Quillette 17 January 2020
Over the past five years, there has been a 400 percent rise in referrals to the Tavistock Centre in north London, the only National Health Service (NHS) clinic in Britain that treats children with gender-identity developmental issues. During this period, there also has been an abrupt shift in the composition of the children seeking treatment. Formerly, a significant majority of patients had been young male-to-female children. Now, a significant majority are biological females who claim to have a male gender identity, often following the rapid onset of gender dysphoria in their teenage years.
We do not fully understand what is going on in this complex area, and it is essential to examine the phenomenon systematically and objectively. But this has become difficult in the current environment, as debate is continually being closed down amidst accusations of transphobia. As I argued in a May, 2019 presentation before the House of Lords, this de facto censorship regime is harming children.
Those who advocate an unquestioning “affirmation”-based approach to trans-identified children often will claim that any delay or hesitation in assisting a child’s desired gender transition may cause irreparable psychological harm, and possibly even lead to suicide. They also typically will cite research purporting to prove that a child who transitions can expect higher levels of psychological health and life satisfaction. None of these claims align substantially with any robust data or studies in this area. Nor do they align with the cases I have encountered over decades as a psychotherapist.
During the 1980s, I assessed adult parasuicides (apparent suicide attempts, or suicidal gestures). A number of my patients had gone through gender-reassignment surgery, and often were angry at the loss of their biological sexual functioning. They also were aggrieved with psychiatric professionals, who, they believed, had failed to adequately investigate the underlying psychological difficulties associated with gender dysphoria.
As a psychotherapist, I consulted with various mental health services that managed patients exhibiting challenging behaviours. In this capacity, I observed that patients who had a history of serious and enduring mental illness or personality disorder sometimes would also develop gender dysphoria. A common theme in their presentations was the belief that physical treatments would remove or resolve aspects of themselves that caused them psychic pain. When such medical interventions failed to remove their psychological problems, the disappointment could lead to an escalation of self-harm and suicidal ideation, as resentment and hatred toward themselves was acted out in relation to their bodies.
One young man, who had a diagnosis of schizophrenia, had a fear of his own aggression, as he had once threatened his mother (whom he relied upon to care for him) with a weapon. After I treated him for several months, during which time he explored his fear of his own explosive temper, he suddenly announced that he wanted to change sex. There had been no previous evidence of gender dysphoria mentioned either in his notes or in his consultations with me.
At that time, schizophrenia was a negative indication for sexual-reassignment surgery. However, the patient was quickly assessed and taken on by Charing Cross Gender Identity Clinic. In my opinion, switching gender likely was a strategy for immobilizing his frightening temper and fear of psychotic outbursts (as women are stereotypically less violent and threatening). I wrote to Charing Cross recommending that the psychotherapy should be allowed to continue, and that the gender-reassignment treatments be put on hold, so that these deeper issues could be addressed. The team treating the patient indicated their disagreement and continued with the referral.
My concerns in this field became more acute in Spring, 2018, after I retired from active work as a therapist and joined the Board of Governors of The Tavistock and Portman NHS, which hosts the National Health Service’s Gender Identity Development Service (GIDS) at the aforementioned Tavistock Clinic—a public facility available to everyone in the UK. Almost as soon as I’d joined, I was made aware of the growing controversy over GIDS. A letter had come in from a group of parents complaining that their children had been fast-tracked through GIDS without any serious psychological evaluation. The author of the letter, a mother representing a group of parents, wrote to me in my role as governor, and I replied, circulating copies of that reply to other governors.
Around the same time, Dr. David Bell, a senior consultant at the Tavistock & Portman NHS Trust and a Tavistock governor, was approached by 10 GIDS staff members (amounting to about one-fifth of the London-based service) who had grave ethical concerns similar to those expressed in the parents’ letter—including inadequate clinical assessments, patients being pushed through for early medical interventions, and GIDS’ failure to stand up to pressure from trans activists. As I discovered, this was not the first time such concerns had been raised. Thirteen years previously, psychotherapist Susan Evans (who, full disclosure, is my wife) had raised her own concerns about the thoroughness of the assessment process by some staff.
As a governor of the Tavistock Trust, I personally witnessed attempts by the Trust’s management to dismiss or undermine both Dr. Bell’s report, which he submitted in late 2018, and the letter from parents. This included accusing Dr. Bell of fictionalizing the case studies he described, questioning his credentials, withholding his report from certain governors, and preventing him from attending a meeting to discuss the Medical Director’s response to his report.
