NHS England Trans Questionnaires Aug 2017

NHS England have today issued two questionnaires – one seeking trans people’s experiences of using gynaecology services in England in the last 5 years, and one seeking trans people’s experiences of using non-GIC speech and language therapy services in England in the last 5 years.

Under the draft NHS specialist gender identity services protocol (currently also out for consultation), these are both services where (some) trans people will access care from general hospital services, so presumably this feedback is intended to contribute to improving patient experiences.

For reasons best known to NHS England, this consultation runs for less than 2 weeks, in the middle of the holiday period (closing 27th August), and you have to reply by downloading a Word document, filling it out and emailing back to a named person (so not exactly super-anonymous for talking about gynaecology experiences). I have already provided feedback on this as a consultation mechanism

The surveys are here:

NHS Questionnaire Gynaecology


NHS Questionnaire Speech and Language Therapy

Survey responses should be sent to:

zuzana.bates@nhs.net

New GIC protocols – some initial thoughts

NHS England has now launched a consultation on adult gender identity services. This runs until 30th September 2017.

Overall, I think there’s a lot of positives in there, and it addresses a lot of the frustrating inconsistencies between clinics. There’s an underlying issue about resourcing and capacity to deliver, but as a statement of what clinics should be aiming to achieve, it’s pretty good.

Here’s my initial thoughts on the positives, and on what could be improved.

Positives

  • Explicit statement of equity for non-binary people
  • Explicit recognition that being trans is not a mental illness and that trans people should have autonomy with regard to gender identity and presentation
  • Commitment to meet waiting time standards
  • They will consider Skype and phone consultations where possible (hopefully avoiding the current situation where some people make a 4 hour round trip for a 15 min appointment)
  • Standardised assessment process, which in most cases is completed in 2 appointments
  • Standardising the age limits for service, with extra flexibility on transfers – 17+ go to adult services, <17 are referred to youth services (but can stay there till they’re 20 if appropriate).
  • Clear statement that physical exams should not be routinely performed.
  • Absolute rejection of conversion therapy
  • Everyone now gets a named professional, who is their point of contact., and who checks in with them regularly (can be by email or phone)
  • Clear recognition that not everyone will seek interventions in the same linear, sequential process. This could for example make it easier for trans masculine people who want top surgery but not testosterone.
  • Clear re-referral process for people who have deferred surgery, then come back to the service for their surgery referral.
  • Clear statement that therapy should be available for those who want/need it, but is not mandatory
  • Referrals are acknowledged within 14 days, and don’t get rejected for not being in quite the right format
  • There’s a clear process for transferring people from one GIC to another, without reassessing them
  • Clinics cannot require that family members attend appointments, and if patients refuse a suggestion that family members come along, this cannot affect their care.
  • Surgeons have to demonstrate that they are performing at least 20 procedures a year, and that they are engaging with peers, talking to them about outcomes and complications etc (this is aiming to avoid the situation where you get a surgeon doing a small number of procedures which they are not very skilled at).
  • Clear standards for what info should be made available at consent to surgery, including offering the patient options and talking about pros and cons.
  • Clear statement that if you’re unhappy with surgery and don’t want to be treated by the same surgeon, you have the right to be referred elsewhere.
  • Clear statement that if your BMI is over threshold, you should still be referred to the surgeon, and an individual discussion had about risk (also, BMI threshold for  top surgery is set at 40 – some clinics had been refusing to refer people for top surgery until their BMI was 30, even though many top surgeons are happy to operate on people in the 30-40 range)

Could be improved

  • The big one is that there is currently a dispute between NHS England and the British Medical Association over the role of GPs in prescribing hormones. The document therefore presents 4 options: GP initiates hormones on recommendation of gender clinic (status quo); gender clinic gives 1st prescription and GP continues; gender clinic prescribes for a year then GP continues; or CCG train a specialised GP who does all hormone prescriptions in that area.
    – I think the third and fourth options are very problematic. The GICs don’t currently have capacity to do blood tests and administer injections, and it would mean a long journey for patients. In particular, patients on sustanon or enanthate might be having to travel to their gender clinic every three or four weeks for an injection – clearly impractical for someone in full time work living a couple of hours away from their gender clinic.
    – A specialised GP sounds great, especially if they could do bridging prescriptions – but I don’t think it’s necessary or sensible to say that they should be the only person who can ever prescribe hormones.  There are patients currently in primary care who have been on hormones, managed by their GPs, for several decades. How does it benefit those patients to send them elsewhere in the CCG (possibly a different town) for prescriptions? Plus what happens when that GP is ill, or on maternity leave? Also, the service specification only says what specialised services will do – it can’t place requirements on CCGs. So if the specialised services specification is drawn up expecting CCGs to commission and recruit to these new roles, then what happens if they don’t? The document also makes it clear that the NHS does not know how many trans patients it already has, but it does know the numbers seeking help are increasing. The demand for the new role would therefore be unknown, and rising cumulatively (an unknown number of trans people already taking hormones would all now have to access this service, plus the increasing number of future patients). Realistically, this would be difficult to commission for, and almost certainly experience problems and bottlenecks.
    – I would prefer a model which encourages CCGs to have a GP specialist, and for that to be a point of support for other doctors – but which does not say that only that specialist can prescribe.
  • Self-referral would have been nice. It seems to be working okay in Scotland. Although I understand the point about GP buy-in, the GP doesn’t have to be the one who refers the patient anyway.
  • The statement that they will not accept referrals of people with acute physical or mental health problems seems too categorical. In practice, waiting lists are currently 12 months or more – it is pretty likely that someone with an acute health problem at the time of referral will have resolved it by the time they get to an appointment. I think it would be better to say that such referrals will be accepted for the waiting list, but the situation reviewed before an appointment is offered
  • Specialised services won’t take responsibility for problems with surgery that are not picked up till after 18 months. Unfortunately, some people who’ve had bad surgical outcomes find that very difficult to talk about, and they do come forward some years down the line. In some cases, the surgeon has told them they’re making a fuss over nothing, and it may not be till they speak to others or see photos of others that they realise their result was very poor quality.
  • To get a second opinion on surgery that has gone wrong, you have to approach your original surgeon in the first instance and ask them to refer you to someone else. Some people may not want to face the surgeon they’re unhappy with again.

