the onset of GD, a sense of exclusion and isolation, difficulties in social communication and engaging with peers, distress in relation to awareness of a developing sexed body and difficulties separating from parents. In retrospect, these young people’s initial determination to medically transition and the subsequent shift in this sense might be better understood in the context of a broader identity confusion (Kaltiala-Heino et al., 2015). Of course, there are multiple factors influencing outcome. However, it possible that in different ways for these two young people, the GIDS assessment provided a platform through which issues of homophobia and internalised shame, familial narratives and relational ruptures, and beliefs and fantasies associated with mid-adolescence (Dallos & Vetere, 2009; Newcomb & Mustanski, 2010; Waddell, 1998) could be meaningfully thought about and integrated into a story of who one is becoming.”

I feel this is the role that GIDS clinicians want to have. They want to focus on parental attachment, identity confusion, internalised shame etc. And perhaps there is a role for this with some children and adolescents. But they seem to look for these issues with every child. They cannot seem to conceive of what role they should be playing in caring for kids who just are trans. Kids who do not benefit from extended psychoanalytical evaluation and enforced ‘exploration’ of self. This tension in the service is not acknowledged at all.

Conclusion as per the authors

“The study highlights the need for the psychosocial assessment to nurture a space in between the internal and external worlds of these young people (Marchiano, 2018). Such an assessment would need to be properly located in a developmental framework which takes seriously the inescapable in between-ness of adolescence and joins with young people and their families to broaden the narratives available to them, to make sense of gender-based distress.”

Conclusion as per the evidence in the paper

The conclusion I would write based on the data in this paper:

Out of a sample of 156 youth, aged 12+ at referral, who had not been approved for medical intervention after a 9.6 month assessment period, 88% are still waiting and wanting medical intervention. The impact on the wellbeing of these 136 adolescents of denial of timely, safe, reversible medical intervention is not considered a research priority by this team. 7 youth (4%) out of this sample (of those adolescents not approved for medical intervention after a 9.6 month assessment) decided they identified as cisgender. These 7 had not had any GIDs specific medical interventions.

End: This is another deeply flawed and potentially harmful publication from GIDS. My concern is that given their monopoly provision and total power, no-one in the UK NHS establishment will notice, yet alone care.