In the last 10 years, there has been an extraordinary increase in teenagers seeking to transition from female to male. What's behind it—and has the NHS been too quick to find a solution?by Emma Hartley / March 3, 2020 / Leave a comment
It is commonly acknowledged that while biological sex is genetically determined, gender is a social construct. A human being cannot—and should not—be reduced to their biology, or indeed their genitals, because psychologically we are as much a product of the way that other people treat us as we are of our genetic inheritance. Homo sapiens are social creatures: our ability to cooperate is what gave us the evolutionary upper hand over our stronger Neanderthal cousins. Without parents, siblings, peers, colleagues, friends and lovers our idea of ourselves would remain ill-defined—we wouldn’t know who we were.
Imagine you were raised by wolves in a cave—let’s call you Mowgli—but then later met another human of the opposite sex. You would notice the physiological differences. But as to interpreting those differences, where would you start? Without being exposed to the concept of “man” or “woman”—let alone “laddish” or “girly”—you’d lack any mental map to provide the pointers to the typically “male” and “female” behaviour instilled in us by human society.
Precisely because gender is a social construct, the evolution of its boundaries and meanings will tell us something fundamental about our society. And gender-wise something really big is going on in the UK—but it’s not the big something you might think.
Transsexuality is a talking point like never before, and a glance at the figures sheds some light on why. The number of children, in particular, being referred to the Tavistock and Portman Foundation Trust’s gender identity development service (Gids)—the NHS service through which all UK candidates for a sex change under 18 are funnelled—is up from 77 in 2009 to 2,590 in 2018-9. But what’s almost as dramatic as the headline numbers are developments in who is transitioning. In November 2017, the Guardian reported that 70 per cent of referrals were female. This was a surprising statistic because only 10 years previously the overall ratio had been more like 75 per cent males seeking to be female, and indeed it is still the gender traffic in that direction that dominates the increasingly noisy, divisive and panic-inflected debate.
Recently, though, alarm bells have begun to ring among a handful of psychiatric professionals about the number of teenage girls arriving at the Tavistock’s door and the nature of their treatment. Right now a legal case is being brought by Susan Evans, a former psychiatric nurse at the Tavistock and Portman NHS Foundation Trust, alongside a parent of an autistic female child wishing to transition to be male, arguing that children are not legally capable of consenting to a gender transition. November last year saw the launch of the Detransition Advocacy Network, a UK group numbering several hundred members. And in January, the NHS announced an independent review into puberty suppressants and cross-sex hormone treatments, to be chaired by Hilary Cass, formerly president of the Royal College of Paediatrics and Child Health.
But until the end of 2019, you could be forgiven for thinking that a panic about trans women using the “wrong” toilet cubicles was the biggest gender issue of the day (instead of something that could be easily solved by affording everyone the same privacy). Whenever the issue flares up politically—as when the Labour leadership candidates were asked to sign a pledge that labelled trans rights sceptics as “hate groups,” or the Scottish government proposed reforms to allow a change of legal gender without a medical diagnosis of gender dysphoria—it always seems to come back to loos and changing rooms. These vitriolic debates keep bubbling up—especially online.
But there is a much bigger scandal brewing than any Twitterstorm. While there have been a great many thoughtful doctors at the Tavistock, the picture is sometimes disturbing. Marcus Evans, a psychotherapist and former governor of the Tavistock and Portman NHS Foundation Trust, resigned in February 2019, citing an institutional rush to prescribe puberty-blocking hormone treatment to children questioning their gender and who may wish to transition. “The Tavistock is behaving recklessly with these kids who are in a distressed state,” he claims. What’s especially odd about the alleged rush to prescribe rather than consider alternatives, he argues, is that this clinic’s international reputation was built on the quality of its talking therapy.
“Over the last five to 10 years there has been a complete change in the profile of the people presenting,” says Evans. “These children believe that they are in the wrong body and they are very persistent and forceful in saying that they want a solution—and that that is physical intervention. But I’ve been in psychiatry for 40 years and when people are in a distressed state they often narrow things down and fix on one thing as a solution, putting pressure on clinicians for a magic bullet.”
In psychiatry “generally,” he says, the aim is to “open things out,” and take the time to ask questions about “what is going on.” After all, “adolescence is a moving picture. We move through experimenting with different identities as our bodies change and our role in society changes. An individual has to tolerate a -certain amount of confusion and anxiety and we should be able to help with that through therapy.” But when it comes to “the Tavistock’s gender identity service,” he says, “this work has not been done… the entire area has become unnecessarily politicised.”
It is undeniable that trans people have faced discrimination and abuse from those who don’t understand their experiences. A vocal rights lobby is quick to push back against transphobia—both real and perceived. Sometimes, though, legitimate challenges tip over into intimidation.
An American academic, Lisa Littman, encountered strenuous opposition when she published an article that coined the term “rapid onset gender dysphoria.” She lost a consultancy job, though remained an assistant professor at Brown University School of Public Health. Littman identified knots of socially-awkward girls drawn together in online chat rooms who reinforced each other’s self-diagnosis of being transgender before presenting to medical professionals. She had been led there by research involving the parents of some of these children, who had mentioned that their offspring had friends who also identified as transgender. (The US is experiencing a similar shift towards female transitioners, as are Finland, Canada and the Netherlands among others.) Along with Marcus Evans, Littman has pointed to a high incidence of autism and eating disorders among the same patients who present as trans. That observation raises some obvious questions about the narrowness of an approach that fixates on hormonal treatment for gender dysphoria.