EPATH 2017

EPATH is the European Professional Association for Transgender Health. Between 6th and 8th April, it held its second conference in Belgrade. I was fortunate enough to be able to go because I am a PhD student whose university makes some funding available for events such as conferences – many people who could have productively contributed to the conference are not in such a position.

It was the first time I’d been to any PATH events – however, as a trans person, several aspects of my life and healthcare have been shaped by the guidelines and standards put in place by the World Professional Association for Transgender Health, and by the practices of its members.

One thing that was absolutely clear throughout the event was that every professional I spoke to or heard a presentation from was dedicated and enthusiastic about helping trans people. However, something that also came across very strongly was just how different the frames of reference for that were. Europe’s a diverse place, and indeed there was discussion of healthcare systems outside what would usually be considered Europe, such as countries in central Asia. During the course of the conference, we heard that that the European Court of Human Rights has ruled sterilisation of trans people as a condition of legal recognition is a violation of human rights. But many of those present had prepared their presentations in countries where this violation is still the law. Many professionals present worked in countries where there is limited social acceptance of LGBT people, and gender roles are relatively restricted. Several clinics were helping their patients navigate restrictive legal systems, or indeed legal systems which made little or no provision for trans people at all. Many medical professionals (perhaps all of them!) were also working in the context of trans health being seen as something of a suspect field by their colleagues, in which even the well-established basics of supporting trans people continue to be seen as controversial and requiring justification.

As a consequence, it perhaps isn’t surprising that there were points in some presentations where it was very clear that some professionals saw their role as involving a lot of gate-keeping, with a focus on creating heterosexual, gender-binary individuals, who would engage in penis-in-vagina sex and could be counted a success if they ‘passed’ for cis. In some cases, I’m sure this impression was heightened by translation issues – it can be hard to get trans terminology right even if English is your first language, and I can only imagine how difficult a task it must be to present on this subject in an additional language at an international conference which brings together such a diverse range of people and experiences. And of course, part of the point of such a conference is to bring  different viewpoints together for discussion. Nonetheless, it didn’t always make the conference feel particularly welcoming for me as a trans attendee

There was one incident during the conference which was particularly overt,  and which I found much more personally distressing than I would have anticipated. It was at the publicly open session of the conference, and one presenter showed multiple slides of naked trans people, which small black boxes over their face, showing their bodies before hormones and then at timed stages while on hormones, with close focus on breasts, chests and genitals. It was hugely pathologising, there was no discussion of consent, and the commentary was all about appearance to the cis gaze. (I understand of course that photographs may at times be appropriate to illustrate surgical techniques etc: this was not such a situation, and the poses complete with small black squares over faces felt like medical textbooks from fifty or sixty years ago). I found it difficult to believe that any trans person would volunteer to be photographed and have their body displayed in this way, unless they felt that doing so was required in order to access to treatment (which of course would not meet academic or medical standards of ‘consent’). I felt unable to continue to sit through that session, but my understanding was that the presentation continued to its end.

I want to stress that the EPATH organisers made a very full apology afterwards, and I do believe they were genuinely mortified. There was a discussion the following day about conference language policy, which also included statements about the use of images. I do think there remains an issue about how such guidance is enforced: I would lean towards every presenter using photos of individuals having to make an explicit statement that they have that individual’s free and informed consent to the display of those images. (Similar to declarations of participant consent for academic journals). I think there should also be consideration of under what circumstances a presentation should be interrupted by organisers/chairs if it does become clear that there is a substantial volume of inappropriate content (and perhaps especially if it is a session where there will be no opportunity for subsequent questions/comments from the floor, in which case there is not even the option for offering a counter perspective afterwards). This is particularly the case given that a code of conduct was issued asking attendees to commit to not disrupting presentations: if EPATH don’t want attendees to interrupt inappropriate presentations, we need confidence that organisers and chairs will.

It was particularly unfortunate this presentation preceded the TGEU presentation, which felt like the only point on the main conference floor where there was very direct consideration of trans people’s own views and lived experiences of healthcare systems  – but I missed the first part of that session because I had been unable to sit through the previous session, and was still too furious to focus for much of the TGEU session when I did come back in. Some of the year in review sessions on the final day of the conference, particularly the legal and social sciences ones, also gave weight to trans people’s lived, situated experiences. There were other trans professionals present at the conference, and several gave interesting presentations or chaired sessions, but these were mostly not on the main conference floor, and the streaming approach within the conference meant that trans experiences and perspectives were frequently discussed very separately to discussing medical interventions. Overall, the main conference sessions which brought everyone together, did quite often feel as if they were “about trans people, without trans people”, which certainly in the UK context is something healthcare is supposed to be moving away from.

Streaming

EPATH was predominantly arranged in different ‘streams’. In most time-slots, there was a surgery stream, an endocrinology stream, a couple of mental health streams, a child and adolescent stream, and a social science stream. There were a couple of sessions on issues like trans people’s perspectives on ICD changes – but again, those were often up against surgery sessions. Of course, streaming is common in academic and health conferences, and it’s important and beneficial that time is used sensibly and professionals attend sessions relevant to their interests and practices.

However, one thing that gets stressed a lot in trans healthcare is multidisciplinarity. Mental health professionals refer their patients for surgery. Surgeons take on patients who are having hormone therapy. Professionals working with children may be asked by children or their parents about what might be possible in terms of later medical interventions. Endocrinologists and mental health professionals should be making sure their patients understand fertility options and implications. And as I have outlined, one thing that really came across in this conference was how different the underpinning social frames were, and that it would have been beneficial to have some cross-conversations on people’s assumptions and beliefs.

My concern therefore is that if (for example) a masculining surgeon attended the conference, believing that sexual function for trans men was dependent on phalloplasty (and comments to this effect were made in at least one presentation that I saw) I’m not sure they would have necessarily have heard from professionals from other disciplines, who might have pointed out that there are other ways of thinking about sexual satisfaction and function. Greater awareness of different perspectives and considerations might be helpful to a surgeon who is talking through options with a patient. So while streaming is beneficial, I think the very hard delineations betwen the streams was not necessarily conducive to open discussion and multi-disciplinary, patient-centred practice, especially given that there was relatively little representation of trans lived experience of health on the main conference floor.

