An open letter to Dr Polly Carmichael from a former GIDS clinician

Dear Polly,

I am writing to you as a former clinician from the Gender Identity Development Service (GIDS) in Leeds. I wish to outline the concerns I had at the time of working there and the concerns that have either grown or developed since I left. I hope that you will address my concerns and also see the importance of investigating the concerns of other GIDS clinicians who have also left the service. During my time at GIDS in Leeds I had very little contact with the London clinic and so everything that I outline here, unless otherwise stated, is related to my experiences of working at GIDS in Leeds.

I think it is a problem that GIDS clinicians are making decisions that will have a major impact on children and young people’s bodies and on their lives, potentially the rest of their lives, without a robust evidence base. GIDS clinicians tell children and families that puberty blockers/hormone blocks are “fully reversible” but the reality is no one knows what the impacts are on children’s brains so how is it possible to make this claim? It is also a problem that GIDS clinicians are afraid of raising their concerns for fear of being labelled transphobic by colleagues.

I worked at the Leeds GIDS clinic as a Band 7 Clinical Psychologist between October 2017 and October 2018. Shortly after starting at GIDS I was in a meeting with three other GIDS clinicians. I said that it was curious to me that there had been so little discussion on gender identity in the field of psychology. In all my years of studying and working in psychology (including the Doctorate in Clinical Psychology) there had been very little mention of gender identity.

I also spoke about how it was interesting to me that I had been a Research Assistant on a Medical Research Council funded longitudinal research study on child development (Wirral Child Health and Development Study) that had commenced in 2007 and that gender identity had not been part of the investigation. I said that it feels as though the gender identity issue has come out of the blue. This attempt to try to explore the context resulted in my questions being described as “transphobic” by one of my colleagues, X.

Several weeks later when X and I had a joint meeting with senior staff X claimed that in the above meeting I had said that transgenderism was a trait of personality disorder. I had said nothing of the sort. I have never thought transgenderism is a kind of personality disorder and would never have said this.

The above meeting was called in response to a disagreement that I had with X over the two cases that we had seen together. As this is an open letter I cannot go into the details of my disagreements with X over these cases but in both cases I felt that X was too quick to recommend the medical pathway and I did not believe there was a current clinical need for puberty blockers in either case.

It was also surreal at the time to be arguing with X that a child’s early interest in [a certain children’s toy] should have no bearing on whether they are diagnosed with gender dysphoria.

In the same meetings with senior staff I also raised the issue of the aforementioned incident where X called me transphobic and another incident where she called me transphobic. The second incident was during a meeting of several clinicians where we were discussing a case of two young transmen who said that they were planning to [embark on something that, at the very least, would have serious health risks]. I had said that I believed that this needed to go to social care due to the risks involved and I believe that X called me transphobic for saying this.

In the meeting with senior staff X denied calling me transphobic and said that she had directed this allegation to colleague Y because she thought that that Y had said that any transpeople [embarking on xxxx] should be reported to social care. I do not remember Y saying this at all. As as far as I’m aware there were no repercussions for X calling either myself or Y transphobic when neither of us was being transphobic.

I had found the meetings to be incredibly stressful particularly as the senior managers although sympathetic and clearly trying to be neutral, did not seem to be taking seriously what I consider to be false allegations by X. I was left feeling very disoriented by the tepid responses of senior staff and both at the time and in retrospect I did not feel that my concerns about X were addressed in any substantial way.

I believe that X calling people ‘transphobic’ when there are clearly no grounds for this allegation causes clinicians to feel anxious about raising concerns.

Since leaving Leeds GIDS

Since leaving GIDS I have continued to follow transgender issues online and one of the things that I have felt concerned about is seeing the bullying and intimidation for those people who raise valid concerns about children making a medical transition being called ‘transphobic’ and ‘TERFS’ on forums such as Twitter.

