Carys Moseley comments on a new and important academic article which criticises the current approach to treating gender confused children and teenagers.
Marcus Evans, one of the psychotherapists who recently blew the whistle on The Gender Identity Development Service (GIDS), has written an important academic article criticising the current pro-trans lobby’s approach to treating gender-confused children and adolescents.
Evans is a former Head of Nursing and Associate Clinical Director of the Adult and Adolescent Departments of the Tavistock and Portman NHS Foundation Trust in London. The article is published in the British Journal of Psychiatry bulletin and is freely available to read online.
Evans’ publication comes at a time when the GIDS is facing legal action from a de-transitioner who had received puberty blockers there. It is also timely given that the government faces mounting pressure to backtrack on plans to make changing gender easier. Finally, it is relevant as it criticises the proposed ban on ‘conversion therapy’ in the UK.
A climate of censorship at the GIDS
Evans’ starting point is the well-attested massive rise in referrals to the GIDS in recent years, and the fact that now most children referred are female. He is very critical of his former workplace. The first criticism Evans makes is that there is still a lack of understanding of this new trend.
He claims that individuals were prevented from expressing their views on the matter or censoring themselves for fear of being accused of ‘transphobia’. This amounts to a climate of censorship at the GIDS.
‘Affirmative approach’ adopted across the UK
Evans takes issue with the so-called affirmative approach to gender dysphoria in children. This is the approach whereby if a child says they are transgendered everybody including clinicians must accept this without question. This then leads to administering puberty-blocking drugs to children.
Alarmingly, he claims that the affirmative approach has been adopted by nearly all children’s services in the UK. This must refer to local Child and Adolescent Mental Health Services (CAHMS). Thus, it would seem that his writing on the subject cannot simply serve as a critique of the GIDS but must lead to a much bigger investigation of CAHMS.
Clinicians’ curiosity and freedom shut down
It is particularly important that Evans criticises the adverse effect of the affirmative approach on clinicians themselves, not only on children. The problem is that clinicians are being prevented from conducting their work to the highest professional standards:
“The ‘affirmative approach’ risks sending children down a path towards concrete and sometimes irreversible medical interventions for what is in very many cases a psychological problem. This approach, in my view, is driven by political ideology rather than clinical need and inhibits the clinician’s curiosity and freedom to explore a child’s underlying belief systems and motivations.”
The other main problem he cites regarding the affirmative approach is its narrowness and tendency to isolate one problem, namely gender confusion, from others:
“The ‘affirmation approach’ looks narrowly at a problem in only one area of psychological functioning, as if one part of the individual could be isolated from other areas of the personality, so ignoring the complex relationship between the overt symptomatic picture and trauma, social anxieties and even the relatively normal turbulence of adolescence.”
‘Conversion therapy’ ban to blame
Evans is critical of the Memorandum of Understanding on Conversion Therapy, which bans therapy that implies that one gender identity is superior to any other. He says this:
“The Memorandum is very often interpreted as obstructing the clinician’s freedom to examine and explore the various pathways that have led to gender dysphoria, but, somewhat surprisingly, when one reads the document one discovers an acknowledgment that the therapist or healthcare professionals’ job is to help the patient discover and come to terms with who they really are.”
He then quotes section 6 of the Memorandum to this effect.
It is unclear whether Evans is simply paraphrasing the Memorandum here or also expressing his own view that some clients ‘really are’ transgender. However, he goes on to make the following argument:
“This Memorandum implies that there is a fixed category called ‘transgender’ which, like eye colour, is simply a given that need not be thought about or understood.”
It is important to state here that Evans does not say where this paragraph originally came from. The first version of the Memorandum makes it clear (in its second footnote) that it first appeared in the Royal College of Psychiatry’s Position Statement on Sexual Orientation, published in April 2014. What this means is that the Memorandum’s manipulative handling of therapy for gender identity problems can only be understood as a case of piggybacking on its prior ban on therapy for unwanted same-sex attraction.
‘Sexual identity and gender identity are developmental processes’
Evans’ next argument is that both sexual identity and gender identity are not simply innate.
“Children’s sexual orientation and gender identity are formed out of a complex developmental process that involves an interaction between their body, their mind and society at large. Sexual identity and gender identity are developmental processes that evolve as the individual goes through the different life stages.”