Overall, I want to stress that the event was interesting, the organisers had clearly put a lot of work into it, and the host venue were incredibly welcoming. The event ran pretty smoothly, and there was a lot of intelligent, interesting discussion. As I say, all professionals I spoke to were clearly enthusiastic, dedicated and well-meaning, and even the presentation which I found uncomfortable was clearly at heart motivated by a desire to help trans people, within a cultural context which is quite different to the UK. EPATH is a relatively new event, and I suspect EPATH may face quite different challenges in conference organising and reaching consensus on language compared to USPATH or CPATH, given the sheer diversity of countries involved, and that English was not the first language of the majority of attendees. The issues I have highlighted are therefore intended constructively to make improvements for the future, rather than as a criticism of this event.

Why TERFs don’t talk about trans men (and why cis men don’t either)

I quite often see discussions about why trans exclusionary radical feminists (TERFs) tend to discuss most of their vitriol towards trans women, and largely ignore trans men. Sometimes, this is presented as a sign that trans men are better socially accepted than trans women. Personally, I don’t think that’s the answer, and at some level, it’s fundamentally a response to entirely the wrong question.

TERFs are described specifically in terms of their focus on exclusion. They are fundamentally focused upon keeping people out. What are TERFs trying to keep people out of? What is the turf they are defending (bad pun, I know)? It’s their notion of womanhood, against those women who they think don’t belong. And that’s your answer to why they aren’t talking about trans men. They don’t need to defend their vision of womanhood against trans men, because according to them the situation is either (a) trans men are in their category of woman, like it or not, on the basis of our presumed chromosomes/presumed reproductive capacity (but we fail to recognis this due to being  poor, deluded, vulnerable fools, misled by modern medicine, or autism, or Tumblr, or Skeletor, or whatever their preferred villain of the week is) or (b) we’ve voluntarily ducked out of the fight, so we’re wusses or traitors, and they can turn their backs against us. Either way, we aren’t encroaching on their turf, we’re trying to escape it. Hence no effort is needed to exclude us. Some TERFs do make an attempt to coercively fence us in, but for the most part they’re more interested in doing that for those who they see as vulnerable and salvageable – kids – than worrying about what us dyed-in-the-wool sell-outs might be up to. Plus deep down, I suspect a lot of TERFs come from a place where they can sympathise with the fundamental desire to escape womanhood, even if they think we’re going about it all wrong.

So the real question with regard to trans men isn’t why TERFs aren’t talking about us, it’s why there isn’t a comparable movement of cis men rallying round to say that trans men aren’t men. Except that isn’t a question, because we all know why. Cis men with an exclusionary attitude don’t see trans men as any kind of a threat to their turf, because no cis-penis. That’s it. They don’t see a need to dress that up with theory, or discussing social constructs, or stuff about innate essences, or socialisation, or selectively-curated research papers, or anything else. Transphobic cis men might mock trans men, or be disgusted by us, or threaten us, but they don’t see any need to waste time arguing with us, let alone bother defending their borders against us. And you can’t spin: “You haven’t got [what I consider to be] a willy” out into a Sunday broadsheet editorial, even if you write it in really big letters.

As trans people who are feminists, I think we’re often particularly outraged by the TERFs, because we feel that they should get it. They’ve thought about gender. Some of them get paid to write about this stuff. And yes, what they write is often dismissive and cruel and harmful, and they should know better. But that doesn’t give transphobic cis men a free pass, just because they can’t even be arsed to try to explain their logic for dismissing trans people, or haven’t thought about it beyond “willies”.

Patrick Califia nailed this years ago. The general social attitude is: Of course women want to be men. And of course they never can be. But that’s not acceptance of trans men, it’s – at best – a pitying glance. And it’s an intersection between misogyny and transphobia. It may well frequently be a less aggressively policed one than transmisogyny, but it’s certainly not acceptance of trans men’s identities as real and valid. I don’t think this particular intersection has been well-mapped out yet, and perhaps at some stage I’ll have a better stab at it. But for the moment, I’d like to point out it’s there.

Scientific truths

It’s a fairly common occurrence that I comments directed to trans people along the lines of “Trans people are denying science” “Science says penis= boy and vagina = girl” “Science says males have XY chromosomes and females have XX chromosomes”, “It’s basic biology, people”, and so on and so forth.

What do we mean by science? Well, my high school memory of what we were taught about science (from Karl Popper) is that the basic requirement is for a hypothesis which  is falsifiable. So for example, the statement that “All swans are white” is a hypothesis which can be proved false if I see a black swan. Seeing millions of white swans does not conclusively prove the hypothesis to be true (though may strongly support it, and in practice we sometimes have to work with the best theory we have), but the moment a black swan is observed, the hypothesis is proven false.

“All men have penises” is, on the face of it, a similar statement to the one about swans. It’s falsifiable if I can find a man without a penis. However, for this to work, we have to have a way of defining “man” which does not involve reference to penises. Otherwise, there is a logical fallacy. To go back to the swans, if I say “All swans are white”, and then I see a black swan and say “No, that is not a swan because swans are white, so that black thing cannot be a swan”, I have made a circular argument. If my definition of a swan requires it to be white, and I will not accept anything that is not white to be a swan, my premise is unfalsifiable. Therefore, it is not a scientific hypothesis, but simply a statement of how I am defining swans.

Now, I expect that if I got the leading world scientific experts on swans together, they’d probably all agree on what a swan is. They’d probably base their definition on a number of long-standing principles and conventions within biology and taxonomy about how to define a species. It would be possible to assess a definition of a species against those conventions. But all the same, that’s still only a convention of how biology goes about definition and classification, not scientific proof that those conventions are correct. And of course, scientific conventions are ultimately rooted within the society that scientists operate in. Why are swans also known as Cygnus, of the family Anatidae? It’s not because it is scientifically proven that Latin is the best way to describe birds. It’s because of the historic position of Latin within academia. This in turn can’t be entirely separated from social issues. Latin’s status as a language of learning derives from the role of religion in society. And throughout the last few hundred centuries, upper-class men have had far more access to Latin than working-class women. The definition swan = Cygnus is not a scientifically proven fact, it is a scientific convention, which arose within a particular social structure, and which is not neutral on issues of class, religion and gender.

