Gender dysphoria: The affirmative model for children and young people, and the role of health and social care educators
Proud to be part of the team that wrote this extended editorial that is available on Science Direct from today
We’re slowly getting the word into the perr-reviewed journals. Robin Ion, Sinead Helyar, Robert Watson and myself wrote this editorial to highlight our concerns about the uncritical adoption of gender ideology in health and social care education. We believe this will be helpful for nurses and other healthcare professionals. This is the link and, for your convenience, I’ve copied and pasted the article below https://www.sciencedirect.com/science/article/pii/S1471595323002500?dgcid=author
Gender dysphoria: The affirmative model for children and young people, and the role of health and social care educators
Authors: Robin Ion, Laura Jackson, Stella O’Malley, Sinead Helyar, Roger Watson
https://doi.org/10.1016/j.nepr.2023.103788Get rights and content
1. Background and clarification of position
The aim of this extended editorial is to outline some significant concerns about the uncritical adoption of gender ideology in health and social care education. For the avoidance of doubt, we share these concerns. Our specific focus is the affirmative model and its application to the care and treatment of children and young people experiencing gender dysphoria. We suggest questions educators might consider, which may help students to make decisions about the safety and utility of what is rapidly becoming a new orthodoxy. In our view, it is incumbent on educators to engage with this topic and that they do so with an open mind which they are prepared to change depending on the evidence.
We write against the backdrop of a growing public and professional concern about the care and treatment of gender dysphoric children and young people - our definition of young people takes in those up to the age of twenty-five. Despite this, and the recent call for much wider and robust discussion (Cass, 2022), the health and social care professions, organisations, practitioners and academics have, with some notable exceptions, been tacitly or openly supportive of practices which some refer to as the next major medical scandal. Moreover, it is becoming increasingly apparent that anyone who questions the narrative related to the treatment of gender dysphoria by, for example, raising concerns that one of the mainstays of treatment — puberty blocking drugs — may be harmful for the young people to who they are administered is liable to ‘cancellation.’ Witness the recent fate of singer Róisín Murphy who was cancelled and vilified for saying precisely the above (Strick, 2023). Given what can befall someone in the public eye, it is possible that concerned health professionals are reluctant even to ask questions.
2. Paradigm shift and voices of concern
The past decade has seen the development and widespread dissemination of a radical set of ideas and related propositions which directly impact how we think about fundamental aspects of the self, including sex and identity. Commonly referred to as ‘gender ideology’ these are influencing aspects of the organisation of society including both health and social care and the education of health and social professionals. This framework of beliefs appears to be underpinned by elements of two theories: gender identity theory; and queer theory.
It would be impossible in such a short space to do justice to the wide range of, in our view, sometimes contradictory and often arcane beliefs which constitute this body of work. It is, however, possible to outline some of the fundamental points which have implications or consequences for health and social care and the preparation of health and social care professionals.
First, many of those who subscribe to this position argue that sex in humans is neither binary nor immutable. Instead, they claim that the biological categories of male and female are not mutually exclusive but exist on a spectrum presumably where some of us are somewhere between the two. The existence of people with disorders of sexual development is sometimes cited as evidence for this spectrum perspective, but the view is also shared by many who do not draw on this.
Second, it is claimed by some that sex is not immutable and that it is literally possible for a man to become a woman and vice versa. It is sometimes argued that this is because the desire to do this – to transition – is driven by the ‘fact’ that the person is somehow trapped within the wrong body. The mechanism by which this occurs is unclear. Others argue that bodies are largely irrelevant in terms of male and female identity. In this view it seems that it is some unspecified essential and individual essence, not gametes or chromosomes nor primary or secondary sex characteristics, which determines gender. Here gender is sometimes used as a synonym for sex, but is also used by some in much the same way that some religious believers think about the concept of the soul, i.e. something immaterial which represents an authentic person.
The final two components of the ideology are that the current practice of observing and recording sex at birth based on genitals is fundamentally flawed. This is based on the claim that the sense of internal gender identity and not physical characteristics is how sex/gender is determined. It follows from this that this is a subjective act which only the individual can accurately decide. Here sex/gender is decided by the individual and not by the external observer.
Given the radical nature and potential consequences of adopting the positions above, it should be of little surprise that there is a developing public and professional concern around the care of gender dysphoria in children and young people. Much of this is focused on the growing realisation that we are amid a medical scandal.