For this reason, he is highly critical of the political influence that he perceives in the Memorandum, by which he means ideological distortion of the evidence on human sexual identity and gender identity. This leads to seriously erroneous healthcare for patients.
Again, considering how the ban on therapy preferring one gender identity over another is piggybacking on the ban on therapy for same-sex attraction is illuminating here. What Evans does not say is that the Royal College of Psychiatry’s position statement also said this:
“It is not the case that sexual orientation is immutable or might not vary to some extent in a person’s life.”
So there we have a clear statement – nobody is born gay, something Core Issues Trust picked up on in its response to this position statement. It is very significant therefore that the Royal College of Psychiatrists declined to sign the second version of the Memorandum. It is said that this was due to its objection to the inclusion of ‘gender identity’ in the prohibition. There is however a question as to whether this was also due to no longer believing the ‘born gay’ theory. This matters with regards to treating children for gender dysphoria, as some have same-sex attraction. Interestingly, Evans does not mention this. Perhaps he is mindful of the ideological forces at work that could prevent him being published at all.
Hypocrisy of ‘conversion therapy’ ban signatories
It is highly significant that Evans quotes both the British Psychological Society and the Royal College of General Practitioners (mistakenly called the Royal Society of General Practitioners) regarding serious misgivings about puberty blockers for gender-confused children. This is because both bodies are signatories to the second version of the Memorandum of Understanding on Conversion Therapy.
It is a major problem that Marcus Evans has not criticised the hypocrisy of these professional bodies in his article, for their opinions carry weight and help perpetuate the culture of censorship he is criticising. For this reason, it is worth devoting some attention to the publications he cites.
The British Psychological Society
The BPS article was published in July 2018 by Christian Jarrett, the editor of the BPS Research Digest. He claims that the BPS has not gone as far down the ‘affirmative approach’ as some other bodies such as the Endocrine Society, citing the BPS Guidelines and Literature Review for Psychologists Working Therapeutically with Sexual and Gender Minorities, published in 2012. The link he gives is broken but you can read the document in its archived format. Jarrett’s article is based on studying a major review of medical evidence on puberty blockers published in April 2018 by the American Academy of Paediatrics in its journal Pediatrics.
Writing for the BPS, Jarrett says this:
“The new review reveals how this advice is based on extremely limited evidence. When it comes to children, teens and young adults aged under 25, we simply do not yet know much about the psychosocial effects of pubertal suppressors … and further hormonal treatments.”
At no point does he call for a complete halt to the use of puberty blockers and cross-sex hormones. It seems that more research is needed – in other words, more experimentation on children. Herein lies the explanation for the fact that the BPS both appears to express concern and still remains a signatory of the Memorandum. Its problem is moral, not scientific. This is the refusal to limit psychological work to the limitations of the human body as given at birth to each child.
The Royal College of General Practitioners
Whilst it isn’t entirely surprising that a group of psychologists should underplay the importance of the human body in this matter, the attitude of the Royal College of General Practitioners is another matter. Its position statement on care of transgender patients recommended expanding gender identity services in the UK, whilst also complaining of the lack of evidence for treatments for children. It makes the following call:
“The promotion and funding of independent research into the effects of various forms of interventions (including ‘wait and see’ policies) for gender dysphoria is urgently needed, to ensure there is a robust evidence base which GPs and other healthcare professionals can rely upon when advising patients and their families. There are currently significant gaps in evidence for nearly all aspects of clinical management of gender dysphoria in youth. Urgent investment in research on the impacts of treatments for children and young people is needed.”
The current gender identity service has already done enough damage. New services would likely be based on the model of the existing one and thus perpetuate the problems. The RCGP is irresponsible in trying to have things both ways.
Just like the BPS, the RCGP wants more research on all types of treatment for gender dysphoria, especially on children and adolescents. Again, this is irresponsible. Are more children going to be given puberty blockers and cross-sex hormones? For the negative effects are in fact already known. The real problem is that they are being concealed from view, as is recently the case with the NHS pages on gender dysphoria.
Medical experts weigh in
Despite the shortcoming of not addressing this hypocrisy, Evans’ paper is to be commended for citing numerous medical experts who have had to deal with the effects of gender reassignment on their own patients. He also discusses his own work with self-harming and suicidal patients, many of whom had gender dysphoria.
Fertility expert Lord Robert Winston is quoted as being deeply concerned about the effects.