Back to penises. There are scientific hypotheses which could be posited on the penis question which are falsifiable, and which do not contain circular logic. For example, the statement “Everyone with XY chromosomes has a penis” is clearly a testable, falsifiable hypothesis. So is “Everyone with testosterone levels between 8 and 30 nmol has a penis”. And “Everyone who self-identifies themselves with the social category man has a penis”. And “Everyone who is legally recognised under UK law as a man has a penis.” However, these hypotheses are not merely falsifiable – they have already been proven false. Remember, you only need one exception. One black swan proves that not all swans are white; one person with XY chromosomes and no penis proves that  XY chromosomes =/= penis. The scientific method does not allow you to  dismiss exceptions to your hypothesis on the grounds of being uncommon.

The problem here is with insisting upon a categoric statement about “All” or “Everyone”. Saying “Having XY chromosomes very strongly statistically correlates with having a penis” or “More than 98% of self-identified men have a penis” are falsifiable, scientific hypotheses which are very strongly supported by the evidence. But clearly they do NOT prove that penis = man.

The whole “science” argument gets even more unscientific when we get into practical implication. Biology has nothing to say about which bathroom trans people should use. I mean, we could derive a hypothesis and test it – “People with penises empty their bladder more efficiently if they are doing so behind a door showing a stick figure wearing trousers” – but I don’t think anyone would seriously expect anything other than a null result in a double-blind randomised controlled trial. Now, social science might well tell us a lot about social views about gender-segregated bathrooms, and why some people might feel upset or confused or threatened if their expectations about bathrooms are not met. But social science would explicitly recognise the role of social norms, and would not claim to have discovered an objective, eternal truth about where people should wee.

The problem is not that trans people are anti-science. The problem is that many of our critics don’t know what science is.

 

Tell your kids that being trans is okay.

There’s a lot in the media at the moment about trans kids. They report that more kids are getting referred to gender clinics, at a younger age. Schools are talking to young kids about being trans. Some kids socially transition, or are offered puberty blockers (blockers are the only intervention ever offered to trans kids under 16 in the UK). And we also have handwringing about sex and relationship education: should it be compulsory? At what age? Do schools really have to include LGBTQ+ issues? The media usually suggests that these issues are problematic, or concerning. They aren’t. Talking to kids about being LGBTQ+ is a good thing, and it should happen as early as possible.

I was born in 1985. Section 28 (a piece of UK legislation which prevented discussing homosexuality in schools) was passed in 1988, when I was three. It was repealed in 2003, after I had left school at the age of 18. For most of my school career, I didn’t even know that there was a controversial law against talking about LGBT issues in schools. Not talking about these things was just how things were.

I had liberal, progressive parents. I had some sex education in school from the age of nine or ten onwards. I grew up knowing where babies came from, and pretty much how they got there. But the mechanics of anal sex between men was explained to me in the school courtyard by Jonathan Pritchard, when we were both eleven. I suppose nowadays, he would probably just have shown me a porno on his smartphone. As a parent or a teacher, you don’t get to decide that kids won’t learn about these things. What you get to decide is whether it’s you that explains it, or whether kids learn about it through rumours and porn, as something whispered and naughty and dirty.

I suppose even at that age, issues around my gender were going on in the back of my head. But I became consciously aware of them when I started secondary school, at the age of twelve. This was before there was any discussion of trans kids in the media. It was before YouTube. Before Facebook. I had no access to words about someone like me. No way of finding out about it. The closest concept I had was ‘lesbian’, since – thanks to the fact that my knowledge about lesbians was also picked up through playground rumour – I was under the impression that lesbians wanted to be men. The only problem was that I was absolutely sure I fancied men.

Slowly, I gained some access to information about trans people. The Jerry Springer Show was sometimes shown on daytime TV during school holidays. But the portrayal of trans people on that was scarcely something I could easily relate to or take much positive from, and anyway, they always showed trans women. I was hazy about whether there was an opposite concept. I went to the school library, which had a couple of medical textbooks. Looked up ‘transsexual’ in the list of disorders. That gave me a paragraph of information – but still no definite word on whether it was something someone assigned female at birth could be.

At this time, I was having counselling for my crippling depression. I had no friends at school. I struggled to relate to anyone my age. But I didn’t tell anyone about the fact that these problems were related to my gender identity. I was still trying to work out if that was even possible. I did tell my counsellor I was unhappy about the way I looked. She told me I should smile more, because I had a nice smile. I decided counselling wasn’t going to help me.

I didn’t tell my parents at this stage either. Not because I thought they’d disown me – I always knew they’d love me no matter what. But the scanty information available to me made me think that being trans was a weird and very rare sexual disorder, and one that I still wasn’t entirely sure a “girl” could have. That’s something that it’s pretty hard to explain, perhaps especially to people you love, who you know are going to be worried and upset for you.

The turning point for me was the Channel 4 documentary, ‘Make me a Man’. It featured four trans men, and one of them was gay (I’ve met him since, and thanked him). It’s hard to describe that overwhelming sense of relief, to find that people like me existed. Moreover, he and the other trans men in the video were people I could relate to. They had lives. Jobs. Families. From there, I found an online group for trans men, and a magazine you could get through the post (run by another hero of mine, who was also in the documentary).

I’ve already pointed out that there are a lot of attacks on trans kids in the media. We’re told kids are too young. That they’re being swayed by parents, or social media, or doctors. That it’s confusing for young kids to hear about these things. That it’s all gone too far, that tomboys are getting marched off to the gender clinic for liking dinosaurs. That there’s a possibility they might regret it, and wouldn’t be better if we just didn’t talk about any of this stuff until they were adults?

Quite aside from the fact that most of what’s written in the media about trans kids is utter rubbish, I’ve lived the “don’t talk about it, don’t let kids know it’s possible” option. It wasn’t even all that long ago. And yes, I survived it. I never self-harmed, and I didn’t attempt suicide, which are often invoked as the big risks. But I spent five or six years of my adolescence lonely and frightened, with no words to describe who I was, and feeling utterly unable to confide in anyone. I had no idea what my future could look like, and whether it would ever be possible for me to live a happy life. I worked out who I was through fragments of bad quality, sensationalist, pathologised information. I didn’t have friends throughout my teenage years. I didn’t date till I was nineteen. I think those experiences have probably had a lasting impact upon me, and the way I relate to others.