There are several reasons for this. These include the recent huge and unexplained rise in the numbers presenting with this condition (Gender Identity Development Service, 2021), the grossly disproportionate, and again unexplained, rise in the number of girls and young women in this group (GIDS, 2021; Zucker, 2017) along with the observation that many of these have co-existing mental health problems, a history of significant trauma and/or autism (Churcher Clarke and Spiliadis, 2019, Kaltiala-Heino et al., 2015), and likely to be ‘looked after’ (e.g. fostered or adopted) (Matthews et al., 2019) It is argued by many of those with concerns that, to provide optimal care, we must have a much clearer understanding of how, or if these factors are significant and related to the dysphoric experience (Levine and Abbruzzese, 2023). Underpinning this concern, is the fact that the dominant approach to care across much of the world is the affirmative model. This is founded on the notion that those who experience gender dysphoria should be treated by confirming that their subjective perception that their physical body is misaligned with their identity. While implementation of the model is variable internationally and not all those who transition will opt for the full range of procedures, some will.
The first stage in affirmation is the social transition of the young person – here names, pronouns and clothing may be changed to reflect the person’s preferences. After this, puberty blockers – alleged to be reversible – may be prescribed. These delay or disrupt the onset of normal puberty in the hope that this will give the young person time to resolve their feelings of dysphoria. Progression to cross sex hormones – which are irreversible – followed by surgical intervention is the next stage in affirmation. This may involve the removal or modification of sex characteristics including breasts, womb, penis and testicles. The aim of these interventions is to align the person’s beliefs about their identity with their body. This may or may not be accompanied by surgery to feminise or masculinise the face.
We hope that few would disagree that these are individually and collectively significant interventions. As subscribers to Mill’s position on freedom (Mill, 2006), we take the view that adults – normally those over the age of twenty-five – are free to choose how to live and what they do with their bodies, particularly if they have the appropriate support. The only constraint on this being that they are rational and that their actions do not cause significant harm to others. In the case of children and young people, however, we believe that the evidence base for interventions of this type is currently insufficient and that the potential adverse consequences of both social and medical/surgical transition are so great that young people cannot meaningfully consent to them.
The above should be considered in the light of BBC journalist Hannah Barnes’ recent book Time to Think which traces the development of the GIDS at the Tavistock clinic in London from inception to the present day, post inquiry, which has led to the imminent closure of the service and its dispersal across other centres in the UK NHS. Very poor records were kept at GIDS both of the number of cases and the clinical effects resulting from young, gender dysphoric people, with the service. GIDS did not provide an intervention, it was a screening service which passed people on to other clinics for treatment. Nevertheless, it is estimated that over 9000 children were referred on by GIDS. In one study carried out at the Tavistock Clinic, a child as young as 9 years old was referred for puberty blockers. Moreover, in the children followed up by the study, no beneficial effect of the administration of puberty blockers could be found; they did not improve the underlying conditions, mainly psychological and psychiatric with which they presented at GIDS. However, no changes were made to the service, and it was only when concerned staff spoke out that a proper inquiry was eventually held.
We agree with those who argue that our approach to care should be built on comprehensive psychological assessment with strong, ongoing therapeutic support. It should be cautious and non-invasive. In the case of minors this should include parental input. Where parents have concerns these should be listened to and taken seriously. Much of this is mirrored in the recent interim report/independent review from the Cass Review (2022) which also recommended the closing of the Gender Identity Disorder Service in England amid concerns about its governance (Barnes, 2023). It also reflects findings in Finland (Pasternack et al., 2023), Sweden (Ludvigsson et al., 2023), and the UK (National Institute for Health and Care Excellence, 2020a, National Institute for Health and Care Excellence, 2020b) where systematic reviews have identified an absence of robust evidence supporting the prescription of puberty blockers for young people with gender dysphoria. Commensurate with these precautions, other countries such as France (Académie nationale de médecine, 2022), Norway (Block, 2023) and Denmark (Hansen et al., 2023) are reviewing their use of puberty blockers and gender-affirming medical care. In addition, in the United States and in the United Kingdom legal action is being taken by previous recipients of affirmative gender care who have subsequently come to regret their decisions and who believe that they are the victims of iatrogenic harm.
