The science of trans health care is far from settled. As Marcus Evans, psychoanalyst and a former Governor of the Tavistock and Portman NHS Trust, writes
“..the understanding of this whole area is extremely limited and it is particularly important to examine it from different perspectives. This is very difficult in the current environment, as the necessary debate and discussion is continually being closed down, either through individuals being prevented from expressing their views or self-censoring through fear of the accusation of 'transphobia'.”
As he puts it:
“We need better psychological assessment, treatment and research of kids suffering from GD. The politicisation of this area has interfered with good clinical care.”
In Ireland as elsewhere, politics is exacerbating the problem.
Lack of medical evidence
In August the Sunday Business Post reported that the treatment of “transgender children” with puberty blockers in Ireland will no longer be referred to as fully reversible in new guidance to doctors. This follows a change in Britain’s NHS guidance on hormone treatment.
Puberty blockers are drugs that stop puberty from occurring in children with gender dysphoria. They have been described by many trans rights groups as an entirely safe way to give children time to decide whether they want to proceed with medical transition, and until recently the NHS said “The effects of treatment with GnRH analogues are considered to be fully reversible..”
It's unclear why puberty blockers were ever described as reversible. The recent changes to guidance follow a court case brought by a former patient who believes she was harmed by current treatment protocols, but they do not seem to have come about as a result of new information; for many years experts in the field have noted the lack of good quality studies. As Professor Carl Heneghan, Director of the Centre for Evidence Based Medicine at the University of Oxford, said in 2019
“In my view, given the paucity of evidence, the off-label use of drugs that occurs in gender dysphoria largely means an unregulated live experiment on children”.
Dr Kirsty Entwistle, Clinical Psychologist and former clinician from the Gender Identity Development Service (GIDS) and Professor David Pilgrim, Department of Psychology at the University of Southampton, discuss this lack of good evidence in a July 2020 article and explain that
“Paediatric gender transition became subject to increasing demand in recent years, before either empirical evidence or prolonged ethical debate had created a clear consensus on an optimal healthcare policy.”
The ongoing lack of an evidence base for trans health care is well illustrated by a recent correction in the Journal of the American Psychiatric Association. In October 2019 it published a widely reported paper which purported to show clear benefit from surgery for trans people. It was described as “the first analysis of the long-term effect of hormone therapy and gender-affirming surgery on transgender individuals’ mental health based on a country’s population”. However on 4th August 2020, the Journal published a correction which showed that in fact no advantage had been demonstrated.
Despite this uncertainty, a narrative has developed that some children simply are born trans, and that the only humane course of action is to affirm their trans identity, and put them on puberty blockers when the time comes, followed by medical transition. As counsellor and detransitioner Carey Callahan puts it, many parents have “been told by a doctor or a social worker that the only route forward that protects against suicidality is to affirm their kid’s trans identity.” This is frequently reinforced in the media. The ITV programme Butterfly ‘inflated the suicide risk’ of children with gender identity, according to the NHS Gender Identity Development Service (GIDS), but nevertheless received positive reviews.
Attempt to replace the existing model of care with WPATH
In January this year Valerie Flynn reported in The Sunday Times:
WPATH and “Informed Consent” reflect an “affirmative” approach for patients.
In 2018 the then CEO of TENI, the Transgender Equality Network Ireland, Stephen O’Hare was quoted in Gay Community News (GCN) as saying that
“Our view and the views shared by the HSE is that services should be delivered in line with international best practice. We would assess that best practice are WPATH guidelines. The responsibility of the HSE and the Department of Health is to ensure adherence to these standards,”
“Dr Paul Moran, a liaison psychiatrist who plays a central role in treating people at the Dublin clinic, says the WPATH guidelines ‘as they apply to assessment and treatment recommendation, are not part of our model of care, are clinically unsafe, and unsuitable for use in a public healthcare gender clinic.’”
