Open Letter to the ACP-UK

Dear ACP-UK Board and Members,

We are a group of clinical psychologists and gender identity specialists with considerable years of experience working within NHS national gender clinics. We include those who have worked or are working in the GIDS and adult gender services, and/or those who identify as gender diverse, plus allied clinical psychologists with LGBT lived experience. We are a mixture of ACP-UK members and members of gender profession specific organisations such as the British Association of Gender Identity Specialists (BAGIS), World Professional Association for Transgender Health (WPATH), Transgender Professional Association for Transgender Health (TPATH), The British Psychological Society Gender Diversity Register, and the HM Courts and Tribunals Psychologists specialising in Gender Dysphoria for the purpose of Gender Recognition Certification.

We are writing in response to the recent position statement, ‘The Cass review and its implications: psychologically informed considerations for the future, written on behalf of the ACP-UK board of directors, with input from members’. This statement was a response to the interim report from the Cass review, which was produced by a team led by Dr Hilary Cass, a Consultant Paediatrician and former President of the Royal College of Paediatrics and Child Health. This letter does not aim to capture or represent all of the clinical complexities that exist in this area.

The ACP-UK states that it seeks to provide a national voice for clinical psychology, seeking to be a representative professional body for clinical psychology, empowering clinical psychologists to provide psychological influence and perspective in order to improve the wellbeing and quality of life of service users, and promoting evidence-based psychological principles and opinion as applied to contemporary issues.

This group of clinical psychologists believe that the ACP-UK has failed in its purpose to provide a representative voice for clinical psychologists on this matter. We believe that the ACP-UK has failed to adequately seek the views of experts within the field of gender identity and diversity when developing this position statement, including those community members who represent trans and non-binary voices, and that this calls into question the credibility of the statement. It is our opinion that some of the issues raised in the report, and the psychological factors considered, have been distorted and amplified, while other relevant factors (and bodies of evidence) appear to have been overlooked. This lack of balance has resulted in a statement that is misleading, and contributes to an atmosphere of fear, rather than one of curiosity and understanding. Without proper consultation to a range of voices with gender experience, there is a risk of professional bodies such as the ACP-UK perpetuating damaging discourses about the work and gender diverse identities more broadly. This will further negatively impact recruitment and retention, at a time when significant expansion of service provision is required.

Language

Deviating from the language of the Cass Review, the ACP-UK statement uses only diagnostic terms to describe the young people receiving gender-related healthcare (“gender dysphoria” is from the DSM, and “gender incongruence” from the ICD). As psychologists we would welcome a move away from this medicalising language, and would suggest “gender questioning” or “gender diverse” as more neutral, descriptive terms.

The use of ‘male’ and ‘female’ in the ACP-UK statement undermines the lived experiences of the people being referenced. The preferred, and more accurate, terminology is ‘assigned (assumed) male at birth (AMAB)’ or ‘assigned (assumed) female at birth’ (AFAB), reflecting that people may now identify with genders that are different from their assigned sex.

It is implied that by ‘transition’ the authors mean ‘medical transition’ which is felt to ignore the many ways in which young people might seek to explore their identity and reduce gender-related distress e.g. social transition.

Context of the Report

The Cass interim report constitutes the first phase of a review process likely to last several years, rather than an end product. Within the report, Dr Cass listed some high level themes that were developed based on the available documentation and listening sessions with families and professionals.

We believe that the way in which some of the findings of the Cass Review have been summarised and reported at the beginning of the ACP-UK position statement fails to provide critical context. Indeed the Cass Review is entirely forward-facing, making recommendations for future configurations of NHS provision, and stating that “it is not the role of the review to scrutinise existing services” (https://cass.independent-review.uk/about-the-review/frequently-asked-questions/).

As gender specialists and clinical psychologists, we acknowledge the complexity of working within an evolving area. As clinicians in the field, we have experience of providing holistic assessment and support for young people who are exploring their gender identities, with a balance of listening to and taking seriously the voices of young people and families, whilst also encouraging exploration, and allowing for uncertainty and multiple possibilities in terms of paths that young people will follow. We are disappointed that a false binary continues to be perpetuated between ‘affirmative’ practice and exploration and curiosity. In the most recent WPATH Standards of Care 8 (Coleman, et al., 2022), it is stated that exploration, curiosity, and difficult discussions are only possible within a trusting therapeutic relationship whereby a young person feels that their identity, thoughts, and feelings are being respected. Being “affirmative” is often misrepresented as meaning that a trans identity is encouraged, or treated as a preferred outcome, when an alternative understanding is that this practice is a stance whereby no particular path or identity is privileged over any other, and gender diversity is viewed as a part of ordinary human diversity.

