I fear they are failing children with many complex problems

FOuR years ago, I wrote a report about the Gender Identity Development Service at the Tavistock, England and Wales’s gender identity service for children and young people, warning it was failing to fully examine the psychological and social reasons behind children and young people feeling at odds with their sexed body, technically called gender dysphoria.

This report was based on the serious clinical and ethical concerns raised with me by a large number of clinicians working at GIDS.

I was concerned that amid the rise in the number of young people questioning their gender, children were being rapidly started on puberty blockers instead of receiving appropriate care for gender dysphoria, which I believe should be treated alongside other mental health problems.

There has been a massive increase in the number of children presenting with gender dysphoria in recent years.

But there is a lot of evidence to suggest this increase is an expression of complex socio-cultural phenomena that we are only beginning to understand. It can often be a socially sanctioned way in which children and young people can express various psychological disturbances.

All psychological problems exist on the border of culture and individual psychology. Cultural changes produce different disorders, for example hysteria was common among women in Freud’s day.

The appraisal of the gender service offered for young people in Scotland by the Sandyford and the endocrinology department at the Royal Hospital for Children in Glasgow takes a thorough look at the data on patients but fails to ask some very important questions.

The survey suggests, unsurprisingly, that the service is similar to GIDS (at the time of my report) in that it is a gender affirming model.

That means that there is a strong pressure within the service to accept in an unquestioning way the child’s self-description as ‘trans’.

THE appraisal reveals that there are high levels of comorbidities among the young people attending the service, which include various serious mental health problems and autism.

However, it is somewhat remarkable that the authors do not come to the inevitable conclusion that we need to examine why so many young people with these co-morbidities are presenting themselves as ‘trans’ and, as a result, are being put on a treatment pathway with irreversible consequences.

I note that the study reveals a very low take-up of fertility preservation (through banking sperm or ova) but lacks curiosity as to what this may represent. Can a young person in acute mental pain, and thus urgently desiring action, be in a position to think themselves into an adult body they do not yet have and calmly consider whether in the future they may want children?

Many of the natal females in this patient group view their female sexual body with hatred and disgust and so their primary urgent aim is to be rid of it forever.

It is of concern that the study has treated this finding so superficially. The low take-up of fertility preservation should act as a warning sign.

Like the GIDS, the Scottish service notes that a very high percentage of young people, once started on puberty blockers, continue on the pathway – going on to opposite sex hormones (the researchers use the term ‘gender affirming’ hormones, an inappropriate term as it perpetuates the idea of affirmation).

The fact that so few young people desist, that is decide to remain with their natal sexed body, should, again, be a concern.

The review of the Tavistock Gender Services of children and young people led by Dame Hilary Cass expressed serious concern that puberty blockers, by impeding normal puberty, can effectively ‘lock in’ children and young people to a treatment pathway which culminates in progression to feminising/masculinising hormones.

Prescribing puberty blockers to children is not a neutral medical act. In effect, it colludes with the idea that their sexed body is disgusting and must be prevented from developing. I note there is no comment in this appraisal as to whether this treatment model is effective – there is no indication of any long-term follow-up of patients. Nor are any concerns expressed as to the potential destructive effects of puberty suppressing hormones.

INDEED, there is a lack of evidence worldwide on the effects of prescribing puberty blockers for gender dysphoria, and there is significant concern that they may interfere with brain and bone development. A child’s development, in any case, is not like a video that can be paused and then played.

I share Cass’s view that a national gender service is the wrong model. These children and young people need to be understood in the context of the other mental health issues they are experiencing, in order that they can be treated holistically and also locally. The NHS Child and Adolescent Mental Health Service is the appropriate clinical context for these young patients.

However, that service is grossly underfunded (this was so even before Covid) and so will urgently need resources to help them manage these patients – a more appropriate use of resources than pouring them into the wrong (national) model.