Transgender issues in the light of the High Court ruling

In the 1990’s I spent six years (part time) working in a research/writing capacity in the Gender Identity Development Service (GIDS) at the Portman Clinic, working very closely with the founder and then Director of the service, Dr Domenico Di Ceglie. The key point to say here is that, at that time, Dr Di Ceglie was not supportive of giving puberty blockers to children under the age of 16 despite pressure both from clients and other international services that saw themselves as more progressive (e.g., Netherlands), and it appears from the judgement that this practice has started since his retirement. Of course, I do not know what Dr Di Ceglie would have prescribed now. This is an area that inflames feelings so quickly and to such a high level that I rarely comment, especially as I am not a clinician and my involvement was over 20 years ago. Consequently, I offer a personal view with some trepidation.

The difficulty with the courts becoming involved in clinical practice, in my view, is that the civil courts take a long time to rumble through to a decision (and the Tavistock/Portman Trust is considering appealing the decision) and it lays down rigid lines that can interfere with the clinical judgment in individual cases, and medical evidence does not stand still and clinical decisions can change over time. Or, to put it another way, the discourse of medical evidence is very different from the discourse of legal evidence as presented in the civil courts.

Just to clarify, I am defining “Sex” as biology and understanding we are all born male, female and a few with an intersex condition or chromosomal abnormality; this can’t be changed, we nearly all are XX or XY. “Gender” I am taking to be the social and psychological roles we adopt within our culture at a particular point in history – girl/woman, boy/man, something more fluid or less definable,  which is why people who transition are very careful to use the word “transgender” and not “transsexual” in the current discourse.

I could be wrong here, but I get the impression that in public comments there is, to an extent, a generational difference, and it appears to be largely around males changing their identity to girls/women and much less around females who want to identify as boys/men. Older people, by and large, are reluctant to  accept that any person can simply self-identify and, on the basis of this to  be recognised as the other gender (or somewhere in between), whereas younger people seem more comfortable at just accepting this self-assertion as sufficient. It is clear, that many older women who identify as feminists are very uncomfortable about males being able to simply self-identify in the other gender and to be able to enter women-only spaces (or do I mean female-only?).

Another bone of contention is changing the birth certificate. Now, the British birth certificate has the category “Sex” on it where (in the vast majority of cases) the word “Boy” or “Girl” is entered – this dates back to when the word “gender” was used as a grammatical term and the word “sex” covered what we now call “sex” and “gender”. Personally, I think changing the birth certificate is complex. The birth certificate is, as its name states, the record of sex/gender(?) at birth, but it is also a living document that is the ultimate proof of one’s identity and, consequently, is a crucial live document. Personally, I think the birth certificate should stay as a record of the sex at birth that can have an amended note added when a person has legal recognition of a change of gender to one that is no longer coterminous with sex assignment at birth.

I also must comment on my concern with social media that an “orthodoxy” very quickly establishes itself and anyone who deviates or even wants to explore that orthodoxy in public can be flooded with opprobrium and very hostile comments; e.g., J.K. Rowling. In my view, this makes it far more difficult to have a respectful space for the exploration and discussion of complex issues including health issues, even when the topic is very emotional. Another example of this surrounds Chronic Fatigue Syndrome.

My main involvements were co-editing with Dr Di Ceglie the second book in the field (after Zucker & Bradley) and first multi-author book; “A Stranger in my Own Body. Atypical Gender Identity Development and Mental Health”; Karnac Books, 1998. (I also attended conferences, gave papers, attended the Mermaids transgender support group). I then led on the first clinical audit (working with Domenico Di Ceglie, Susan McPherson and Philip Richardson) of the service for the trust, and which meant producing a classification for analysing the case files retrospectively – this is methodologically unsatisfactory but was the best we could do in the circumstances as the Trust wanted historical information. (See ) We then published two papers in peer-review journals on our findings one primarily looking at associated psychopathology and one looking at the impact on non-transgendered children of having a parent changing gender. At this point, in the first ten years of the service (including before it moved with Dr Di Ceglie to the Tavi/Portman) there were around 130 cases and I analysed around 100 cases, so I base a lot of my understanding on having analysed every record in these files. One difference between what I read now and then is that in the early years of the service the majority of referrals were males and now it is females.

Generally, we found that the young people referred had a higher level of psychopathology than in the general population. I am not going to speculate whether this elevation was because of distress caused by the gender dysphoria or whether the distress existed and the young people sought a solution in changing their gender identity, or it varied from case to case and was not necessarily either/or. I also think, from my reading, that there was a difference between a relatively small group who were completely convinced from a young age that they were living in the wrong body and the majority of referrals at this time who desired a change. 

What was also very important was that through many years of careful support (both for the client and family) and treatment from a small multi-disciplinary team, outcomes were quite often not the obvious, and a substantial number of young people were able to find an identity that did not involve transitioning and the consequent decisions around life-long taking of drugs and various degrees of surgery. A lot of what the service was offering at that time was security and a feeling of being “held securely” within which the young client and family could explore their feelings and desires over a number of years. 

More recent research by Prof Simon Baron-Cohen et al, at Cambridge University, has found elevated rates of autistic traits and other neurodevelopment and psychiatric diagnoses amongst young transgender people. This in no way invalidates the referrals but makes me want to emphasise just how complex these cases are, how difficult it can be to reach a resolution that is considered “satisfactory” for the remainder of the client’s life,  and the danger of generalising too much.

One other important issue to consider is around the taking of puberty blockers.  There appears to be findings that the density of minerals in bone marrow is decreased from normal levels, which means that each individual needs to be closely monitored by a paediatric endocrinologist and the potential long term consequences are unknown and need to be considered. 

On reading my original post on a social media platform, a female British GP commented; “My journey had a very happy ending. I would also say that I certainly had autisticky features as a child. I work on the ASD pathway up here, and can see myself as on the right of Simon Baron Cohen’s bell curve. I maybe wouldn’t have got a diagnosis but wonder looking back whether it was a factor, and many of the girls I see who have gender identity issues have a degree of social communication issues at least. Hugely interesting. I had great parents btw, who encouraged us to get education and completely went along with my quirks. They let me be me!”

Personal anecdote. In the early 1980’s we got to know another family firstly at a local playgroup where a carer stayed with the child and then our first children spent eight years together going through the local primary school in the same class. The mother and I became good friends Our second children were also of a similar age and we would often meet again at the playgroup. Her second child, her son, showed from an early age atypical gender play in his choice of games and dressing up clothes and play – this was obvious to me without any special knowledge. Sometimes we chatted about J’s behaviour at the school gates and the mother was very tolerant but bemused. 

When J was not very old he was referred to the GIDS. J and the family received a comprehensive, long term service from the multidisciplinary team at the GIDS. Years later, when I became involved with the GIDS and had gained some knowledge in the field, I thought to myself that J was just the sort of boy who would go through the transition to living as a girl/woman, and I might have even made a small bet on it. Once I started the analysis of the files I promised the mother that I would not look at her son’s file and, consequently, I do not know what it contains. But, and here’s the important point, when I have bumped into the mother in subsequent years and we have chatted about our families, the resolution was that her son did NOT did not transition to life as a woman and did not undergo “sex change” surgery; she has said that he has had a very tough time (as has the family) and is not contented in every aspect of his life, but he has found his way through without transitioning or undergoing major surgery. This makes me reflect on two points: the GIDS offered a successful service to a child and family over many years out of which came a satisfactory outcome. Second, you can’t always predict an individual outcome from an early presentation and makes it all the more important to proceed with flexible thinking, and care and caution.

David Freedman

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