Clinical Assessment

It is disappointing that the ACP-UK board and the contributing members have not further explored the meaning of the use of ‘diagnostic overshadowing’. The term is typically used to identify situations in which a person’s difficulties are all seen through a singular lens, meaning that some things may be missed. An alternative interpretation is that it is possible to provide support for distress related to gender identity where mental health needs and neurodiversity are also present, and remain cognisant of all factors within formulation based practice. The authors challenge the idea that the presence of mental health difficulties and/or neurodiversity automatically impedes a person’s self-knowledge and agency.

There has long been an understanding in the field and an associated robust strong evidence base linking neurodiversity and gender diversity through the lifespan. There is no evidence however to suggest that the presence of either should negate that of the other — instead we propose the need to be thinking holistically about a person’s needs and experiences.

Similarly gender dysphoria can be associated with other difficulties such as low mood, anxiety, eating difficulties, and shame-based difficulties. The assessment of support needed for these difficulties should be made within the broader holistic context of the person’s needs, including gender diversity. Importantly, evidence from Minority Stress Theory in LGB groups (Meyer, 1995, 2003), and gender diverse populations (Testa et al, 2015; BPS, 2019; Meyer et al, 2020) suggests that internal and external/structural gender minority stress creates physical and psychological health disparities in society for trans, non-binary and gender diverse people. For example, an increase in self-harm behaviour (Gosling, Pratt and Lea, 2022) and an increase in suicide outcomes (Gosling et al, 2022). These experiences of significant psychological distress are often further compounded by naive or simplistic understandings of gender diversity and the experience of dysphoria by clinicians, amounting to non-inclusive healthcare experiences. It is vital therefore that as clinicians we seek to understand people’s experiences collaboratively and in the fullness of their context, especially when authentic gender expression and acceptance in healthcare has been shown to provide gender diverse people with a sense of empowerment and self-acceptance that could help to protect against external minority stressors, and self-harm and suicidal behaviours (Gosling et al, 2022).

Psychological and social factors

Gender identity and sexuality are separate and differentiated aspects of identity that emerge and coalesce at different points across identity development. The statement that ‘we are aware that many young people who experience same-sex attraction will, at some stage, question their gender identity or experience gender dysphoria’ is refuted on the basis of practice-based evidence. We put it to the authors of the statement that this is an amplification of the issue and it is wrong to assume that this is a majority experience for ‘same-sex attracted’ young people.

Equally, this statement seems to imply that young people might be seeking to transition to resolve negative feelings towards their own (LGB) sexual feelings or to ‘be straight’, overlooking the fact that the majority of trans and non-binary people actually identify as lesbian, gay, bisexual, asexual, queer, or ‘other’ (77% in the 2011 USA Transgender Discrimination Survey, Grant et al., 2011). Homophobia and transphobia are damaging issues in society and we support the need to better understand the impact of this on the overall gender and sexual development of young people. It is unhelpful to limit this exploration to a singular relationship between gender identity and homophobia.

The evidence base around the concept of ‘detransition’ is emerging, and is a complex issue encompassing a broad range of behaviours, pathways, and presence/absence of regret for those that identify as a ‘detransitioner’. Detransition may be conflated with the exploration of gender expression. There remains a dearth of literature for the UK population, with many studies relying on international cohorts and self-report data. Emerging evidence suggests that the numbers of people who choose to stop medical treatment initiated in the GIDS remain very small (Butler et al. 2022). Additionally, a growing body of evidence suggests that the main reasons for detransition are not identity changing, but rather due to a lack of social and personal support (Landen et al., 1998) or dissatisfaction with surgical results (Lawrence, 2003); and that overall rates of regret for those that may socially or medically detransition are very low (Davies et al. 2019, Turban et al. 2021). It is also important — given that this statement only pertains to young people — that it is made clear when discussing surgery that in England, the NHS only offers gender affirming surgery to adults (i.e. those over the age of 18) in adult gender services.