A word that often gets used for LGBTQ+  young people is “confused”. It’s a way of patronising and dismissing their experiences and – bizarrely – it’s often used as an argument for not giving young people information. Often young people aren’t confused at all – but where they are, lack of good quality information is part of the problem, not the solution. You don’t confuse kids by telling them that different types of people exist, and are valued, and that it’s okay for them to grow up to be any type of person. Telling them that makes them feel reassured, and secure, and loved. Hiding information, or treating it as embarrassing or shameful, that’s what hurts kids.

Thoughts on ‘Transgender Kids: Who Knows Best’

I haven’t posted for a while, but I feel like I’ve got a lot to say today.

I don’t really want to get into discussing Zucker and the reasons why he’s controversial, nor about the best therapy for trans children. There are other people who know more about this than me, who can discuss it better than me.

Instead I want to focus on the documentary itself – what messages did it give, and how did it do that? In my view, part of the reason this was such a poor documentary is that in fact it wasn’t entirely clear what this was a documentary about, and it ended up mixing together several rather poorly-explained issues. I can see several possible strands to the documentary’s narrative, but only the fourth was done effectively. And if the fourth was what the BBC was intending – well, I don’t really know where we go from here. Other than to say complain.

Strand 1 – Closure of Dr Zucker’s clinic

If this was a documentary investigation of the circumstances that led to Dr Kenneth Zucker’s clinic being closed, and giving a voice to Dr Zucker’s views on that, then I would have expected some detail on the circumstances of that closure. Who decided to close the clinic? How were decisions taken? When? What meetings took place? Who was at those meetings? What criticisms are there of the process followed, and are there rebuttals to those criticisms? Absolutely fundamentally: what were the officially stated reasons for closing this service and rendering Dr Zucker unemployed?

Contrary to what was implied, “transgender activists” did not fire Kenneth Zucker for not being gender affirming enough. How could they? They weren’t his employers, and I suspect that even in Canada, trans people are not powerful enough to merely point at a medical service and say “Close that” and it happens. (If they were, I get the impression that this clinic would probably have been closed rather earlier than it was). Campaigners and service-users make plenty of calls for public figures they don’t like to be sacked every day of the week, but that doesn’t usually happen.

As I understand it, the Toronto Centre for Addiction and Mental Health (CAMH) ran the clinic. CAMH became aware that the practices at this clinic were controversial and commissioned a review, undertaken by professionals, who took steps such as seeking the views of other medical practitioners in this field and listening to the views of current and former patients. A report was published, and the review process culminated in management deciding to remove Dr Zucker from post, and wind the service up. It appears from other accounts that Dr Zucker thinks the review process was biased, and at least one allegation in the original report may have now been retracted. I do not know enough about the details of these events to discuss them.

But if the closure was the issue under debate, then the documentary should have given me those details on how and why the clinic was closed. The BBC should have had interviews with someone  from CAMH. Or if no-one from CAMH was prepared to go on the telly, refer to press statements issued by CAMH at the time and make it clear that CAMH now refused to comment. Talk to the reviewers. Get hold of a copy of the review report. Discuss what the allegations were, what’s been retracted, what still stands. Test the credibility of some of the disputed allegations. Look at relevant national and international guidelines on good practice for clinics, and consider how the concerns raised might or might not have contravened those guidelines. None of this happened. It seems pretty poor journalism to do a piece on the closure of a health service without looking at the formal reasons given by decision-makers for closing it (or indeed, without really acknowledging that there were decision-makers involved and instead imputing everything to “activists”).

Strand 2 – Debates over the best approach for supporting gender diverse young people

This was certainly what the title of the programme seemed to imply the programme was doing. But if the programme was looking at debates over medical care for prepubescent gender diverse kids, it needed to (a) explain what the debate was, and (b) stay focused on the subject.

Gender affirmative care is not and never has been focused upon preparing young children for medical intervention. As far as I am aware, gender affirmative practitioners are well aware that some young kids who turn up at gender identity services will not go on to transition, and would seek to make it clear to those kids that it’s okay to not to be trans too. Every practitioner would seek to tailor their approach to the child and family involved. No practitioner would want a child to have medical intervention which is not in their best interests, nor put a young child on an irreversible path to medical transition before they are capable of making a decision. There are no medical interventions (hormonal or surgical) which anyone advocates being given to a trans child not yet in puberty.  These are not ways in which Dr Zucker’s approach differs from gender-affirmative practice, and they are not principles which I think any vaguely competent, ethical practitioner working with children would disagree with. (Additional clarification  14/1/17: Although not discussed at all within this documentary, intersex children and young people do require protection from inappropriate surgical intervention).

Within the programme, Dr Blanchard seemed to state that there were indeed a core group of kids who would go on to transition regardless of intervention. Dr Zucker and another colleague of his suggested that for young children, it was simply impossible to distinguish children who would go on to transition from the wider pool of children attending gender identity services. As I understand it, this is different to the views of some gender-affirmative practitioners, who do believe that they can assess which children are most likely to go on to transition. The discussion on this issue was not presented in a particularly balanced way. However, I don’t think this is the core of the issue since, as I have already said, there seems to be widespread agreement that approaches should be tailored to the child and family, and that irreversible medical interventions should not be undertaken with young children.

The most significant controversy with regard to pre-pubescent children is whether the focus of therapy should be making it clear to the child that they are free to explore what makes them most comfortable with regard to identity and expression, including potentially taking steps like changing hairstyle, clothing etc., and telling that they are accepted regardless (affirmative approach) or whether attempts should be made to encourage the child to change their behaviour and self-identity to be more in line with their birth sex, and hence discouraging or preventing the child from doing things like dress in ways not conventionally consistent with their birth sex (reparative approach). The British Association for Counselling and Psychotherapy, the World Professional Association for Transgender Health standards of care 7 (which all UK gender clinics work to), and the law in Toronto have all stated that actively attempting to change gender identity, or dismissing it, or making someone feeling ashamed about themselves is not merely an unorthodox or unconventional approach – it is unethical and potentially harmful.