We are aware that some readers will not share our views. We trust, however, that all will agree that health and social care are best served by educational preparation which is driven by evidence rather than ideology, or personal belief. Unfortunately, as most readers will know, questions around sex and gender have become highly charged – at present, there are few more difficult topics to discuss (Ion & Maxwell, 2022). Silence and fear do not serve patient care well and ideological commitment is no substitute for critical thinking and robust analysis of evidence.
In our view there are steps that educators might take which maximise the likelihood that their teaching will, as far as possible be free from the taint of bias, activism and political point making.
3. Preparing for teaching
As we have done here, teachers should consider transparency and openness with students about their own position on this contested topic. If this is not possible, then it is crucial that arguments for and against specific points are presented in good faith. This should extend to the inclusion of people with lived experience where good practice should amplify the voices of those who have benefitted from transition as well as detransitioners and those with concerns. Similarly, if input from external organisations is sought, this should be balanced; for each speaker who advocates transition in young people, there should be a voice which describes the potential harms of transition. Educators should also make time to sensitively discuss any misunderstandings and misrepresentation of facts. In the case of speakers with a clear ideological position, it is the responsibility of the educator to make this clear to students. Underpinning all of this is the requirement for critical evaluation of research. Regardless of personal belief it is vital that the strengths and limitations of research are explored in some detail.
The Socratic Method is a teaching and learning approach that involves a process of questioning and critical inquiry to stimulate critical thinking, self-examination, ethical reflection and a deeper understanding (Makhene, 2019). Self-examination encourages students to reflect on their own beliefs, values and bias, allowing them to consider alternative viewpoints. It is well suited to situations where knowledge is contested and where students are likely to hold a range of views. Its purpose is not to force a view on the learner but to facilitate their engagement with different perspectives.
4. Some questions to consider
In this section we suggest some questions which might be used to stimulate curiosity and prompt discussion in the classroom:
•
Are sex and gender synonyms for the same concept or do they mean different things?
•
What are the issues involved with informed consent for transition in children and young people, especially in the context of vulnerable and/or extremely distressed individuals?
•
What evidence is there to support the claim that people can literally change sex?
•
What explanations have been put forward for the very significant rise in the numbers of young people, many with co-existing mental health issues, autism and histories of abuse, who present with gender dysphoria?
•
Why are girls overrepresented in those seeking gender reassignment?
•
What evidence is there for and against the use of puberty blockers in the treatment of young people with gender dysphoria?
•
What is known about the long-term outcomes for young people who transition in terms of their mental and physical health?
•
What is known about the long-term outcomes of those who medically transition, especially those who have taken cross sex hormones for an extended period?
•
Some gender affirming clinicians use colloquialisms such as ‘bottom surgery’ and ‘top surgery’ instead of ‘castration/penile removal’ and ‘double mastectomy’ in medical discourse. Why might this be the case?
•
Surgical transition may involve the removal or modification of healthy body parts. Are there any other areas of medicine where patients consent to removal of healthy body parts for the relief of psychological distress?
•
What is meant by the term ‘watchful’ waiting’ and is there evidence to support the view that most young people with GD ‘recover’ if this approach is provided?
What is meant by the term ‘detransition’’?
•
What is known about the health needs of young people who detransition?
5. Conclusion
It has become difficult to talk about sex and gender without fear of criticism and sometimes abuse and threat. The topic is however one which most health and social care workers will have to consider at some point. Our aim in this article has been to present thoughts on how this might be done.
Editorial note
Editorials in NEP are not reviewed and are published at the discretion of the Editor-in-Chief. We welcome a constructive rejoinder on this editorial provided it is not offensive or personal.
References
H. Barnes
Time to think
Swift Press,, London (2023)
J. Block
Norway’s guidance on paediatric gender treatment is unsafe, says review
BMJ, 380 (2023), p. p697, 10.1136/bmj.p697
Accessed August 19, 2023
View article
Cass, H. (2022). The Cass Review: Independent review of gender identity services for children and young people: Interim report. Accessed August 19, 2023, https://cass.independent-review.uk.
Churcher Clarke and Spiliadis, 2019
A. Churcher Clarke, A. Spiliadis
‘Taking the lid off the box’: the value of extended clinical assessment for adolescents presenting with gender identity difficulties
Clin. Child Psychol. Psychiatry, 24 (2) (2019), pp. 338-352
Accessed August 19, 2023
〈https://pubmed.ncbi.nlm.nih.gov/30722669/〉
View article
Gender Identity Development Service, 2021
Gender Identity Development Service (2021). Referrals to GIDS, financial years 2010–11 to 2020–21. https://gids.nhs.uk/about-us/number-of-referrals/.