Research and evidence-based practice

There is evidence to suggest that different types of ‘transition’ (such as social and medical) lead to positive outcomes in terms of wellbeing (Gosling et al, 2022). There remain a number of challenges which mean that certain classes of evidence will never be available in this field (e.g. randomised control trials). Assigning people randomly to receive hormonal interventions would be highly unethical, and it is not possible to conduct blind trials due to the impact of the medical interventions on the body. The evidence base will therefore always be based on studies that are viewed as ‘lower quality’.

GIDS and associated partners have a well-established research team who have been conducting long-term prospective and retrospective research since 2019 (Kennedy, et al, 2021., Kennedy et al., 2021 McKay, et al, 2021). This will be further strengthened by the work of Professor Lorna Fraser (University of York) who is leading a review of the national data set of the medium- and longer-term outcomes for children and young people receiving NHS support and/or treatment as part of the Cass Review. It will look at the full cohort of children and young people, not only those that progress to medical treatment, and will potentially help answer questions that remain (web reference).

Supporting staff

We appreciate the authors’ recognition of the immense pressures involved in working in a service like GIDS, but also regret that this paragraph does not recognise the strengths, expertise, and resilience within the existing multidisciplinary clinical teams. GIDS staff have a broad range of clinical and research experience, and access ongoing support and training through comprehensive induction programmes, regular supervision, CPD, research meetings, complex case discussions, reflective practice groups, conferences, and an ethical sounding board.

Recommendations

We put it to the authors that any recommendations for the future of gender services should be informed on the basis of the expertise and experience of gender specialists who have worked with gender diverse young people, as well as by soliciting input from those young people and their families who are “experts by experience”.

1. Include and consult with clinical psychologists who have relevant clinical or lived experience in the field of gender identity.

2. For the profession to acknowledge that this clinical area sits in a place of complexity and uncertainty.

3. Make use of positive evidence based practise and practise based evidence to date.

4. Consider the voices of families, carers, and young people, alongside those who are unable to access services when formulating recommendations.

5. Consider identity as an experience from an intersectional perspective and use collaborative formulation to understand an individual’s needs.

6. Commit to the development of a more nuanced and less reductive understanding of the diverse journeys of both gender-diverse people and those who may identify as detransitioners.

7. Clinical work should be collaborative and consider power imbalances between the clinician and service user at all times.

8. Create spaces where gender diversity is embraced.

9. NHS commissioning bodies, across all nations, to commit to further investment to support the reduction of waiting times to access gender services.

10. Clinical Psychology Doctoral training courses to commit to including teaching on gender identity development across the lifespan, including gender related distress; and to increase the number of clinical psychologists who are skilled in working with this population.