Dr Zucker was clearly rhetorically opposed to affirmative practices, but denied he undertook a reparative approach. However, the “dog food” quote seems to imply that he thought young children’s gender expression could and should be limited to some degree. There were some anecdotal accounts about individual children Dr Zucker had worked with, given by both Dr Zucker and others, in which the description of the approach taken didn’t seem hugely controversial with regard to those individual children. However, nothing in the programme really explained to me what Dr Zucker’s general principles were, and what he felt was the fundamental difference between what he did and either the affirmative approach or the reparative approach. I felt the programme left it ambiguous (possibly deliberately) whether Dr Zucker was himself opposed to controversial reparative therapeutic practices, or whether he felt such practices were  sometimes acceptable but he just didn’t like the terminology. If Dr Zucker is of the view that these types of interventions are harmful, and that he feels he has been entirely falsely accused of practices which he would never seek to justify, that should have been explicitly stated within the programme. If he is not of the view that they are harmful, or (more likely) felt some such practices may be suitable in some situations, this should have been clearly outlined, and the areas of disagreement explicitly highlighted, including specific reference to issues such as ethical standards of practice, clinical guidelines issued by professional bodies etc.

Another significant problem was the frequent references to trans adolescents and adults, which was done in a way which tended to conflate interventions for young children with those for adolescents and adults. Even practitioners with a fairly sceptical approach to treating young children, such as Dr Zucker and Dr Blanchard, do support some older adolescent and adult trans patients accessing medical transition interventions such as blockers and (later) cross-sex hormones and surgery. So why did the programme include a section on an eighteen year-old having surgery, and a section on someone who had had surgery at twenty and regretted it? Since no-one was suggesting that pre-teens should be offered surgery, what relevance did this have to a debate about trans children? Since Dr Zucker and Dr Blanchard were not (as far as I know) suggesting that adults should never be offered surgery, what relevance did these interviews have to discussing their views? The purpose of including these sections seems to have been to either imply that medical care for trans adults was also contestable under the same sorts of arguments as those made by Dr Zucker (false, and if this was being asserted, it should have been addressed much more thoroughly), or to suggest that providing gender affirmative therapy to children inevitably leads to surgery (also false).

I want to make it clear that I absolutely think people who have undergone elements of medical transition and regretted it should be given a voice, and should not be subject to harassment for talking about their experiences. Gender services should learn from these cases, and I would hope that the trans community can support people in these situation, and if this hasn’t happened, we should work on improving. However, this discussion was simply irrelevant to talking about the decisions for pre-teen children. It was included without adequate context to explore the issues raised; and it may have falsely given the impression that surgery for young children was being advocated by some parties (reinforced by clearly false statements about surgery for primary school children from Emily Maitliss of Newsnight made prior to the programme).

Strand 3 – “Born in the wrong body” and “brain sex”.

I’m a trans man. I do not believe I was born in the wrong body. My hands are mine, my face is mine, my ears are mine, my nose is mine. My weird feet with too long big toes are mine. And yes, even some anatomical bits that are not conventionally associated with being male are mine. And I don’t believe I have a “blue brain”. Nor am I particularly stereotypically masculine. I don’t like trucks, or football, and I throw up if I drink beer. I believe that there are no hard and fast differences between male and female brains, and that gender is complicated and almost certainly a mix of different factors. Oh, and I have a long-term boyfriend, and have only ever had relationships with men, so I really don’t think I’m a confused lesbian either.

Not all trans people share my views. There are loads of interesting and informative discussions that could be had on the subject of trans identity and gender. A straw man argument of “Trans people are so silly to believe they were born in the wrong body. They’d be fine if only they’re realise boys can like pink too/it’s okay to be gay” is not one of those informative discussions. In fact, it’s frankly insulting to a wide variety of trans academics and activists (yes, including people with titles like Professor and Doctor, based at big universities you will have heard of, publishing in peer-reviewed journals) who have put forward nuanced, eloquent arguments on these subjects.

Also, for the sake of balance for my trans friends who do hold essentialist beliefs, the BBC has in the past been quite happy to wheel out scientists who do believe there are fundamental, innate sex differences in the brain and usually make it clear that there are multiple different scientific views on the subject. It seems to be only when trans issues are being discussed that we get told that the “experts” say that innate gender identity is impossible, and that trans people who believe otherwise must be wrong.

Ultimately, I don’t think these arguments are actually particularly relevant to debates about supporting kids. Researchers are still debating whether or not there’s a gay gene, and if so, whether it explains all same-sex attraction and behaviour in all people. The fact that there is a debate, and that there is a fairly strong case for saying that the idea of a gay gene is a bit simplistic, would be unlikely to get cited on the BBC nowadays as a justification for trying to turn gay kids straight. So why is this straw man argument wheeled out to try to question support for gender diverse children?

Strand 4 – Hatchet job on trans people

Ultimately, I think that’s what this documentary comes down to. It wasn’t a rational, nuanced, carefully made debate on any of the subjects above. As I’ve indicated, it jumped around between topics, didn’t even stay focused on the issue of children, and was often based upon attacking straw men opinions supposedly held by “trans activists” (what, all of us? If the programme-makers seriously believe that trans activists are of a single hive-mind on trans issues, then they have little experience of trans activism). It was the wheeling out of multiple tropes that trans people have been wearily challenging for years. Julia Serano wrote a very good article a while back outlining pretty much everything that was wrong with this kind of debate – indeed it’s tempting to believe that the producers of this documentary read Julia’s piece and deliberately decided to make a documentary which would fall foul of as many points within it as possible.

I find it hard to believe that this can all have been sheer incompetence. That something so ham-fisted was made and – what? No-one at any stage thought about ‘What message is coming across here about trans people and is that fair’? No-one thought ‘Hey, this is a documentary about care for young children, so why have we set up interviews discussing the experiences of people who had surgery as adults’? No-one thought ‘Hey, let’s ring up CAMH and try and clarify what this whole “getting fired” business is really about’? No-one thought to have a quiet word with a couple of contacts with some knowledge of the area (not necessarily trans people: health, social care or third sector professionals working in this field would have done), just to check the basic premise wasn’t too far off? Someone went ahead and wrote a write up for the website on an obviously controversial subject which didn’t even reference the fact that they were including opinions from more than one perspective? But if it isn’t incompetence, then the BBC deliberately went ahead and commissioned, screened and promoted a documentary about trans issues which they knew would be subject to serious questions over bias and fairness, with regard to a) children and b) a group that the Leveson Inquiry and the Women and Equalities Parliamentary group have already acknowledged get a rough deal in the media. I think that’s worse.

