An open letter to the medical profession

 

In recent years, the presence of transgender issues in the public consciousness has seen a seemingly exponential rise. There has been a concurrent rise in referrals to the Tavistock and Portman paediatric gender clinic, with almost two thirds of those referrals being for natal females (1). Though there is currently no NICE guidance governing the treatment of trans-identified children, said children are routinely treated with GnRH analogues (aka puberty blockers) from as young as the age of 12 and cross-sex hormones from the age of 16 (2, 3). This policy is next up for review in 2019, and a number of transgender charities are calling for the age limit for cross-sex hormones to be lowered, with some demanding hormones be freely available over the counter (4). A private GP, based in Wales, recently took matters into her own hands, prescribing cross-sex hormones to children as young as 12, despite an acknowledged lack of evidence (3, 5). She is currently under investigation by the General Medical Council (GMC) (6).

I first became involved in trans activism around 2011. I had long felt uncomfortable in the female ‘gender’, both in terms of the roles imposed upon me and my secondary sex characteristics. As a child I was terrified of growing breasts, and used to fantasise about having a male chest. I climbed trees, loved the colour blue and for a period of several months refused to wear anything but my brother’s Captain Scarlet uniform. At school I always wanted to play male characters in drama, confiding in my schoolmates that I dearly wished to be a boy

At the time I didn’t realise there was anything unusual about me, but I distinctly remember when this began to change. It was the mid-90s. I was hanging from a branch on my favourite tree, dangling over an adjacent cycle path where two elderly women ambled on their daily stroll. I recognised them, waved, and in a feat of acrobatics I have not matched since, flipped myself over to land directly in front of them.

‘My, you are a little tomboy?!’

Though these words were obviously spoken with warmth and affection, I found them much more perturbing than I did flattering. The women went about their day, leaving me to ponder exactly what was meant by this new word, ‘tomboy’, and why there was a special name for girls like me…girls whose very spirit defied societal expectations. What was it about climbing trees that made me a tomboy? Was I behaving like a boy? Was this the reason I felt so choked by my female identity and its associated trappings? Was this the reason I enjoyed behaving ‘like a boy’? Was I really a boy?

At 21 I moved away from home to start my first degree. Free from the clutches of my misogynist, homophobic upbringing, I started to explore my identity for the first time. A recently out trans friend and her partner introduced me to the modern notion of ‘queerness’ and a short while later I was signed up to all of the transgender forums I could find. Encouraged by the people I met there, at 23 I saw a gender specialist. My online friends assured me I was entitled to rapid intervention; after all, it was this or suicide they said. The doctor told me he was unwilling to prescribe hormones right away and I left his office in tears. Shortly thereafter I bought testosterone off the internet and started injecting. The forums were very supportive of this; not a single member tried to discourage or explore alternatives with me. ‘Not treating you is a death sentence’ they said. I was convinced I had no choice.

I was passionately convinced I was transgender. A belief bolstered by the discovery of words like ‘non-binary’ and ‘genderfluid’. I clung to this new lexicon like my life depended on it; I was convinced I’d finally discovered my true self, and I was hostile to all who suggested otherwise. Whilst I was busy shrouding myself in trans rhetoric, I unnecessarily injected androgens. I damaged my voice and I grew a lot of very dark, coarse hair on my face that I now have to epilate regularly. Now, at the age of 30, I often find my mind wandering to the possibility of children, but I have no idea if I’m still fertile.

Whilst I only took testosterone for a year, I bound my breasts and wore only men’s clothes for considerably longer. I knew by this point that what I’d done wasn’t right for me, that I hadn’t been ‘born in the wrong body’, but I didn’t have the insight or the language to understand why. I was also frightened by the possibility that I might not be transgender. The identity had been so comforting; who was I without it? Finally facing up to that innominate abyss took me 29 years.

Some (interested parties) might say ‘Ah! But clearly you weren’t trans! So what relevance does this have to real trans people?’

The standard retort to the concept of detransition is “you weren’t trans to begin with, therefore you can’t have detransitioned”. This attitude is nothing short of cognitive dissonance. Currently there is a huge push towards gender self-identification following lobbying from high profile LGBT charities such as Stonewall. Indeed, their most recent policy on trans rights includes the following:

‘[Vision for change:] a reformed Gender Recognition Act to secure all trans people the right to self-determination…’ (7)

So, if we are to accept self-identification as the only necessary criteria for validation of gender identity, it follows logically that the only person who can decide if I’m transgender is me. Regardless of how I perceive myself now, for a period of 29 years I identified as transgender therefore I was transgender.