Signatories

1. Dr Laura Charlton — Consultant Clinical Psychologist, Gender Specialist, Leeds Gender Identity Service — Clinical Lead, British Association of Gender Identity Specialists (member), British Psychology Society Gender and Sexual Diversity Specialist Register (member), World Professional Association of Transgender Healthcare (member). HM Courts and Tribunals Gender Specialist Register (member). GIDS 2014–2020.
2. Dr Aidan Kelly — Principal Clinical Psychologist, Gender Specialist, Nottingham Centre for Transgender Health. British Association of Gender Identity Specialists (member), Association of Clinical Psychologists- UK (member). GIDS 2016–2021.
3. Dr H Eli Joubert — Consultant Clinical Psychologist, Gender Specialist, Clinical Director Leeds Gender Identity Service, British Association of Gender Identity Specialists (member), World Professional Association of Transgender Healthcare (member), British Psychology Society Gender and Sexual Diversity Specialist Register (member), HM Courts and Tribunals Gender Specialist Register (member).
4. Dr Anna Laws — Consultant Clinical Psychologist, Northern Region Gender Dysphoria Service. British Association of Gender Identity Specialists (council member). British Psychology Society Gender and Sexual Diversity Specialist Register (member). HM Courts and Tribunals Gender Specialist Register (member).
5. Dr Amber Keenan — Clinical Lead, Gender Identity Clinic, NHS Grampian. British Association of Gender Identity Specialists (member). HM Courts and Tribunals Gender Specialist Register (member). Association of Clinical Psychologists — UK (member).
6. Dr James Lea (He/They) — Principal Clinical Psychologist, Clinical Academic and Researcher focussed on understanding the experience of psychological distress in people who identify as Gender, Sex/Sexuality and Relationship Diverse (GSRD).
7. Dr Claudia Zitz — Consultant Clinical Psychologist, Gender Specialist, GIDS, British Association of Gender Identity Specialists (council member), Association of Clinical Psychologists- UK (member), British Psychological Society (member), GIDS staff member 2013 — present.
8. Dr Rob Whittaker — Consultant Clinical Psychologist, GIDS 2013–2019
9. Dr Jos Twist — Principal Clinical Psychologist, Gender Specialist, British Association of Gender Identity Specialists (member), GIDS staff member 2016- present
10. Dr Francine Washington — Highly Specialist Clinical Psychologist, GIDS staff member 2018 — present.
11. Dr Debby Jackson — Principal Clinical Psychologist, Gender Identity South West/West of England Specialist Adult Gender identity Clinic 2015-present, British Association of Gender Identity Specialists (member),British Psychology Society Gender and Sexual Diversity Specialist Register (member). HM Courts and Tribunals Gender Specialist Register (member), World Professional Association of Transgender Health (member).
12. Dr Heather Wood — Principal Clinical Psychologist, Gender Specialist, British Association of Gender Identity Specialists (member), GIDS staff member 2014- present
13. Dr Lorna Hobbs — Highly Specialist Clinical Psychologist, Gender Specialist, Clinical Academic and Researcher (UCL) in LGBTQ+ health and sexual health, British Association of Gender Identity Specialists (member), World Professional Association of Transgender Healthcare (member). GIDS staff member 2018 to present.
14. Dr Danielle King — Clinical Psychologist
15. Dr Lyndsay Hall-Patch, Consultant Clinical Neuropsychologist
16. Dr Aliénor Lemieux-Cumberlege — Clinical Psychologist
17. Dr Gareth Davies — Principal Clinical Psychologist — Welsh Gender Service
18. Emma-Ben Lewis — Clinical Psychologist in Training
19. Dr Elinor MacCormac — Highly Specialised Clinical Psychologist, Welsh Gender Service.
20. Dr Simon Levinson — Highly Specialist Clinical Psychologist, GIDS.
21. Dr Tom Matthews — Principal Clinical Psychologist, GIDS 2016–2019.
22. Dr Rebecca Yeates — Clinical Psychologist, GIDS 2016–2019.
23. Dr Rachel Eastaugh, Clinical Psychologist, GIDS 2019–2022.
24. Dr Sarah James — Psychology Lead/Principal Clinical Psychologist, Gender Specialist, The South West Gender Identity Service, British Association of Gender Identity Specialists (member).
25. Jess MacIntyre-Harrison — Trainee Clinical Psychologist at UCL, Honorary Lecturer in LGBTQ+ Mental Health, GIDS staff member 2019–2020.
26. Dr Luke Squires — Clinical Psychologist, British Association of Gender Identity Specialists (member)
27. Kirsty Conway — Clinical Psychologist in Training.
28. Dr Paul Withers — Clinical Psychologist, Trans Support Service, MerseyCare NHS Trust
29. Dr Mehul Elliott-Joshi — Highly Specialist Clinical Psychologist, GIDS 2019 — present.
30. Dr Bernadette Wren — Clinical Psychologist
31. Dr Pippa Hembry — Clinical Psychologist, GIDS 2018–2019.
32. Dr Ella Rafferty — Consultant Clinical Psychologist, Gender Specialist — Welsh Gender Service. HM Courts and Tribunals Gender Specialist Register (member).
33. Dr Rosie Sharville, Highly Specialist Clinical Psychologist, GIDS staff 2019-present
34. Dr Sarah Davidson, Consultant Clinical Psychologist , GIDS 2006–2021
35. Dr Nick Stenning, Principal Clinical Psychologist, GIDS 2016–2020
36. Dr Polly Carmichael, Consultant Clinical Psychologist, Clinical Director of GIDS 2009-present
37. Dr Rosie Jones, Principal Clinical Psychologist, GIDS 2020-present
38. Dr Karen Gurney, Clinical Psychologist and Lead Clinician at Trans Plus
39. Dr Josh Goulding-Talbot - Specialist Clinical Psychologist, GIDS
40. Dr Adele McGovern, Highly Specialist Clinical Psychologist, GIDS staff 2018 — present
41. Dr Nicolas Burden, Principal Clinical Psychologist, Gender Specialist, GIDS
42. Dr Charlotte Rice, Clinical Psychologist. Trainee Clinical Psychologist at GIDS 2021–2022.
43. Olivia Carrick, Trainee Clinical Psychologist.
44. Anonymous Consultant Clinical Psychologist with over 10 years previous experience in GIDS — name supplied
45. Anonymous Consultant Clinical Psychologist (name supplied)
46. Anonymous GIDS clinical psychologist 2014–2019 (name supplied)
47. Anonymous Principal Clinical Psychologist, Gender Specialist, BAGIS (member) 10 years experience of working in adult gender services (name supplied)
48. Anonymous Highly Specialist Clinical Psychologist, GIDS staff 2018-present (name supplied)
49. Anonymous Clinical Psychologist, GIDS staff 2015–2019 (name supplied)
50. Anonymous Senior Clinical Psychologist, GIDS staff 2018–2020 (name supplied)
51. Anonymous Principal Clinical Psychologist
52. Anonymous Principal Clinical Psychologist

