UK Gender Identity Service at Crunch Point as Pressure Mounts

Becky McCall

Disclosures

January 03, 2020

More adolescents than ever are being referred for treatment at gender identity centres in the UK, leaving under-resourced services that facilitate transition to the opposite sex struggling to cope with demand.

One consequence of this is complaints surfacing from some staff and patients that the decision to start the process of gender transition is, at times, hasty and misguided.

In recent months, an increasing number of young people who have transitioned have spoken publicly about their regret, and desire to return to the sex of their birth - so-called detransitioning. In late November, these voices reached a critical mass with the launch of The Detransitioning Advocacy Network, a platform on Twitter where views can be aired and shared around this difficult topic.

Clearly, the landscape of gender transitioning - including blocking puberty and medical treatment with cross-sex hormones - is shifting, both in terms of numbers wanting to transition and in the emergence of those who subsequently seek to reverse their transition, and concerns around the gender transitioning process in young people.

Deep Concerns

Now, an ex-staff member of England's only NHS Gender Identity Development Service (GIDS) for young people, at the Tavistock and Portman NHS Foundation Trust, psychotherapist Sue Evans - who resigned because she felt so 'deeply concerned' about the fast-tracking of young people into medical treatment - is seeking a judicial review of the service.

Evans wants to obtain a ruling from the court that the current practice for informed consent for hormone treatments for children aged under 16 years be deemed 'unlawful'. Through a crowd-funded legal case she aims to prove that this kind of experimental treatment is unsuitable in under 16s due to the adult nature of the potential side effects.

Speaking to Medscape UK in an interview, she explained her grievances. "I am concerned that the burden of hormonal treatment for children is very great. In particular this first step on the medical pathway," Evans asserted.

In the year leading up to March 2018, the Tavistock GIDS Centre received a record number of referrals of 2500 - a 25% increase from the previous year and a 50-fold increase from 12 years ago.

There has also been a giant switch from boys to girls presenting - natal female referrals for gender dysphoria have grown from 42% of the total in 2009-2010 to 72% in 2017-2018.

Numbers of people seeking to detransition are unknown and are generally considered small, but their voices are growing in strength and people are starting to listen.

Possible theories for the escalation in numbers – both in those seeking to transition and detransition - are multi-fold, but open scientific discussion on these dramatic changes is very often stifled by a fear of being branded 'transphobic', according to those who try to enter such a discourse.

However, as more concerns emerge, the research gap, as recognised by nearly all stakeholders, is reinforced, with more evidence needed to ensure the right patient is receiving the right therapy to meet their individual needs.

Fast-tracking Adolescents Into Treatment 

Evans is increasingly concerned about the fast-tracking of adolescents into treatment for gender dysphoria, including puberty blocking and cross-sex hormone treatment.

She told Medscape UK: "I say to NHS England, that you've let a treatment regime unroll at huge pace without a robust evidence base, including outcomes data. This wouldn't be allowed in any other area of medicine and especially not paediatric medicine.

"But they consistently deny it is a problem and claim they are following international best practice recommendations," she explained.

The GIDS service has a disproportionate number of referrals for the resources available. Waiting times are currently around 2 years.

With the huge increase in referrals, a large number of staff resignations, and so many potential and under-researched factors implicated in the transition process, doubts are being voiced about whether GIDS can fulfil its best intentions of optimising patient outcomes.

This is not the first time questions around the service have been asked.

Due to 10 staff whistleblowing around issues related to the service, Dr David Bell, a senior staff member, wrote a report in 2018 addressed to the GIDS board raising concerns about whether personal histories - including other possible underlying mental health issues - were adequately explored, for example trauma or autism, or whether children were being swayed by social pressures prior to referral to transitioning therapy.

An internal review was carried out by GIDS, but the centre dismissed the review's report as 'not fit for purpose'.

James Caspian is a psychotherapist who has helped both young people of 16 years and over, and adults with gender identity concerns for over a decade. He says the clinical landscape - with reference to surging numbers and a switch from majority born males presenting to born females - started to change around 2014.