Professor Donal O’Shea, Consultant Endocrinologist at St. Columcille’s and St Vincent’s Hospitals in Dublin warned last year of the need for a holistic model of care, where the ultimate decisions about treatments ranging from hormones to surgery, are made jointly with the individual once a detailed psychosocial assessment has been carried out.
Last year the HSE established a steering committee to develop services for those with gender identity issues.
However in January 2020 The Sunday Times reported that doctors at the National Gender Service at St Columcille’s Hospital warned that the steering committee is basing its work on an “unsafe” model of care:
Leaked minutes indicated the HSE has based the steering committee’s work on its own proposed model of care. Dr Paul Moran, consultant psychiatrist at St Columcille’s, was quoted as saying this proposal is “unsound and unsafe” because it “does not enable adequate assessment of patients and does not require proper qualification of professionals”.
Professor Donal O’Shea was reported as saying that the St Columcille model was approved by the Royal College of Physicians of Ireland and was in line with best international practice, so doctors would continue to implement it.
Who are the political parties listening to?
Nevertheless, the “affirmative models” have found support among Irish political parties.
In their 2020 manifesto, The Social Democrats promised to “introduce an informed consent model of trans healthcare” and Sinn Féin’s leader Mary Lou McDonald announced that her party wanted to “reform trans healthcare towards an informed consent model”.
The WPATH model was included in Fine Gael’s programme for government earlier this year.
The new coalition government of Fianna Fail, Fine Gael and the Greens now also plans to create & implement a general health policy for trans people in line with WPATH:
In a democracy it’s of concern when politicians join in the silencing of discussion
When RTE’s PrimeTime ran a programme in January 2019 looking at both sides of the debate, Jon Williams, Managing Director of News and Current Affairs at RTE, asked that people watch before rushing to judgement.
Green Party politicians Una Power and Hazel Chu called for the programme to be boycotted using the hashtag #TurnOffPrimeTime.
The then Minister for Social Protection Regina Doherty, the minister who had appointed the Gender Recognition Act review group which was yet to report, said on Twitter:
The acronym ‘TERF’ (for trans exclusionary radical feminists) is a slur commonly used to silence any questioning of transgender matters. It is primarily used against women as journalist Helen Lewis has explained when writing of its impact and misogynistic overtones.
Despite this, it has even been used by some elected representatives of Irish political parties, such as Councillor Chris Pender of the Social Democrats:
And Councillor Peter Kavanagh of The Green Party:
The effect of the slur ‘TERF’ is to discourage discussion or questioning. As James Kirkup reported, in Ireland legislative change on transgender rights has come about with no real public debate, a strategy recommended by the report "Only adults? Good practices in legal gender recognition for youth”, a document written by staff from the legal firm Dentons in conjunction with Thomson Reuters Foundation and LGBT pressure group IGLYO.
Rather than enabling discussion that would help to ensure best practice, trans rights groups and many politicians have instead made it difficult for experts and other stakeholders to raise concerns. As Dr Entwistle and Prof Pilgrim write,
“There is clear evidence that those expressing ethical or political doubts about clinical routines, which are predicated on a gender-affirmative approach, which prioritizes the diagnosis of gender dysphoria over psycho-social formulations case by case, are being constrained or silenced.”
Concerns dismissed in the UK and Ireland
The Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust provides the two clinicians who see Irish children here.
In June 2020 the BBC reported that clinicians had claimed child protection and safeguarding concerns were "shut down". The Tavistock have a named person clinicians can turn to to discuss specific safety concerns, but “staff allege they were discouraged by GIDS Director Polly Carmichael from going to see the Trust's safeguarding lead, and from referring cases to social services.” Sonia Appleby, the safeguarding lead at The Tavistock, is now taking the clinic to court. She says that
“..the Tavistock misused its own procedures to besmirch me and therefore jeopardize the role of safeguarding within the Trust”.
