Newsnight report on GIDS

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rebeccaroisin
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Newsnight report on GIDS

Post by rebeccaroisin » Fri Aug 14, 2020 1:14 pm

Is anyone else concerned by this Newsnight report on the NHS Gender Identity / Development clinic?

From that report, it sounds like serious concerns from staff about young people's reasons for wanting to transition (including family homophobia and sexual abuse) are not able to be properly explored and understood. And that's really bad in the long term, because the evidence base for puberty-blocking treatments for trans children is also not strong.

I know that this is a very complex topic and I'm of course not an expert in this area, but it really sounds like there have been potentially really big safeguarding failures. Huge numbers of staff leaving and the Safeguarding Lead bringing a lawsuit against the trust are not good signs.

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miriam
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Re: Newsnight report on GIDS

Post by miriam » Fri Aug 14, 2020 4:24 pm

Or, it could be that in a field where there are small numbers of highly distressed individuals with huge risk of self-harm, exploitation and death by suicide, because of stigma against trans people and those who don't fit neatly within a binary gender identity or straight sexuality, clinicians are doing their best to follow the evidence against a backdrop in which celebrities are using their platforms to catalyse public transphobia and a fear of children being railroaded into gender reassignment, which really isn't happening. It is inevitable that with a topic like this, there are very strong and polarised opinions based on moral and religious views amongst clinicians and the public, and differing views about the right solution for individual cases.

Gender identity isn't my area of expertise, but it seems from my conversations around this topic that part of the difficulty is that each person has a complex story and context, and the clinicians can't resolve all the wider social and family issues - particularly outside of specialist services and with limited NHS resources. So they are trying to make least worst decisions. And amongst these, using puberty blockers to allow the young person longer to work out their gender and sexual identity, whilst delaying the much harder to reverse surgical and medical interventions, is one option that can avoid the distress of going through puberty in the short term, and give the person who does decide to transition a final appearance that is more true to their identified gender.

In client groups where abuse is prevalent, there is always subjectivity about which cases need a child protection response and what that means to the other work that is going on. I'm not going to get my words exactly right when explaining this, but there is also an inherent tension because childhood sexual abuse does have an impact on gender identity and sexuality, or at least an association with non-straight and non-cis identities (it is hard to unpick whether children with these traits are more vulnerable to abuse, or whether abuse makes these traits more prevalent). As such, the person's gender identity and/or sexuality and/or sexual behaviour can be viewed as a symptom of their traumatic experiences as well as a part of their inherent sense of self. It is therefore understandable that in some cases, some clinicians believe that without the abuse the person's gender/sexuality or behaviour might have been very different, and that these elements of identity should be considered like any other symptom when treating the person's trauma and distress. But other clinicians might feel that we have to start with respecting the person's own view of their identity, and that it is heteronormative/homophobic or transphobic to consider that non-cis/straight gender or sexuality is a symptom that needs to be fixed.

I've hit this issue myself when talking to a person with a history of physical, emotional and sexual abuse who viewed his adolescence as the happiest time in his life, because he felt loved and powerful, when to my eye - as a clinician who has worked with children who have experienced abuse, trauma and exploitation - this was a time in which he was being sexually exploited by adult men because of his vulnerability. The idea that this could have been a negative thing or a symptom of his prior trauma was abhorrent to him, and would have immediately driven him away from engagement in services, and he would not have engaged in any child protection investigations at the time or subsequently. So, I can imagine that there would have been a lot of splitting and differing perspectives between clinicians had he been engaged in services as a teen, with some viewing him as a young gay man making choices about his sexual life and others viewing his sexual behaviour (and potentially even sexuality) as a symptom of his earlier abuse. Some would feel they could protect him more by engaging and working with him, whilst others would see it exclusively as a child protection matter. And of course each person would bring their own moral and religious views, in which some see gender as binary or God-given and any non-straight sexuality as sinful or unacceptable, whilst others view these as constructs that are more fluid. The most complex cases bring the most complex and polarising team dynamics, and can play out parallel processes to those experienced by the individual. So it doesn't surprise me if there is more staff turnover and disagreement about how cases are handled in these kinds of specialist services.

