Dear Kirsty Entwistle,
Re An open letter to Dr Polly Carmichael from a former GIDS clinician (https://medium.com/@kirstyentwistle/an-open-letter-to-dr-polly-carmichael-from-a-former-gids-clinician-53c541276b8d)
I was saddened to read your open letter dated July 18th and the subsequent article in The Daily Mail. As myself and my husband were mentioned, I felt compelled to draft a response.
It is true that, historically, there has been very little education around the issues of gender identity. I am not familiar with the syllabus covered by psychologists in their training, but I do know that there is no formal education in medical school, neither at foundation level for doctors, or in the specialist training modules to become a GP or hospital consultant.
Healthcare professionals needing to learn about gender identity in order to best help their patients can turn to the numerous, excellent, research papers and guidelines that have been published in more recent years. (https://www.liebertpub.com/doi/10.1089/trgh.2017.0004) (https://academic.oup.com/jcem/article/102/11/3869/4157558)
There is nothing, however, that can negate the existence of gender incongruent people, who have been readily identifiable throughout history. We have a rich and diverse set of narratives from trans adults who have been willing to share their stories and help educate cisgender people to aid their understanding of what it feels like to be trans.
There is no doubt that the volume around the subject of gender identity has risen significantly over the last few years. Acceptance and belief have allowed gender diverse people to finally begin to come out of the shadows and join society as themselves, rather than under a false pretence.
Importantly, every single trans adult was once a trans child. They may not have had the vocabulary to describe or understand their feelings, they may have been shamed or punished for ‘cross-dressing’ or voicing their thoughts.
There certainly wasn’t enough professional help available to allow them the opportunity to ‘try out their gender’ through social transition, or suspend puberty to prevent life-changing developments which could forever brand them as ‘trans’.
Today’s gender variant children are more fortunate in many ways. With sensitive help from professional healthcare providers, they can explore their feelings in safety, without fear of being shamed or punished.
They can press pause on puberty, to allow them time to reflect on their future and plan their gender journey. They can choose to have intervention to allow them the puberty that matches their gender identity, rather than have their bodies masculinise or feminise, potentially setting them at a disadvantage for the rest of their lives. The gift of not being identifiable as trans, and to be in charge of your own gender journey, is an extra special one. Ask any trans adult.
Unsupported trans children and adolescents have higher rates of mental health issues. A significant proportion hurt themselves and, in the worst cases, even take their own lives.
However, ‘Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group.’ (https://pediatrics.aappublications.org/content/137/3/e20153223)
There is no question that GIDS has an unenviable task. It is criticised by some for going too fast and criticised by others for moving too slowly. It works according to its own service specifications rather than to International standards of care for the treatment of gender variant children. It has recently been described as being ‘the most cautious in the world’. (https://www.pinknews.co.uk/2019/07/18/uk-gender-identity-services-trans-kids-cautious-painstaking/)
In an ideal world, every young patient would have the right amount of resource and support to help them make the best decisions with the knowledge and experience that they have. They would have intervention when needed and at a time governed by clinical need, rather than by waiting times or fear.
They would strike up an excellent relationship with their psychologist and doctor who could support them on their journey with their gender identity, for the rest of their life. No matter where it might take them. Those would be very fortunate patients.
In your letter you talk about medical intervention for children. There is no medical intervention needed for children, they only require support, belief and exploration of their gender feelings. Medical intervention is only prescribed for adolescents, once they have reached puberty. When a failure to intervene appropriately would cause harm.
You mention your concern that ‘a child might have Body Dysmorphia rather than Gender Dysphoria.’ I presume you refer to the ICD-11 classification ‘6B21 Body dysmorphic disorder’, which is ‘characterized by persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others.’ Gender Dysphoria in children, on the other hand, is classified as ‘HA61 Gender incongruence of childhood’ and ‘is characterised by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children.’
Certainly, speaking from first hand experience, of which I have a considerable amount, the trans children that I have met have been far more concerned about their gender identity than a defect or flaw in their appearance.
I am sorry that you did not find your work with trans youth rewarding. In all my work throughout my career, this has been by far the most rewarding area for me. To be part of a young person’s life, to be with them while they share their difficult feelings of how their body doesn’t match their identity, and how this impacts them on a daily basis, is a genuine honour.
Being trans is not easy, neither for the person experiencing the gender variance, nor their friends and family. Knowing how best to help, as a healthcare practitioner, can be equally challenging. But simply ignoring the situation, in the hope that it will go away, is not an option.
All children, adolescents and those who care for them need strong support from healthcare professionals, based on current best evidence and clinical consensus.
Trans children exist and they need our support.
Dr Helen Webberley
@MyWebDoctorUK
www.GenderGP.co.uk