To be honest, the fact that this is the BBC makes it hurt more. For a start, I pay for the BBC. And I suppose, despite past problems with BBC coverage of trans issues, I was still naïve enough to believe that the BBC is in some way a little bit better, a little bit more rational and balanced. That the BBC has some interest in equality and fairness, rather than just putting out sensationalist nonsense to get the punters in on a Thursday night. I think that belief died last night.

Gender Identity doesn’t need science

So once again, a rash of articles and blog posts by “gender-critical feminists” asserting that we can’t offer protection for gender identity based on self-determination because there is no scientific consensus on what gender identity is. These articles then neatly segue into a discussion (usually biased) of the science, hoping no-one will notice the entirely false premise.

Scientific consensus is not required to protect a minority group. Virtually none of the “protected characteristics” in the UK Equality Act are the subject of scientific consensus. Sexuality? The scientists are still arguing whether it’s the gay gene, the size of your hippocampus, how many older brothers you have, or good old environmental factors. Race? The definition in the act talks about colour, nationality and ethnic origins, none of which is exactly amenable to ready scientific categorisation, and pretty much all scientists now consider the idea of absolute distinctions between races to be Victorian pseudo-science. Disability? The definition is an impairment with a substantial impact on someone’s day to day life – again a definition which is contingent on social factors, and hence established for equal monitoring purposes by self-definition. As for the scientific consensus on religion – well, the less said about that, the better.

We live in a pluralist society. We understand that it would be both ridiculous and hugely problematic for the government to impose central, monolithic categorisations for race, or disability, or religion, and apply them to everyone at birth, and place them on every government document. We would consider it to be a sign of an intolerant authoritarian government if you had to get formal permission to change those categorisations. And yet we can still manage to operate equality protections, despite the fact that definitions are fuzzy, despite the fact that some people may change how they describe themselves. We do this through the legislation being broadly phrased: the religion category does not come up with a list of religions and say these are the protected religions and this is how we define who belongs to which: it protects any religion or philosophical belief. Same for ethnicity and disability. That doesn’t invalidate or diminish concepts such as “Christian” or “Asian” or “blind”, nor mean that those groups aren’t protected under equality legislation, but it allows for flexibility and fluidity around these categorisations, and allows for the potential emergence of new groups who might also require protection.

As a society, we have a blind spot when it comes to the protected characteristic of “sex” (and by extension, to “sexuality” and “gender identity”, which are defined by reference to sex). Up until fairly recently, it was assumed that it was the government’s role to regulate this, and to do so in a clearly discriminatory way. It was assumed that it was necessary to be able to define who could marry who on the basis of genitals; that it was necessary to be able to treat women and men differently in tax and pay and pensions and insurance. Therefore the government needed to have a central definition, and it made sense to write M and F over every official document going. That’s out of date now. Thinking has changed, and from any feminist perspective that surely has to be a good thing. The government’s role now is to eliminate discrimination and promote equality. Therefore we should start to think about legislating for sex, gender and sexuality in the same way as we do for other equality characteristics, where multiple definitions and fuzzy categories are possible, but discrimination is still unacceptable.

 

The times they are a-changin

Oh baby boomer progressives*. I hate to be the one to break it to you, but you’re in serious danger of turning into your parents. Complaining about the sexual and gender liberalism of the youth of today. Why can’t they just uphold the gender norms you grew up with, eh? Get a proper haircut and stop challenging society’s beliefs about the proper roles for men and women.

And what’s with all this namby-pamby politically correct hippy nonsense they’re teaching them in the polytechnics these days? All this right on stuff about liberation movements and challenging prejudice, and trying to be supportive towards people with mental health vulnerabilities. Whatever happened to the good old British stiff upper lip? Pack ’em all off to ‘Nam, that’s what I say. Toughen ’em up a bit. Weren’t things better in the days when you could insult ethnic minorities, and women, and gay people, and trans people, and Jewish people, and Muslims without anyone taking offence (or at least, not anyone who really counted?) It’s political correctness gone mad!

After all, topics such as “Are all homosexuals paedophiles?” and “Aren’t trans people just deluded perverts?” and “Shouldn’t women be in the kitchen having babies?” and “Are people from some ethnic groups naturally inferior?” are perfectly legitimate questions of academic debate (even when there’s no evidence). Only those who hate free speech would refuse to participate in such a debate, or challenge the appropriateness of such a debate taking place where they live and work, or criticise you for suggesting that these are valid debates.

Think of prominent and dedicated social campaigners (like Mary Whitehouse) getting heckled when speaking at higher education institutes by disrespectful students (like Julie Bindel)** That’s just not fair, is it? Honestly, you’d think university students would understand that it’s their role to sit there and silently absorb what their seniors tell them is correct about gender and sexuality.

Dylan covered this in ‘The times they are a-changin’. The difference is, you’re the writers and the critics now, the mothers and the fathers. So, try not to criticise what you can’t understand, and don’t speak too soon while the wheel’s still in spin, cos the order is rapidly changing.

And for God’s sake, someone remind me in twenty or thirty years time that you can’t take social change movements out of a box, let them run a bit and then put them back when you’ve had enough.

 

 

*Not all baby boomer progressives.

**Described in Bindel, J. (2014) Straight Expectations

Trans Inquiry – the Final Report

I have to start by saying that overall, I am extremely impressed by the report from the UK Parliamentary Inquiry into Trans Equality. The vast majority of the recommendations are progressive, sensible, and have genuinely taken trans people’s views on board (and I’m not only saying that cos they quoted me). I absolutely praise and endorse the Committee for that, and for the hard work that went into that.

However, there are two areas where they have fundamentally missed the point, and several others whether they have acknowledged a problem but copped out of proposing action. It seems to me that those are tied together by some unspoken assumptions about gender that we need to address.

Spousal veto

Let’s start with an analogy. My friend Laura is a devout Catholic. When she started dating, it was important to her that her partner also be a Catholic. She met guys through Christian dating websites, and church events. When she got engaged to Jack, the two of them had marriage preparation classes with the parish priest, got married in the parish church, and agreed that the kids would be baptised and raised Catholic (and in fact, they were sent to Catholic schools).

Let us imagine that Jack now wants to convert to Judaism. For Laura, that would be a fundamental reshaping of the basis on which they entered the marriage. As far as she is concerned, they said their vows in front of God, and that was a religious contract. She probably wouldn’t have started dating Jack if he hadn’t been a Catholic. That doesn’t necessarily mean Laura would want a divorce – she and Jack are very close, and they might find a way to deal with this. But there has been a fundamental change in their marriage, and that could end in divorce.