Finally, I know from my own work around child protection that in every story reaching the news the salacious cherry-picked examples are published, whilst confidentiality prevents the other perspective being shown, and the full complexity and wider picture cannot be conveyed to the general public in easy soundbites. Likewise, there are many regressive individuals trying to raise their platform at the cost of vulnerable minorities, whilst the media have a bias towards stories fitting the populist narratives of "nanny state" or "PC gone mad" which the right wing foster to challenge progress towards equality and diversity. I'm not sure that a BBC report about some people objecting to an unpublished single study is a balanced overview of the literature about puberty blockers. When faced with a shocking headline or claim, it is generally a good rule of thumb to check the sources and look at whether credible individuals offer opposing views. In this case, the anti-trans headlines seem more likely to relate to the furore whipped up by Graham Linehan and JK Rowling, which has been widely discredited as based on selective or biased information, than to the evidence base.
Miriam

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alexh
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Re: Newsnight report on GIDS

Post by alexh » Sat Aug 15, 2020 9:01 am

Kirsty Entwistle's letter is well worth a read.

https://medium.com/@kirstyentwistle/an- ... c541276b8d

rebeccaroisin
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Re: Newsnight report on GIDS

Post by rebeccaroisin » Sat Aug 15, 2020 3:27 pm

Thank you @Miriam for writing such a detailed and nuanced response. I really appreciate that you addressed a lot of the very real complexity of each individual person's history. Especially on a topic that is often really polarising and inflammatory.

Your point about identity and history of abuse really gets to the heart of a lot of my concerns in this area. I've talked before on this forum about working as a HCA in a low-secure CAMHS ward. A lot of the young people in a setting like that have very high risks of suicide and self-harm, so need to be constantly observed by ward staff - sometimes including when they use the bathroom / shower. For obvious reasons, these observations are carried out by a staff member of the same gender. Even then, the experience of clinical observations generally (not just "Level 4 1:1") / being on a mental health ward can be very traumatic for young people - especially if they have experienced sexual abuse. For example, the lack of privacy, lack of control over personal space / boundaries; and having adults enter your bedroom when you don't want them to (to give medication, check that you are OK, stop you from hurting yourself) are all stressful, frightening and potentially re-traumatising.

That gets even more complex if a young person has a transgender / non-binary gender identity, or expresses a desire to explore that. Even for just social transition, there is a tension between wanting to respect the young person's right to be recognised as their chosen gender and to alleviate dysphoria; and the potential risk of causing further harm - especially if the young person later prefers a different gender presentation, or when there is reason to worry that dysphoria is more related to specific experiences of abuse, rather than a deeply held gender identity. But, as you say, how do you even untangle those?

[I'm being vague here, but these were the kinds of decisions that senior members of the MDT where I worked needed to make]

Consequently, I do feel concerned when I see the concerns raised in the Newsnight report and in Kirsty Entwhistle's open letter (thank you @alexh!). It seems that a lot of the young people referred to GIDS have extremely complex histories and that these are not being thoroughly explored (presumably because of a lack of resources, long waiting times, and high-risk of self harm/suicide) before a medical pathway is started. This may indeed be a least-worst option. However, it also seems that clinical staff feel out of their depth and unsupported in raising concerns about the way in which treatments like puberty blockers are presented to young people and their parents/carers.

In terms of published scientific studies, the evidence around using puberty blockers really is very thin, because it's a really new area. The big concerns seem to be that the blockers reduce bone density in a way that may not be fully reversible - which has long-term health implications. There are two studies (here and here) that both find some significant reductions in bone density in transgender teenagers who take puberty blockers. There are similar findings in children who take blockers for precocious puberty and in women who take the same drugs to treat endometriosis.
(It's fiddly to make a direct comparison, because they are only used for short-term treatment for endometriosis; and for precocious puberty you may want to reduce bone density, as it's a sign of the body going through puberty. And it's full of acronyms related to a field I don't know!)

That risk might be worth it (least worst option), if the blockers were effective, but that's not really clear either. This is probably the most comprehensive study of puberty blockers on mental health in transgender teens. It does find a significant effect of blockers in reducing mental health symptoms, but no effect on dysphoria symptoms. Sadly, there's also no control group, so it's hard to tell how much the changes are actually related to the blocker (although I appreciate that it's hard to get a big enough sample size, etc with such small numbers of relevant cases; and that it's really not going to be easy to run a blinded study, so a full RCT isn't really an option here).

In that context, early findings that blockers actually increased self-harm/suicide ideation in the Tavistock study are concerning. This comment piece from the BMJ has more details -- both about the early findings and about whether the consent forms appropriately highlighted the potential risks around bone health. It is somewhat unfairly harsh towards the study design, but does raise some genuine, valid concerns.