BBC Newsnight has now reported that it had obtained a copy of a 2005 review into the clinic. It reveals that safeguarding concerns had been raised by some staff back then, fifteen years ago, before Irish children had ever started to be referred there.
Concerns about the use of puberty blockers were subsequently raised by other staff in the internal 2019 review of the service.
Earlier this year three Irish doctors working in the field expressed grave concerns over the service provided by the Tavistock and Portman NHS Foundation Trust for Irish children at Crumlin “but their concerns were suppressed” according to The Irish Independent.
Consultant endocrinologist Professor Donal O'Shea and consultant psychiatrists Dr Paul Moran and Dr Ian Schneider said that among their patients who had been previously treated at Crumlin, some did not appear to be suitable or ready for such treatment, and appeared to have mental health problems that had not been identified or addressed. Issues raised and calls by the doctors for the service to be "terminated with immediate effect" were omitted from draft minutes of a meeting between doctors and hospital staff at Crumlin in March 2019. Dr Moran was reported as saying that when he protested about the omissions in the draft minutes, these were not corrected.
Gender care has a history of suppressing academic freedom
The lack of robust studies or debate today is an outcome of the culture of the last two decades in gender identity care. Campaigns of intimidation and discrediting go back at least to 2003, when Professor Michael Bailey published his book on transsexualism, The Man Who Would Be Queen. The book undermines the theory of a male or female ‘essence’, framing transsexualism instead as a psychological condition. The backlash to Prof Bailey's book included attempts to have him fired. The campaign against him was so severe that Dr Alice Dreger, an ethics scholar, wrote a paper on it and later it formed a significant section of her book on scientific freedom, Galileo's Middle Finger. In a New York Times article, Dr Dreger says,
“What happened to Bailey is important, because the harassment was so extraordinarily bad and because it could happen to any researcher in the field.”
Dr. Kenneth Zucker is an international authority on gender dysphoria in children and adolescents, and was head of the Child Youth and Family Gender Identity Clinic (GIC) at Toronto's Centre for Addiction and Mental Health (CAMH) until it was closed in 2015. Rather than affirming a child's belief that they are trans, he worked to explore other possible causes for their gender dysphoria.
Despite good mental health outcomes for many of the children he treated, Dr Zucker's approach was viewed by some as transphobic and akin to conversion therapy. In 2015, CAMH responded to criticism from activists and launched a review into the GIC, which resulted in Dr Zucker's dismissal and the clinic being closed down. In January 2016, Dr Zucker filed a lawsuit against CAMH for defamation and wrongful dismissal, a case that he won in 2018, when CAMH publicly apologised to him.
Jesse Singal wrote an in-depth report of the incident, which refuted the claims made against Dr. Zucker. It's worth quoting one passage in full:
"It seems as though many parents, clinicians, and others face significant pressure to embrace the gender-affirmative approach these days. According to an influential strain of trans politics, Zucker’s more nuanced, 'Why?'-focused method is offensive. This sounds like a caricature, but right there in the External Review that helped get him fired and his clinic shuttered, two professional psychiatrists state that asking 'why' is improper."
Dr Susan Bradley was Dr Zucker's predecessor at CAMH, and in a 2018 interview with Dr Debra Soh she discussed the effect she believes CAMH's closure has had on services for young people with gender dysphoria.
D.S. : How has the clinic closing affected the way that other clinicians approach kids with gender dysphoria?
S. B.: Well, I think it's silenced a lot of people who might have felt that these kids deserved a more intensive assessment or more support, and things like that. A lot of people have said that they're afraid to speak out about it. The other clinics – I mean they have appeared, at least to me, to accept at face value an individual's statement rather than doing what we would regard as a proper psychiatric and psychological assessment of the child and family.
D.S. : Because they're afraid of losing their jobs?
S. B.: They are.
D.S. : So why is it you aren't afraid?
S. B.: Because I'm retired and old. [laughs] They can't do very much to me.