I am also concerned that the attempts of Tavistock & Portman professionals, including former GIDS clinicians, to voice concerns about GIDS practice do not appear to have sunk in. Polly, as I’m sure you know very well, Clinical Psychologists are not known for going to the press but several former GIDS clinicians have done so anonymously. I cannot think of another time when Clinical Psychologists have gone to the press about concerns for the welfare of the children in their service, you have to take them seriously.

I believe that Clinical Psychologists working elsewhere presume that because GIDS is part of Tavistock and Portman that it is working in line with the high standards and prestigious reputation that the trust has earned over the decades. I wish to make it clear to other Clinical Psychologists that most of the gender identity assessments being undertaken at GIDS are not being underpinned by the psychodynamic approach that the Tavistock is famous for.

There are children who have had very traumatic early experiences and early losses who are being put on the medical pathway without having explored or addressed their early adverse experiences. At GIDS no one directly tells you that you’re not allowed to suggest that perhaps these early experiences might be connected to a child’s wish to transition but if you make the mistake of suggesting this in a team meeting you run the risk of being called transphobic.

I think there are others, like me, who went to work at GIDS expecting to do complex assessments and differential diagnosis but the reality is that you run the risk of being called transphobic if you propose that, say, a child might have Body Dysmorphia rather than Gender Dysphoria.

Mermaids

I am also concerned to see that Mermaids continues to receive financial support and endorsements from high profile people whilst not being subjected to any proper scrutiny of its practice. I believe that it is the duty of GIDS to disclose their concerns about Mermaids as GIDS is one, if not the only place, where information about what goes on at Mermaids is known via parent reports. I also think that it is unethical that GIDS associates with Mermaids when they have associated with the Webberleys (from their website it looks as though they no longer do so).

GIDS policy on ruling out transgenderism

I also strongly believe that it is GIDS duty to make it known that it is highly unlikely that any child presenting there will be told that they are not transgender. One of my biggest ethical dilemmas whilst working at GIDS was that there were parents who brought their child to GIDS anticipating that we would confirm that the child was not transgender but we are not able to tell parents that actually there is some unspoken rule that means GIDS clinicians do not tell families, “your child is not transgender”.

Since leaving GIDS I have, over time, been learning about organisations and academics who present a more critical approach to gender identity and the medical pathway for children. I have also seen accounts of young people who no longer identify as transgender, even after medical interventions and are now distressed about having been put on the medical pathway. It is by seeing their courage that gives me the courage and the ethical duty to speak up.

I urge you to look up the stories of “detransitioners” (currently mostly American and Canadian young people) who report that they were not offered differential diagnosis of their gender dysphoria and that they were either coerced into medical transition or were not mentally well enough to give informed consent. I believe it is only a matter of time before we start to hear similar stories from British young people and that there needs to be a service available to give them support.

Many of these young people talk about feeling as though they have been in a cult and that they did not have access to any information or responses other than the affirmative approach.

Polly, one of the things that I have realised since leaving GIDS is that you used to say in the service meetings that at GIDS it was our job to hold the middle ground in this polarised field but after having read the criticisms of the ‘affirmative model’ and the medical pathway for children I don’t think GIDS holds the middle ground at all and is more closely aligned with the affirmative model, informed consent stance and is a very long way away from with the critical stance.

At GIDS I did not receive any training on WPATH or legal issues or any training on gender identity more generally that left me in a very vulnerable position. The GIDS approach is mostly about learning about gender identity from the more experienced colleagues you have joint cases with which I think is problematic given the experiences described above.

Complexity of GIDS Referrals

Whilst I was at GIDS one of the things that I frequently voiced concerns about was the referrals meeting. In previous services I’ve worked in it has either been senior staff who process referrals or it is done by the whole team. I was surprised that at GIDS junior members of staff are dealing with referrals — even trainee clinical psychologists in their early days of placement process referrals.