What would not happen in this situation is state involvement. Jack could declare himself to be Jewish on all government documents, and expect total equality on faith grounds in all areas of work, goods and services. Jack would not be required to submit evidence to a Faith Recognition Panel from 2 rabbis, confirming that he was really Jewish. He would not have to demonstrate to the FRP that he’d been living as a Jew for two years. He would not have to confirm whether or not he’d been circumcised, and if not, get a doctor to explain why not. The Women and Equalities Committee seem to have basically got the point that there is no reason to treat gender as being different from faith in this respect. However, they still want to retain a distinction with regard to spousal involvement. In my analogy, Laura does not have to consent to Jack’s religious conversion, at any stage. If she feels a mixed faith marriage is intolerable to her, the option open to her is to seek divorce. However, if I were married, my partner would have to consent to my gender recognition. I do not think it is reasonable for the state to decide that gender is fundamental to my relationship , but faith is not fundamental to Laura’s. People are different. What they think is important is different.

There are other, more practical issues with the spousal veto. The Committee has acknowledged spousal veto is open to abuse. Good. However, they don’t seem to have thought about situations where consent isn’t an option. Suppose you have an older married couple, and one partner has dementia and lives in a care home. It is fully agreed the person with demetia no longer has legal capacity, and the other partner has power of attorney for them. The other partner is in the process of transitioning, but continues to visit their spouse regularly, and the person with dementia seems to be aware that their visitor is someone who cares for them. Under the spousal veto, the options open to the trans person are either to divorce their spouse (which, aside from the horrendous emotional impact, would probably also create financial and legal complications) or to wait for them to die. That seems needlessly cruel.

I think the reason for the difference in attitudes towards faith and gender is that, after a few hundred years of bickering, the state has basically now grasped that it should not intervene in matters of religious conscience.  But we’ve only very recently come out of a period in which gender was regulated by the state. Until pretty recently, it was considered well within the state’s remit (indeed, possibly part of the state’s duty) to use things like marriage and pensions legislation to reinforce social norms on gender relationships. We need to establish that that isn’t the state’s role any more.

Informed Consent

Much as  I like him, I think John Dean of the Laurels GIC was responsible for giving the Committee a misleading view of this. As far as I’m aware, no trans person is seriously calling for hormones and surgery to be available on the NHS on instant demand. What we are saying, as the Committee’s report itself acknowledges, is that the current system is paternalistic, arbitrary and does not treat trans people as active participants in their own care, and that needs to be fundamentally re-thought.

How does the current system work in practice? Well, despite the fact that no-one has ever proved the existence of a gay gene, Dr James Barrett, consultant at the London GIC wrote a book in 2007 in which it’s pretty clear he believes homosexuality and gender variance are linked and run in families – so if you go to London GIC, you might well get asked if you’ve got any gay relatives. On the plus side, they’ll probably assess you and offer you hormones you in two appointments – provided you’ve got your deed poll sorted. The Laurels makes you have compulsory sessions of psychotherapy; Daventry will give you a physical exam and ask you to write your life history; Nottingham will make you bring a parent or a partner to an appointment; Sheffield needs to see you six times before it will consider hormones. The Laurels is known for being pretty supportive of non-binary options, but many of the others won’t consider (for example) chest surgery for AFAB people who don’t want to take testosterone, or else treat it as some extra special situation that requires extra sign-off.

Whether you want to talk about “informed consent”, “evidence based medicine”, “patient centred care” or any other buzzword of the day, the current system has nothing to do with individual patient needs. None of the requirements above have anything to do with the international standards of care the clinics say they work to – in fact, some of them explicitly contravene information in the standards (for example, the standards explicitly say you do not need to socially change role before starting hormones, but most clinics require this, or at least put you through the system faster if you have). They’re simply practices that have grown up over the years and turned into rules.

The NHS Constitution already includes the following right:

“You have the right to be involved in planning and making decisions about your health and care with your care provider or providers, including your end of life care, and to be given information and support to enable you to do this. Where appropriate, this right includes your family and carers. This includes being given the chance to manage your own care and treatment, if appropriate.”

If that was consistently met, I suspect we wouldn’t really be discussing informed consent, except as a philosophical issue. I know plenty of trans people who would be capable of managing their own care and treatment, and where it would be appropriate for them to do so. Just give us the rights the NHS has already said we should be guaranteed.

The cop-outs

Particularly where it came to young people and non-binary people, the Committee were very cautious. They did recognise there were problems, and in some cases proposed adjustments that would be helpful, but they often stopped short of concrete recommendations.

I think this comes back to the tendency to paternalism with regard to gender, which I’ve already outlined as being relevant to both the spousal veto and the GIC system. Neither medicine nor parliament seems quite ready to let go of the idea that it might know best about a person’s gender. And while the report does mark a shift, the shift is strongest for binary adults. There still seems to be a tendency to talk about non-binary people and young people as being potentially “confused”, and thus needing protecting from themselves.

There are two things to say to that. Firstly, a lot of the non-binary people and gender variant young people I know are extremely unconfused. Some non-binary people have been out and campaigning for recognition for years. Some young people have been saying the same thing about their gender, consistently, for years. It is unfair and patronising to treat them as confused, or to say that they need protection from themselves.

On a slightly separate point, the whole idea of people who are “confused” needing protection by making it harder for them to be recognised seems deeply flawed. It seems to me that the converse is true – they would be better protected if the law recognised that gender can be fluid, and it’s not the end of the world to change your mind. I change my mind regularly about whether I call myself gay or bisexual (although I wouldn’t necessarily describe myself as confused on the subject, more hampered by terminology). I find it far more freeing that I am able to change my mind about how I describe myself, and am not expected to prove myself, or make a permanent commitment, than if I had to prove I was *really* a particular sexuality and intended to stay so permanently before I could be recognised as such.

Given that legal recognition is explicitly not tied to decisions such as surgery, and generally has pretty little relevance to anything any more, I say let people be confused. Let young people experiment and change their minds if that’s something they need to do. Let genderfluid people be fluid.

It’s time for the state to realise that its job is to promote gender equality, not control gender. The report shows we’re getting there – but we’re not there yet.