With recent public discussion around regret and reversal of transitioning in young people, Caspian says this points to the strong possibility that other underlying mental health problems might be at play in many individuals.

"Firstly, most people who discuss their detransitioning say they've had lots of mental health problems, and in my clinical experience with young people presenting with gender identity issues, the majority had complex and unresolved mental health problems that they believed would be resolved by transitioning. The argument to support this has no solid evidence base at all," he points out. 

Staged Counselling and Medical Therapy 

GIDS provides counselling services to presenting children and refers to endocrinology services if the psychological assessments deem medical therapy to be the most appropriate course of action.

In a 2018 interview with the Tavistock, Medscape was told that GIDS patients undergo an exploration of their development and gender identification in the context of their family background and life experiences, before any medical intervention is considered. During this stage, behavioural and emotional functioning - including features of autistic spectrum disorder and potential for self-harm - are assessed. Of note, approximately 35% of children referred present with moderate to severe autistic traits.

The first stage of medical treatment (if a child has not gone through natural puberty) involves suppression of puberty using hormone blockers for a minimum of 12 months, providing time for gender exploration without the pressure of ongoing pubertal development.

At 16 years of age, partially reversible cross-sex hormone treatment may begin with oestrogen or testosterone, depending on the direction of transition. From 18 years of age, surgery may be considered, as patients would be deemed adults from that age onwards.

Blocking Puberty More Concerning Than Cross-Sex Hormones

Endocrinologists are one step removed from the initial assessments that are the responsibility of the specialist gender identity clinic.

Ken Ong is a paediatric endocrinologist from the University of Cambridge School of Clinical Medicine, who has referred patients to GIDS.

He says that, from an endocrinologist's perspective: "There's an important distinction between puberty blocking, and therapy for cross-sex purposes.

"In theory, cross-sex hormones might have effects on weight gain, brain development and fertility," he explained to Medscape UK.

A previous article by Medscape  referred to concerns about bone health as a result of puberty blocking, with experts noting that data demonstrate a fall in bone mineral density (BMD) Z scores during treatment with puberty blockers. One 2015 study that followed BMD development during puberty blocking - which involves use of gonadotropin-releasing hormone (GnRH) analogue therapy - in patients with gender dysphoria, through to the age of 22, found a decrease in BMD Z scores in both natal sexes, but it was more marked in natal girls.

Ong agrees with these concerns, although he says: "It seems more feasible from a clinician's perspective to give puberty blockers - because it buys time for further psychological assessment before more drastic steps are initiated - this still requires caution because of potential effects on bone health.

"Another area of uncertainty relating to blocking puberty - which I am aware of through the media - suggests that blocking puberty might reinforce or amplify a patient's own uncertainty about their gender by preventing the natural process of puberty," he observes, adding that - for this reason, among others - it is recommended that these puberty blockers are only used after specialist assessment at one of the UK's gender identity clinics.

Ong says the current issues with transgender medicine are a fairly recent problem that has escalated enormously in terms of the numbers of patients in recent years and as such the evidence base has not built-up.

But he also believes it is wrong to do nothing because of a lack of evidence.

"We are gathering the evidence as we go. We need to act for the benefit of the patient in front of us. But it is important that we record the evidence base to inform practice for future patients."

Sub-optimal Assessments Set Alarm Bells Ringing, Especially Over Autism

When Evans joined the GIDS team in 2004, all children under 18 years were treated, but only those aged 16 years or older received hormones.

"I expected that young people would be assessed in depth and given support and psychological treatment over several years, but the alarm bells began ringing for me when, at a team meeting, I heard that a child who was 16-years-old had only been seen four times and was then referred to the endocrinology department for hormone therapy," she told Medscape UK.

Given the often complex histories and co-morbid factors that patients present with, Evans believes that the three to six assessment sessions that are standard at GIDS is completely inadequate.

She explains that several studies show that many children (up to about 89%) with gender dysphoria will find their symptoms start to improve following the natural period of adolescent growth with the surge of their own natural sex hormones.