“What I’ve been seeing in a fertility clinic are the long-term results of often very unhappy people who now feel quite badly damaged. One has to consider when you’re doing any kind of medicine where you’re trying to do good not harm, and looking at the long-term effects of what you might be doing, and for me that is really a very important warning sign.”
Endocrinologist Donal O’Shea is quoted as being highly critical of the World Professional Association for Transgender Health’s (WPATH’s) Standards of Care. He says that their use – promoted by NHS England – would be very harmful to gender-confused people. Psychiatrist Paul Moran is equally scathing, saying that the standards ‘are clinically unsafe, and unsuitable for use in a public healthcare gender clinic.’
Institutional attitudes stifle research
Continuing on the theme of censorship, Evans is particularly concerned about the way in which transgender activists managed to get Kenneth Zucker, the pre-eminent clinician in the field, sacked from his post as head of the Child, Youth and Family Gender Identity Clinic in Toronto, accusing him of conducting ‘conversion therapy’.
Closer to home, Evans notes the case of James Caspian, who was barred from conducting research on de-transitioners because Bath Spa University feared a backlash from transgender rights advocates. He is also troubled by The Guardian’s attack on Lisa Littman’s research on Rapid-Onset Gender Dysphoria in adolescents as “a poisonous lie used to discredit trans people.” Such institutional attitudes make proper clinical work impossible.
Understanding ideological pressures
Although Evans repeatedly blames ideological pressures on clinicians and trusts for this lamentable state of affairs, there is a question as to how well he understands these pressures. For example, he does not understand why the Memorandum of Understanding allows exploration of sexual and gender identity.
In addition, in his discussion on whether children can give informed consent to treatment, Evans appears not to understand why gender clinics are allowed to operate differently than other parts of the NHS.
“In the National Health Service (NHS), clinicians are usually required by law to discuss the potential negative effects of any treatment. However, for reasons that are not clear, the treatment for gender dysphoria has evolved operating outside the usual medical/professional practice.”
Surely the push for de-pathologising gender dysphoria and treating gender identity as a human rights issue explains why gender clinics have not been subjected to the relevant criteria Evans discusses. Particularly relevant here is the fact that the number of children referred to the GIDS shot up after the Equality Act 2010 was passed. Transgender activists managed to get gender reassignment to be listed as a protected characteristic in schools in the Act. This went through Parliament unchallenged at the time. Where were the gender specialists and medical experts back then?
Assessing Evans’ recommendations
Evans makes the claim that ‘thoughtful enquiry’ is “the very thing that is most needed to protect children from harm,” and that this is lost due to accusations of transphobia. Whilst this sounds plausible, it is arguably wrong and may perpetuate the problems. The problem is that gender transition is being allowed at all. More talking therapy is not going to put a stop to that. Domenico Di Ceglie, the founder of the GIDS, made it clear in an academic paper that from the very beginning in 1989, the GIDS kept all the treatment options open. He wrote this:
“Our stance was to maintain an open mind as to what solution an individual would find to the mind/body conflict.”
This blind spot may account for Evans’ recommendation that a new regulator be created that would have oversight of gender identity services. He wants it to have “a more clinically rigorous, balanced and ethical approach,” and thinks that the Human Fertilisation and Embryology Authority is a good model for this. History suggests this is not a promising approach. The HFEA has presided over unprecedented expansion of the fertility industry, somewhat proving Parkinson’s Law – that work expands to fill the resources allotted.
Time for plain speaking
Evans’ article is an incredibly important contribution to the debate on gender-confused children and adolescents. This is both because of his long professional experience as a nurse and psychotherapist, and because he is willing to speak out in the press. It deserves a wide audience especially as it is accessible to those of us who aren’t professionals.
From reading Evans’ writing, I suspect that he does not believe in physical treatments that enable adolescents to ‘change gender’. He repeatedly warns that it is not really possible to be rid of the sexual characteristics present at birth. The question is, how is his great insight into and expertise concerning the problems to bear fruit across the NHS? What is needed is thorough opening up of the records of the GIDS to outside investigation and an end to all gender reassignment for minors as fundamentally contrary to medicine. If Marcus Evans and other clinicians do not believe in gender reassignment for minors, they must start saying so plainly and publicly otherwise nothing will ever change for vulnerable children.
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