I don't think that all of those concerns should be dismissed as coming from a rigidly moral/religious world-view. This is a really complex topic: transgender young people are often extremely vulnerable and the scientific evidence about the risk/benefit of medical interventions like puberty blockers is ambiguous. This piece is a detailed review about the ethics of prescribing puberty blockers longer-term in an individual experiencing severe effects on bone health. It's very balanced and shows the depth of consideration that is needed for each individual case. It seems like every referral to GIDS should be treated with equivalent care and attention. Perhaps they are, and the BBC reports are just fuelled by anti-trans hysteria. But the staff quoted in that report and the concerns raised by Kirsty Entwistle suggest that this doesn't happen effectively. And they aren't hysterical - they are clearly expressing genuine concerns in a balanced and careful way. That suggests to me that there are real concerns about the current process at GIDS and that ignoring them may result in further harm to already extremely vulnerable young people.

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Re: Newsnight report on GIDS

Post by workingmama » Sun Aug 16, 2020 2:29 pm

I keep a keen eye out for further data on the neuropsychological implications of puberty blockers when not used to delay a precocious puberty (which is what we use them for in my service), given that disruption to any typical neurodevelopmental process will likely have unforeseen and wide ranging effects on the endpoint development of the neural system. I am interested that this sort of data is not yet available. I was also interested to read the retraction of the (I think) American study that had claimed to show the psychological benefit to transition this week, given that clinical practice decisions were/are (rightly) made in the context of best evidence. I wonder what difference that may make (if any) to decisions made about transition in the childhood period. Clearly we are in need of more robust research to help us work to the best of our ability with this group.

I am also interested in the language used around this topic of 'anti trans hysteria'. I would want any child or young person whom I work with to have best evidence to inform my practice and that of my colleagues. We are a long way from having all the data that we would want in an ideal world to support this vulnerable and very rapidly growing group (I note the substantial uptick in referrals of girls to gender identity clinics), and I am keen that appropriately questioning practice, in the context of careful formulation (which is, of course, what we train to provide) is not reframed as 'transphobic'.
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Re: Newsnight report on GIDS

Post by miriam » Sun Aug 16, 2020 2:57 pm

Indeed workingmama and Rebeccaroisin. At the moment we really do lack the evidence to make effective decisions. There are huge issues about the impact of abuse and the risk of re-traumatisation when trying to keep the person safe or help them to process their experiences. And there are pros and cons to every type of medication. I know I wouldn't want to be the doctor weighing up a possible reduction in bone density with the risks of mental health problems, self-harm and suicide - both in the short term, or in the longer term - according to how many young people do and don't choose to transition, and how visually plausible the end result is for those who do transition, and whether transitioning improves their mental health or not.

My own view is that there are many societal, social and systemic changes that would potentially reduce the incidence of gender dysphoria. At a societal level we need a less sexist society with less stigma around non-cis and non-straight identities and less rigid constructs about gender (meaning it is okay for anyone to have more feminine or masculine traits or interests or self-presentation regardless of sex). We need more education about child abuse and opportunities to disclose and be believed, better child protection services, greater support post-abuse, more services offering support with parenting, and for children and young people to feel safe, accepted and heard. We then need better access to, amount, and individualisation of psychological supports for children and young people experiencing distress in all forms, but particularly those who have experienced trauma/abuse and/or feel uncomfortable in their sense of self and identity. We need to ban/criminalise conversion therapies, and exclude people with intolerant beliefs from imposing those on others (even from the cover of religion). If there was less shame about our appearance and the degree to which we conform with externally imposed ideals, I think we'd all be a lot happier. On top of that we need better processes for creating and disseminating the evidence base, and accurate means for evaluating services and protecting the public, as well as rules to protect whistle-blowers.

However, wishing for all these things doesn't change the reality. Change is slow, and each step towards greater equality takes brave pioneers and many years of campaigning to achieve. The political pendulum has swung further to the right than it has in many generations, there is more prejudice and polarisation on visible display than there has been in my lifetime, whilst a decade of austerity has stripped away supports and cut services back to the bare bones. The resources to support vulnerable people are inaccessible, given in insufficient rations and rarely allowed to have the depth and level of individualisation required. And the evidence base is still emerging. So I am sure that we are far from the ideal in many ways, and that providing services within the constraints of the current reality involves more compromises than any of us would want to make.