M.V. Hansen, A. Giraldi, K.M. Main, J.V. Tingsgård, M.E. Haahr
Health services for children and young people with gender dysphoria
Ugeskr. Læg., 2023 (185) (2023)
V11220740. Accessed August 19, 2023
〈https://ugeskriftet.dk/videnskab/sundhedsfaglige-tilbud-til-born-og-unge-med-konsubehag〉
Ion, R. & Maxwell, E. (2022) Questions about sex and gender: some thoughts on a way forward for the profession. Blog - Evidence Based Nursing, June 26th. Accessed 4/10/23 https://blogs.bmj.com/ebn/2022/06/26/questions-about-sex-and-gender-some-thoughts-on-a-way-forward-for-the-profession/.
R. Kaltiala-Heino, M. Sumia, M. Työläjärvi, N. Lindberg
Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development
2015
Child Adolesc. Psych. Ment. Health, 9 (1) (2015), Article 9, 10.1186/s13034-015-0042-y
View PDF
This article is free to access.
S.B. Levine, E. Abbruzzese
Current concerns about gender-affirming therapy in adolescents
Curr. Sex. Health Rep., 15 (2023) (2023), pp. 113-123, 10.1007/s11930-023-00358-x
View PDF
This article is free to access.
Ludvigsson J.F., Adolfsson J., Höistad M., Rydelius P.A., Kriström B., Landén M. A systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatr 2023 Apr 18. Accessed August 19, 2023, https://onlinelibrary.wiley.com/doi/10.1111/apa.16791.
A. Makhene
The use of the Socratic inquiry to facilitate critical thinking in nursing education
Health SA Gesondheid, 24 (2019)
T. Matthews, V. Holt, S. Sahin, A. Taylor, D. Griksaitis
Gender dysphoria in looked-after and adopted young people in a gender identity development service
Clin. Child Psychiatry Psychol., 24 (2019), pp. 1-128
Medicine and gender transidentity in children and adolescents – Académie nationale de médecine, 2022
Medicine and gender transidentity in children and adolescents – Académie nationale de médecine (2022). Une institution dans son temps. (n.d.). Access August 19, 2023, from https://www.academie-medecine.fr/la-medecine-face-a-la-transidentite-de-genre-chez-les-enfants-et-les-adolescents/?lang=.
Mill J.S. (2006) On Liberty and the subjection of women. Penguin classics.
National Institute for Health and Care Excellence, 2020b
National Institute for Health and Care Excellence (2020b). Evidence review: gender-affirming hormones for children and adolescents with gender dysphoria. Accessed August 19, 2023, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726_Evidence-review_Gender-affirming-hormones_For-upload_Final.pdf.
National Institute for Health and Care Excellence, 2020a
National Institute for Health and Care Excellence (2020a). Evidence Review: Gonadotrophin Releasing Hormone Analogues for Children and Adolescents with Gender Dysphoria. Accessed August 19, 2023, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/file:///C:/Users/hodt1/Downloads/20220726_Evidence-review_GnRH-analogues_For-upload_Final.pdf.
Pasternack I., Söderström I., Saijonkari M., Mäkelä M. Lääketieteelliset menetelmät sukupuolivariaatioihin liittyvän dysforian hoidossa. Systemaattinen katsaus. [Medical approached to treatment of dysphoria related to gender variations. A systematic review.]. Published online 2019:106. Accessed August 19, 2023, https://app.box.com/s/y9u791np8v9gsunwgpr2kqn8swd9vdtx.
Strick K. (2023) How Róisín Murphy became the most vilified female celebrity since J.K. Rowling The Evening Standard 16 September (https://www.standard.co.uk/insider/roisin-murphy-album-trans-culture-war-puberty-blockers-b1106947.html; accessed 18 Sptember 2023).
K.J. Zucker
Epidemiology of gender dysphoria and transgender identity
Sex. Health, 14 (5) (2017), pp. 404-411
Accessed August 19, 2023
Your position is the one the HRC should be adopting.
Excellent article!
Brilliant! 👍