When I started my transition I didn’t know there had been cases of regret. The case studies I had investigated gushed with positivity. Why was there no coverage of detransition and the people who experienced it? We appear to be growing in number, yet trans activists remain ominously silent and those that do comment simply deny its existence. In the many interactions I have had on this issue, I have been quite shocked at how quickly a trans activist/ally withdraws when they find out I’m a desister. Others have made it abundantly clear that I’m a bigot for questioning trans rhetoric and not worthy of life. Scientologists have a process called ‘disconnection’: if someone decides to leave, those who remain are encouraged permanently shun them (8). It would appear that trans activists been borrowing from their script.

We are too much of an inconvenient truth to acknowledge.

Gender is nothing more than a perpetual performance. Masculinity and femininity are the leading roles we play out ad infinitum upon a stage fabricated from violence and oppression. Both men and women are burdened by these synthetic constructs we assume to be essential for our existence. The cruel irony of identity politics is that its relentless and aggressive shoe-horning of what are essentially just tastes and preferences into ‘trans’, ‘cis, ‘non-binary’ (or whatever label is popular this month) boxes, only serves to reinforce toxic gender stereotypes and to oppress us further.

As a child I learned to associate femininity with weakness, incompetence and vulnerability. I learned that women are not listened to and are celebrated only for select biological functions. Those biological processes men find distasteful we are expected to keep private. I learned that my likes and interests were not feminine, but those of a ‘tomboy’. This lack of femininity lead to me being bullied at school, harassed in the street and understandably feeling an extreme sense of dissociation and alienation from my physical sex. The transgender community offered me an identity, a remedy and, crucially, they offered me love, acceptance and belonging. I was an extremely isolated, awkward and abused autistic child. Suddenly being given such inclusion by a group of people who seemed to know what I was going through was, to paraphrase John Denver, like ‘coming home to a place I’d never been before’. Affirmation is intoxicating.

As medical professionals we examine our actions through the lens of medical ethics and evidence-based medicine: is what we are doing in our patient’s best interests? Do they realistically have the autonomy to consent to such radical treatment? At what age does a person have the capacity to consent to sterilisation, the removal of healthy organs (breasts, genitalia, reproductive organs etc), a life of hormone therapy and dealing with the potential sequelae? All because (maybe?) they were just unhappy with the pseudo-identity imposed upon them at birth.

Just as I was.

Women who wish to be sterilised have to jump through numerous hoops before finally accessing the procedure, and doctors are cautioned about offering the treatment to women under 30 (indeed, some say obtaining such is almost impossible for women under 30) (9). Why then, are we offering cross-sex hormones (thus likely chemical sterilisation) to 16-year-olds (or in the case of Dr Webberly, 12-year-olds)?

Regardless of where you stand on the sex vs gender debate, are you confident that medical interventions for trans children are in their best interests? Given that capacity is decision-specific, are you confident that a child can consent to such treatment? Can you cite a decent number of high quality studies demonstrating trans children persist in their gender identity and that the risks of GnRH analogues and long-term cross sex hormones are ameliorated by the benefits of transition? Are you aware that research on the use of these drugs in trans children is scarce, inconclusive and misused? Data from the long-term safety of puberty blockers comes from children with precocious puberty, NOT trans children, and there is no evidence on the impact of such drugs on a child’s cognitive development.

Earlier this year NHS England, NHS Scotland, the Royal College of General Practitioners and a host of other healthcare organisations signed a Memorandum of Understanding on Conversion Therapy in the UK. Contained within is the following paragraph:

‘For the purposes of this document ’conversion therapy’ is an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to supress an individual’s expression of sexual orientation or gender identity on that basis.’ (10)

There are numerous problems with this statement (don’t even get me started on the conflation of sexuality and gender identity so often and erroneously used to throw weight behind the latter), but what strikes me most is the wording. Such vague and easily misinterpreted language is oddly reminiscent of the infamous ‘Section 28’, where a lack of clarity lead to generations of British children being denied the chance to talk about their sexuality at school because teachers were terrified of being seen to ‘promote homosexuality’.