"This means that medical intervention is avoided altogether, which is a far better outcome. These children need much better psychological support during this period in order to bear the confusion, distress and anxiety associated with this time. To accommodate this, local child and adolescent mental health services (CAMHS) need to be hugely improved," she notes.

Essentially, Evans takes issue with a lack of thorough psychological assessment before affirming the diagnosis of 'gender dysphoria' and referral to medical therapy.

"Patients presenting with gender dysphoria will definitely experience distress, but in the same way an anorexic persists in being thinner, you would not say to an anorexic 'you're so stressed that I'll let you starve yourself'."

Like Evans, around 30 other psychologists have also resigned from GIDS over the past 3 years.

Staff are under enormous pressure there, Evans says. Most psychotherapists not at GIDS generally have a maximum of 35-40 patients at one time, but those at GIDS often have caseloads of up to 130 children.

She explained that those who feel uncomfortable leave the service and therefore the expertise in the team reduces: "Now they have to employ psychotherapists straight out of college, and overall, the team has insufficient experience to manage the young people presenting there."

Evans also says that to the best of her knowledge, GIDS does not have an autism expert on the team, despite up to one-third of patients presenting with gender dysphoria also having some form of autism spectrum disorder.

She adds that the whistleblowing staff, and also some parents, claim that a child's autism is often treated as separate or irrelevant to the gender dysphoria.

Some Clinicians Fear Being 'PC' Outweighs Evidence-Based Medicine

Whilst at Bath Spa University in 2017, Caspian made an application to research gender reassignment reversal, or 'detransitioning'. The application was refused because the university feared it would be perceived as 'anti-trans', and might leave it open to criticism on social media, says Caspian.

For the past 2 years, Caspian has awaited a decision from the Court of Appeal for a Judicial Review of the university's decision.

His research aim had been to generate much needed evidence to support choices around gender reassignment therapy. Caspian has helped many people successfully go through gender transition but stresses that there are complex and different reasons why people present with gender identity issues seeking treatment.

"Of those who have regretted and reversed their gender transition, some have published their histories of complex mental health problems on social media. This includes backgrounds of sexual abuse, and self-harm, and they express their anger of going down the treatment path," he explains.

Some trans men said that they had just hated being female and one person actually told Caspian directly, "'I thought that if I didn't have a vagina I wouldn't be raped again'," he recalls.

There is a palpable fear among professionals about speaking up about any concerns they have about treatment—again for fear of being labelled as 'anti-trans', he says. And relevant professional bodies are also stymied by political correctness, so that they cannot properly assess the evidence base for the management of gender dysphoria.

Dangers of 'Affirmation'

In 2012, the World Professional Association for Transgender Health (WPATH) drew up guidelines for the treatment of gender dysphoria.

"They removed the requirement for counselling prior to treatment from the guidelines … due to transgender activists believing that they were being discriminated against by medical professionals," explains Caspian.

Effectively, WPATH decided that by requiring clinicians to look broadly across a range of possible mental health issues, it would stigmatise patients asking for treatment, Caspian adds.

In 2017, Caspian sat on the Board of the UK Council for Psychotherapy and advised a committee that drew up a Memorandum of Understanding (MoU) to formulate policy aimed at preventing so-called 'conversion therapy' in transgender people.

"I warned them that the wording was dangerous because it appeared to promote affirmation, implying that a therapist was required to affirm a patient's self-diagnosis of varying gender identity," Caspian points out.

"And most patients say they are certain of their gender identity when asking for treatment," he adds. If the patient says they are uncertain, the MoU notes that exploration of other possible issues should be permitted, he says.

"Despite my recommendations, some of the representatives on the committee decided not to make it clear in the MoU that some patients regret and reverse their decision to transition …and that it is an ambiguous area that therapists should explore in depth with that patient. This MoU became national policy in 2018."

The Tavistock GIDS Centre was contacted in an effort to seek comment in response to the points made in this article but did not respond by the time of publication.

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