Lost at sea?
A response to Pilgrim (CPF 319)
This piece was originally submitted as a letter to Clinical Psychology Forum (a publication of the British Psychological Society’s Division of Clinical Psychology) in response to an article by David Pilgrim in an earlier issue of the same publication. A much shorter, edited version of this letter is due to appear in a forthcoming issue of CPF.
Founder and former Director of the Tavistock’s child adolescent gender identity service, Domenico Di Ceglie (2018), suggests that the use of metaphors such as ‘navigating between Scylla and Charybdis’ and ‘working at the edge’, allow the professional to hold on to multiple perspectives and to maintain a certain degree of ambiguity. Indeed, during my four and a half years working at the same service, I often turned to Di Ceglie’s words to help me find an anchor in the turbulent seas of gender identity debates. Pilgrim’s (2019) very welcome exploration of the different ontological positions that inform ideas about transgender identities similarly provides a metaphorical map to help us negotiate some of the philosophical twists and turns in current debates around gender transition. However, whilst I believe that being aware of the philosophical landscape is a necessary basis for psychologists working with issues around gender identity, at the same time, on its own, this knowledge is insufficient. We must also consider how we position ourselves and act in relation to the discursive possibilities available to us.
Equally, in my experience, Di Ceglie’s metaphors on their own do not possess a magic power automatically equipping clinicians with an ability to take up a variety of different theoretical and ontological positions. These words can only ever be a jumping-off point: they are not in themselves the goal. But in fact, metaphors such as these are often drawn upon both by individual clinicians and services alike as justification for the seductive notion of finding an imagined position of ‘neutrality’, which they then hope to occupy. Once sat atop this assumed vantage point, there is perhaps the temptation to believe one is able to survey the various positions and debates without being part of them. In my experience, however, those who believe they hold this supposedly neutral position often appear at pains to robustly defend the moral fortress. Such a siege mentality does, however, come at some cost.
Describing the pitfalls of the concept of neutrality in family therapy, Cecchin (1987) notes that ‘for many therapists, neutrality has been regarded as the cultivation of a position of noninvolvement, of not having strong opinions, and of not taking responsibility when necessary’. This reminds me of the stalemate – or blocked dialectic – that Pilgrim usefully describes in current discourse on transgender experiences, which can risk becoming a central feature of clinical work with gender non-conforming children and adolescents. In practice, a ‘neutral’ position is anything but that: it involves tacitly accepting, if not wholly subscribing to, a set of beliefs about identities and their formation and an ever increasingly more permissive bioethical position when it comes to medical interventions such as hormone blockers. It also minimises the position held by clinicians and services as powerful actors in the field, given their central role in shaping how gender identity can be thought about, discussed, and produced.
The language used to describe active medical intervention to disrupt the body’s production of sex hormones and the biologically pre-programmed development of secondary sexual characteristics is also commonly framed in terms of neutrality. Hormone blockers are described as putting a ‘pause’ on further pubertal development, or as providing ‘thinking space’ for further reflection. However, in clinical practice we know, for example, that the overwhelming majority of young people who have been put on hormone blockers in early puberty will continue on a medical transition pathway (e.g. Gunn et al, 2015; de Vries et al, 2011). That is not to say we should not offer pharmaceutical solutions to crises of identity development – that is a different question – but we should be careful not to imply it is a neutral option. Other positions (e.g. “watchful waiting”) come of course with their own ethical and philosophical assumptions and are not neutral approaches either.
Pilgrim rightly draws attention to the need for us to be able to have open conversations about gender identity. One barrier to such openness, which I believe arises in some NHS contexts, is the construction of gender identity services as neutral thinking-spaces, constantly and valiantly maintaining a neutral position despite being buffeted by the wild winds of public debate. For example, a recent press release (Tavistock and Portman, 2019) proclaims that the child and adolescent service I used to work for, ‘has always taken a balanced approach’ and that it ‘attempts to occupy a thoughtful position based on the best available evidence while facing criticism from both ends of the spectrum of opinion in a highly scrutinised area of practice.’ Of course, all groups construct stories about themselves in order to create or preserve a sense of purpose and cohesiveness. However, when NHS services construct narratives of themselves as being a neutral, benign force, it naturally requires that dissenting voices are positioned as emanating from the extremes. If it is unable to acknowledge its own stake in the game, is an organisation not likely to struggle to appreciate its own agency and at the same time ignore the human cost of the psychological ‘work’ it must do to maintain an illusion of neutrality? As such, rather than accepting Cecchin’s invitation to view neutrality as ‘the creation of a state of curiosity in the mind of the therapist,’ does the idea of neutrality perhaps in fact risk being reduced instead to theoretical entrenchment and a closing down of curiosity?
Revisiting one of Di Ceglie’s metaphors, in Homer’s telling of the story, Odysseus sails close to the six-headed monster Scylla in his attempt to avoid the whirlpool of Charybdis, and in so doing sacrifices six of his bravest men. However, as those familiar with the Odyssey will know, the ship is later lost when Zeus strikes it with a thunderbolt, the rest of the crew drown and Odysseus is swept up in the swirling waters of Charybdis – despite his earlier efforts to avoid it. Odysseus, naturally, manages to survive to tell the tale but his crew, and his ship, were gone.
Pilgrim’s article is a long-overdue call for people from across the political and philosophical spectrum, including the liberal-left of the professional middle classes to interrogate current ideas about gender more closely and from a wider variety of angles, and also to consider the epistemological claims made from these different positions. There are of course winners, people who already do well out of the current ways in which our profession is navigating the ethical dilemmas in working with gender identity. But we need to also ask ourselves: who and what is getting lost at sea along the way?
Cecchin, D. (1987) Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity, Family Process, 26(4), 405–413. DOI: 10.1111/j.1545–5300.1987.00405.x
Di Ceglie, D. (2018) The use of metaphors in understanding atypical gender identity development and its psychosocial impact, Journal of Child Psychotherapy, 44(1), 5–28. DOI: 10.1080/0075417X.2018.1443151
Gunn, H.M., C. Goedhart, G. Butler, S.N. Khadr, P.A. Carmichael, and R.M. Viner. (2015) Early medical treatment of gender dysphoria: baseline characteristics of a UK cohort beginning early intervention. Archives of Disease in Childhood, 100 (Suppl 3): A198.
Pilgrim, D. (2019). What is and what ought to be: transgenderism and free speech. Clinical Psychology Forum, 319, 42–47.
Tavistock and Portman NHS Foundation Trust (2019, 14th July). Gender Identity Development Service – response to recent statements in the media [Press release]. https://tavistockandportman.nhs.uk/about-us/news/stories/gender-identity-development-service-response-recent-statements-media/. Retrieved on 27.08.2019.
de Vries, A.L.C, Steensma, T.D., Doreleijers, T.A.H. & Cohen‐Kettenis, P.T. (2011) Puberty Suppression in Adolescents With Gender Identity Disorder: A Prospective Follow‐Up Study. The Journal of Sexual Medicine, 8(8), 2276–2283. DOI: 10.1111/j.1743–6109.2010.01943.x.