Doctors have a duty to ensure any interventions are in the patient’s best interests. Where there is doubt, or said interventions are irreversible and life-changing, it is absolutely essential that we feel safe to explore the patient’s thoughts, feelings and expectations. When confronted with a child manifesting gender dysphoria, a part of any initial consultation or assessment should include exploring the possibility of the feelings passing with time, especially since the research we currently have suggests most trans children will not persist with their gender identity (11). With this in mind I’m, curious to know how registered UK medical professionals (particularly GP, since your college has signed up it) feel about this document. If a child presented to you with gender dysphoria would you be comfortable deviating from this ‘gender affirmative’ approach and instead exploring the possibility they may grow out of it? If said child or their parent then threatened to report you to the GMC for transphobia and for seeking to ‘suppress an individual’s expression of […] gender identity’ would you stick to your guns? Do you feel comfortable challenging the lack of evidence regarding paediatric gender dysphoria the safety and reversibility of GnRH analogues in trans children (12)? For the sake of your young and very vulnerable patients, are you brave enough to challenge the rhetoric of identity politics when it seeks to subvert medical ethics?

I am not talking about doctors who, through ignorance or prejudice, choose to be dismissive, insensitive or even hostile towards transgender patients; there is no place for any of those behaviours in medicine, ever. Nor am I suggesting we scrap the notion of medical transition. I know exactly how distressing gender dysphoria is, and I very much want transgender people to access the healthcare they need, be that transition (where appropriate) or honest and supportive psychotherapy. I am simply asking…begging…that we be allowed to examine this issue critically. Raising concerns about patient safety and welfare is not transphobic. Raising concerns about the lack of evidence behind a particular treatment is not transphobic. Having a sensitive, but open and honest discussion with your patient is not transphobic. This irreversible and erroneous manipulation of children’s bodies has the potential to be one of greatest medical blunders of the 21st century.

I am just a medical student. I have no established practice or reputation and no colleagues who will spring to my defence if I find myself in trouble. Though I am not yet registered with the GMC I am bound to those same professional regulations by my medical school. If my identity were revealed, it’s quite possible raising these concerns could cost me my career. I have quite literally shed blood, sweat and tears for the sake of medicine. I have just as much, if not more to lose than you do. I also have chronic mental health issues that are not helped by stresses such as this, yet here I am, speaking out regardless of the personal cost.

I know better than most how precious a career in medicine is and I am willing to risk it for the sake of preventing harm. Why aren’t you?

 

References

1. BBC. Gender identity clinic for young people sees referrals double 2016 [Available from: http://www.bbc.co.uk/news/uk-36010664%5D
2. Kendrick K. NHS Transgender Clinic Gives Puberty Blockers To 12-Year-Olds: Huffington Post; 2017 [Available from: http://www.huffingtonpost.co.uk/2014/08/14/nhs-transgender-clinic-gives-puberty-blockers-to-12-year-olds_n_7354972.html%5D
3. NHS England. Clinical Commissioning Policy: Prescribing of Cross-Sex Hormones as part of the Gender Identity Development Service for Children and Adolescents. 2016.
4. Edinburgh Actio for Trans Health. Trans Health Manifesto 2017 [Available from: https://edinburghath.tumblr.com/post/163521055802/trans-health-manifesto%5D
5. Lyons K. UK doctor prescribing cross-sex hormones to children as young as 12. The Guardian 2016.
6. BBC. GP probed for giving child, 12, gender-changing hormones2017. Available from: http://www.bbc.co.uk/news/uk-wales-41213534%5D
7. Stonewall. A Vision for Change: Acceptance Without Exception for Trans People. 2017.
8. International CoS. What is disconnection? 2017 [Available from: http://www.scientology.org.uk/faq/scientology-attitudes-and-practices/what-is-disconnection.html%5D
9. Brockwell H. Why can’t I get sterilised in my 20s? The Guardian. 2015.
10. UK Council for Psychotherapy. Memorundum of understanding on conversion therapy in the UK Version 2. 2017.
11. Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(6):582-90.
12. GIDS Tavistock and Portman NHS Foundation Trust. Evidence Base. 2017. [Available from: http://gids.nhs.uk/evidence-base%5D

My immense gratitude to my beloved wife for her proofreading, editing, feedback and for helping me realise the strong woman I am.