Note: the only signatories included in the letter were qualified and trainee clinical psychologists. Supporting signatures from other professional groups were excluded.

References

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Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., De Vries, A. L. C., Deutsch, M. B., … & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health

Davies, S., McIntyre, S., & Rypma, C. (2019, April). Detransition rates in a national UK Gender Identity Clinic. In 3rd biennal EPATH Conference Inside Matters. On Law, Ethics and Religion (p. 118)

Dunlop, B. J. & Lea, J. (2022: Under review). “It’s Not Just In My Head: An Intersectional, Social, and Systems-based Framework in Gender and Sexuality Diversity.” Psychology and Psychotherapy: Theory, Research and Practice

Gosling, H., Pratt, D., Montgomery, H. & Lea, J. (2022). The relationship between minority stress factors and suicidal ideation and behaviours amongst transgender and gender non-conforming adults: A systematic review. Journal of Affective Disorders. 303, 31–51. https://doi.org/10.1016/j.jad.2021.12.091

Gosling, H., Pratt, D. & Lea, J. (2022). Understanding self harm urges and behaviour amongst non-binary young adults: A grounded theory study. Journal of Gay & Lesbian Mental Health. DOI: 10.1080/19359705.2022.2073310

Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force: Washington, DC, USA

Kennedy, E., Lane, C., Stynes, H., Ranieri, V., Spinner, L., Carmichael, P., … & King, M. (2021). Longitudinal Outcomes of Gender Identity in Children (LOGIC): study protocol for a retrospective analysis of the characteristics and outcomes of children referred to specialist gender services in the UK and the Netherlands. BMJ open, 11(11), e054895

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Lawrence AA. (2003) Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav: 32:299–315

MacKinnon KR, Kia H, Salway T, et al. Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. JAMA Netw Open. 2022;5(7):e2224717. doi:10.1001/jamanetworkopen.2022.24717

MacKinnon KR, Kia H, Salway T, et al. Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. JAMA Netw Open. 2022;5(7):e2224717. doi:10.1001/jamanetworkopen.2022.24717

McKay K, Kennedy E, Lane C, et alLongitudinal outcomes of gender identity in children (LOGIC): a study protocol for a prospective longitudinal qualitative study of the experiences and well-being of families referred to the UK Gender Identity Development ServiceBMJ Open 2021;11:e047875. doi: 10.1136/bmjopen-2020–047875

Meyer, I. H. (1995). Minority Stress and Mental Health in Gay Men. Journal of Health and Social Behavior, 36(1), 38–56. https://doi.org/10.2307/2137286

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. doi:10.1037/0033–2909.129.5.674

Meyer, I. H. (2015). Resilience in the study of minority stress and health of sexual and gender minorities. Psychology of Sexual Orientation and Gender Diversity, 2(3), 209–213. https://doi.org/10.1037/sgd0000132

Steensma TD, Biemond R, Boer FD, et al (2011) Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clinical Child Psychology and Psychiatry, 16, 499–516.

​​Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77.

Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health. 2021 May-Jun;8(4):273–280. doi: 10.1089/lgbt.2020.0437. Epub 2021 Mar 31. PMID: 33794108; PMCID: PMC8213007.

Web addresses

https://cass.independent-review.uk/research/#:~:text=The%20Review's%20quantitative%20research%20programme,of%20children%20and%20young%20people