There is a ‘system’ for scoring the referral as low, medium or high complexity. I frequently voiced my concern that colleagues were not seeing abandonment/estrangement by a parent as an indicator of complexity. For me, this was another reason that made me feel so disoriented. In my Clinical Psychology training and in other services the loss of or abandonment by a parent would be something to be explored and the impact understood but I felt that at GIDS this factor was often minimised or dismissed.

I was also shocked by the complexity of referrals. I read many referrals of children who have been sexually abused and many children have witnessed and/or been subjected to domestic violence.

I also felt that was an overrepresentation of the young people who were living in poverty. I had a young person whose family were living within such extreme financial constraints that he considered it a treat to buy a can of pop. I also had another young person who was living in a very complex and unstable arrangement who arrived to sessions in a poor state of hygiene and said that there wasn’t money for hygiene products. How is it ethical to undertake a gender identity assessment with the view to a medical pathway when there are children and young people do not have their most basic needs met?

In terms of complexity I also had on my caseload several young people who declined to communicate verbally or communicated verbally to a very limited extent. I think that at GIDS verbal communication difficulties are often minimised as transmales being afraid to speak because they have a ‘feminine voice’ but in all of these cases I believe that there was something more complex than that going on. Again, it’s very difficult to undertake a gender identity assessment with a young person who struggles to communicate verbally, especially within the time constraints of the service.

Failure of support from CAMHS and Social Care

One of the other major factors that meant that I could not sustain working at GIDS was the failure of social care to provide support to the young people I referred. As the children come from all over the North of England I was dealing with several different social care teams trying to get support for my patients who were either doing risky things, living in risky situations or in contact with risky people. In none of my cases was input from social care secured.

How is it possible to undertake a gender identity assessment when young people are living in these circumstances and sometimes even more extreme? I do not believe that GIDS can claim to function effectively when it is part of a broader system that is failing to provide adequate support and protection for children and young people.

I also believe that there are clinicians at GIDS who are putting vulnerable children on the medical pathway when they are not receiving proper input from CAMHS and Social Care with regards to mental health problems and complex family and housing difficulties.

I have more issues that I wish to raise but this is probably enough to say for now. I believe that a proper investigation of the concerns by current and former GIDS staff is required. I know that other GIDS staff left without challenging the issues that they were concerned about. In my experience psychologists are often anxious about conflict and are unwilling to challenge senior professionals. I think GIDS clinicians also worry that openly criticising GIDS will give more power to Mermaids. I certainly felt like this at the time but having distance from the service makes me realise that it is crazy to not speak out on this basis.

The main thing that I hope for by writing this letter is that everyone, especially former and current GIDS clinicians, will dig beneath the surface layer of information on transgenderism and take the time to read the work of the minority of clinicians, academics and organisations who are taking a critical stance (and receiving verbal abuse and losing their jobs) and the detransitioners (also receiving verbal abuse) who are telling their stories.

I also hope that GIDS clinicians will feel safer to confirm to parents when they do not think a child is transgender and better able to discuss with children and young people what else they think might be going on for that child.

It’s a shame that it has to come to such an extreme as to write an open letter like this but when I tried to deal with the above issues within the service I don’t think my concerns properly addressed by Leeds management and I have seen how you haven’t taken seriously the concerns of other GIDS clinicians. I believe that if I had sent this letter privately it just would have been batted off.

My main hopes for writing this letter is that you will at least:

· finally truly listen to the concerns of current GIDS clinicians and give former GIDS clinicians a formal opportunity to express their concerns;

· that you will protect and support GIDS staff when they are falsely accused of transphobia and take formal action against people who make false accusations of transphobia;

· that you will better protect children and young people by ensuring that every child at least has a comprehensive psychosocial assessment before the medical pathway is considered;

· and that GIDS clinicians will stop giving the message that hormone blockers/puberty blockers are “fully reversible” when there is currently no way of knowing what is the long term impact on the brain

Yours Sincerely,

Kirsty

(Dr Kirsty Entwistle — Clinical Psychologist)