I have learned, through long experience with managing clinical areas in the National Health Service, that such efforts to dismiss or discredit serious concerns about a service or clinical approach typically are driven by those seeking to evade accountability and shield their methods from criticism. Such a defensive, self-serving approach would be dangerous and objectionable in any NHS context. It was particularly worrying in the context of a service that treats vulnerable young people in the midst of life-changing, often irreversible decisions that have unknown medical consequences. And so in 2019, I resigned from the Tavistock board of governors, in protest over the Trust’s failure to address the serious concerns that Dr. Bell and parents had raised.
Many mental-health professionals share these concerns. But saying so publicly is difficult. Journalists who have researched this area report that while interviewees are willing to speak in confidence about their concerns, they shy away from being named, for fear of being accused of bigotry or taken up on human-rights claims. In an excellent 2019 book, Inventing Transgender Children and Young People, authors Heath Brunskell-Evans and Michelle Moore brought together a mix of experienced clinicians and academics to critique certain approaches to gender dysphoria. In an extraordinary step, GIDS threatened legal action against the publisher, and demanded to see the book before publication.
What’s worse, the effort to suppress unfashionable views has been joined by some leading organizations, including the American Academy of Paediatrics (AAP), whose policy statement on the issue, Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents, was scathingly debunked in a recently published peer-reviewed journal article by James Cantor. “Although almost all clinics and professional associations in the world use what’s called the watchful waiting approach to helping gender-diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach,” Cantor writes. The AAP’s approach, like that implemented by many clinicians at GIDS, appears to be driven more by political ideology than the clinical needs of presenting children.
…. When doctors always give patients what they want (or think they want), the fallout can be disastrous, as we have seen with the opioid crisis. And there is every possibility that the inappropriate medical treatment of children with gender dysphoria may follow a similar path. Practitioners understandably want to protect their patients from psychic pain. But quick fixes based only on self-reporting can have tragic long-term consequences. And already, a growing number of trans “desistors” (also known as detransitioners) are seeking accountability from the medical professionals who’d rubber-stamped their trans claims. And in 2019, when a formerly trans-identified British woman named Charlie Evans went public with her desistance, she was contacted by “hundreds” of other desistors, and formed a group called The Detransition Advocacy Network to give them a voice and support in a contentious environment that has been dominated by dogmatic trans ideology.
… In 2016, the U.S. Center for Medicare and Medicaid Services reviewed the long-term outcome studies of sex-reassignment surgery. Of the 33 studies reviewed, most were found to have methodological problems that rendered their conclusions unreliable. And the studies deemed reliable failed to show substantial improvements in psychological functioning after gender-reassignment surgery—despite the fact that anecdotal evidence suggests a strong bias toward the funding and publication of studies that align with affirmation-based approaches (and a countervailing effort to bury data that fails to support such methods).
In fact, several studies have been closed down prematurely following expressed opposition from pro-trans lobby groups and their media allies. In 2017, Spa University denied the extension of research being performed by psychotherapist James Caspian into patients seeking to reverse the effects of gender-reassignment surgery. “The fundamental reason given,” he said, “was that it might cause criticism of the research on social media, and criticism of the research would be criticism of the university, and they also added it was better not to offend people.”
… In his report to the Tavistock and Portman NHS Trust Board, Dr. Bell cited the high percentage of patients suffering from gender dysphoria who also suffer other complex problems, such as trauma, autism, a history of sexual abuse and attention deficit disorder. This finding is consistent with a growing body of knowledge that connects the development of gender dysphoria with psychological factors. Since resigning my position at Tavistock, I’ve been contacted by many parents asking advice about trans-identifying children who often tend to exhibit one or more of these factors. Typically, the parents were concerned that services such as Tavistock encouraged the idea that their child’s problems could be comprehensively addressed merely by changing gender.
… “First do no harm,” should be the least we expect from those who treat our children. Yet in 2019, it was revealed that the GIDS program at Tavistock clinic had lowered the age at which it offers children puberty blockers on the basis of a study that—it later was revealed—concluded that “after a year of treatment, ‘a significant increase’ was found in patients who had been born female self-reporting to staff that they ‘deliberately try to hurt or kill myself.’” The fact that Tavistock officials ignored such evidence suggests they have bought into the idea that transition is a goal unto itself, separate from the wellbeing of individual children, who now are being used as pawns in an ideological campaign.
This is the opposite of responsible and caring therapeutic work, which is based on the need to re-establish respectful but loving bonds between mind and body. Such are the norms in every other area of therapeutic practice. And it is high time that the ideologues who have hijacked therapy’s gender subculture be held to account.
Marcus Evans Tweets at @marcusevanspsyc. He is a Psychoanalyst in private practice and formerly served as Consultant Psychotherapist and Associate Clinical Director of Adult and Adolescent Service at the Tavistock and Portman NHS Trust. He is the author of Making Room for Madness in Mental Health: The Psychoanalytic Understanding of Psychotic Communication.