I don't feel like I'm in a position to judge the quality of a service I've never worked in or used, where I don't have any knowledge of the evidence base or sufficient experience of the client group. Nor can I judge personal anecdotal accounts without knowing more about the clinicians involved, or the unredacted contents of their complaints. It would be tempting to think that there is no smoke without fire, and that if clinicians feel uncomfortable or there is high staff turnover that means that something is going wrong. It might be. However, some examples are so non-specific or trivial that it is hard to be sure, whilst others appear to reflect the fact that under-resourced services still have to try their best to meet need, even if this is in a way that is far from the ideal. That might be because they are stymied by confidentiality, or trying to present a balanced account, I don't know. But I was struck by how surprising the level of complexity of the young people seemed to be to the NQ psych, how she felt frustrated that none of her referrals to other agencies had received the response she had hoped for, and how little knowledge she had of the issues from her training. So there was clearly a mismatch been the individual or her expectations and the reality of the post, whether the culture was problematic or not.

It reminds me of the naive idealism I had when I was a newly qualified CP. I remember feeling very negative about the "failure to thrive" clinic I was part of one morning per week, thinking the paediatricians who led the team saw child protection concerns everywhere, and didn't start with a position of trust and engagement with the parents, and disliking the idea of being assimilated into the clinic culture. I thought the clinic name was stigmatising. I remember being sceptical about their unspoken rule of thumb that children without diagnosable medical conditions don't fall below certain centiles or lose weight without child protection being a prominent part of that. And I was concerned that they saw potential sexual abuse everywhere. I felt it was inappropriate that they wanted to weigh and measure children in just their underwear to check for bruises, and did genital examinations of some children to look for signs of abuse. I raised concerns in supervision, and struggled to know how to work in that context. Yet as time went on I saw how often they were right, that many children who came to the clinic were so hungry they'd eat 10 digestive biscuits, or had bruises in places that suggested non-accidental injury, or whose weight went up or down depending on whether particular family members were in the home or not. And I found out that some of the children were being physically, emotionally and/or sexually abused - including a really memorable example of reading disclosures from other family members of the sadistic abuse they had experienced at the hands of people I thought we should be trying to work with and not be so cynical about. So, whilst there were definitely things that needed to change about the clinic to better protect the children and the clinicians, I also found out that I didn't have the whole picture. Sometimes the culture is shaped by the more senior/experienced staff having a better awareness of the issues, or more sensitive radar for certain themes that they had learnt to be pertinent, or being more jaded about the availability or usefulness of other services with which they interface. Whilst at other times the norms and evidence base move on, and fresh eyes highlight problems that have been normalised. But like the child protection court cases that reach the tabloids, this appears to be a situation where we are given snapshots when we need the whole story to understand the truth.

Oh, and just for context, this is a fantastic article about some of the issues, written in response to JK Rowling's transphobic comments on twitter.
Miriam

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Re: Newsnight report on GIDS

Post by workingmama » Sun Aug 16, 2020 3:04 pm

Hi Miriam. I'd be interested to know which comments specifically that you found transphobic of the JK Rowling piece (unless you were meaning other things written, such as social media 'tweets' etc?).
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miriam
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Re: Newsnight report on GIDS

Post by miriam » Sun Aug 16, 2020 4:36 pm

It was mainly on twitter, where I used to follow her. I struggled with her insistence that "people who menstruate" was an inappropriate term to use in relation to talking about personal hygiene concerns for impoverished/vulnerable/displaced people during covid-19, thinking the word "women" should have been used instead. I didn't have any problem with the article's terminology, which also referred to "women" and "women who menstruate". In my view there are many women who don't menstruate (including those post menopause, who have had a hysterectomy, have ceased menstruation due to malnourishment, and girls prior to menarche, as well as some people who identify as non-binary/trans). There were a few other comments too that seemed to suggest she held transphobic views. But then, when criticised, her leap frog from that to claiming trans women are not women and that women are not safe if trans women are allowed access to women's toilets was, in my opinion, transphobic. And to think that violent men will dress as women in order to exploit this new loophole to get access to women only spaces seems to lack evidence as justification for being trans-exclusionary. As far as I understand it, trans women are at great risk of assault (particularly if forced to use male toilets), but do not present a great risk of assault to others, and I am unaware of any recorded instance in which a man has declared himself to be a woman in order to gain access to harm a woman. So to view every trans woman as potentially being a violent man in disguise seems transphobic. I can understand it, particularly if the person believing it has been harmed by men in the past, in the way that I can understand that every man is "Schrodinger's rapist". But that doesn't make it justifiable to base legislation that infringes the rights of everyone in a group based on that perceived risk. That's a nasty slippery slope to get onto (and any moves in that direction, to prevent harm, would need to start with groups like male university students and sports fans, who statistically have a much higher risk of committing sexual assault).
Miriam

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