The Tavistock pushes back against accusations that it is too quick to assume its patients are transgender and to provide hormones. “Our work with young people is not to affirm or deny,” they told me. “We respect children and young people’s sense of themselves and our assessment process considers gender identity development within the context of a psychological, biological, developmental and social framework, meaning that it is designed to give assessors a broad picture of the young person’s past and current gender identification.” Their work, they went on, is “cautious” and “considered” and whatever clinical interventions they do undertake are “laid out in nationally-set service specifications.” Hormone blockers are prescribed. But surgery cannot be performed until the age of 18.
Anna Hutchinson, who worked at the Tavistock until 2017 as a clinical psychologist and who is now in private practice, isn’t convinced. She believes there is an uncritical “affirmation” of gender dysphoria and the Tavistock is not as “cautious” as it should be. “The young people are making sense of themselves in the best way they can,” she tells me. “They often aren’t aware of anything other than the affirmative approach for managing gender dysphoria.” If they heard “different points of view,” they might be better placed to make “balanced and informed decisions about what they need,” she suggests. She describes a rush to treat: “Affirmation involves a quick assessment and then you get them into the medical system, on to hormone blockers if this is age appropriate. The next step is cross-sex hormones with their irreversible effects. Nearly 100 per cent make that journey once they start on the blockers.”
Hutchinson suggested that I look at an advisory organisation called the World Professional Association for Transgender Health (WPATH), alleging that its “best-practice” guidelines in this field, which have been adhered to internationally and spread through professional development courses for practitioners, have often been activist-led rather than evidence-led. Critics charge that senior members of WPATH have been behaving as advocates for transsexuality, rather than dispassionate advisers on mental health. Indeed, such advocacy is included in WPATH’s mission statement.
The WPATH guidelines say that “children as young as two may show features that could indicate gender dysphoria. They may… prefer clothes, toys and games that are commonly associated with the other sex and may prefer playing with other-sex peers.” A very distinct perspective is on show here: one that venerates individual feelings of identity, and yet also regards the social categories of gender with such solemnity that a girl toddler’s fondness for toy tractors is now seen as a marker of dysphoria. There is little room for interrogating either the feelings or the categories: it’s the biology that needs to change.
The guidelines add: “Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success… Such treatment is no longer considered ethical.” While the WPATH guidelines counsel against pathologising gender dysphoria, these guidelines arguably have the effect of pathologising the natal sex of the person in question.
WPATH has the level of influence that it does, it has been suggested to me, because until the sudden increase in numbers of people questioning their gender no one paid much attention. WPATH began as the Harry Benjamin International Gender Dysphoria Association in 1979, when there might only have been a few hundred patients a year presenting in the UK and these tended to be adult males. Each could be dealt with on a case-by-case basis. Given the vast and rapid increase in the number of people wanting to change gender, there is bound to be a danger that discretion goes out of the window, and “guidelines” become rigid rules. (WPATH did not respond to questions.)
“The WPATH guidelines may have had the effect of de-skilling professionals who have been trained to provide therapy,” says Hutchinson, adding that in Gids the clinic simply “can’t” provide the traditional therapy for which the Tavistock is known, and which medics from across the country might expect when they refer patients here.
Hutchinson points to Gids’s own service specification (which doesn’t include talking therapy as a long-term treatment option) and a memorandum about conversion therapy published by the UK Council for Psychotherapy in 2017. Along with the influence of WPATH it is, I think, the missing piece of the jigsaw that reveals how the “affirmation” approach to gender reassignment has become the norm in the UK.
“Different issues may have been conflated, despite the best of intentions,” explains Hutchinson. She argues that a “false equivalence” has been drawn between pro-active conversion therapy for sexuality, where clinicians attempt to alter patients’ sexual responses, and talking people into becoming more comfortable with their bodies. Non-medical therapy for people with gender dysphoria has come to be seen as effectively trying to argue them out of identifying as transgender, as people were once convinced that they shouldn’t be gay. But the distinction between medical acts and medical omissions has been lost somewhere here, a serious matter in a profession whose traditional starting point has been “First, do no harm.” (The Tavistock responds: “We operate with no preconceptions and outcomes for any given young person.”)
Traditional ideas about the physician assessing the patient in the round also seem at risk of being forgotten. “We generally don’t talk about the relevance of the incredibly high incidence of autism spectrum disorder among these new, young, female patients,” says Hutchinson. “Autism often also means black-and-white thinking and struggling with the onset of puberty, so we have to ask the question ‘can this simply be a coincidence?’” And can it be a coincidence, either, that the stampede to transition is so concentrated among girls and young women?
An instructive parallel case can be found in Eastern Europe. In the former Soviet bloc, and especially in 1980s Poland, more women than men requested sex changes. “Polish sexologists knew about this difference [with the west] and were startled by it,” said Ludmila Janion of Warsaw University, who recently completed a PhD on the subject.
Why was this? The experts I spoke to while researching a book in the 2000s suggested that the reverse statistics might have something to do with it being especially awful to be a female under Communism, propelling some to jump immediately from questioning their sexuality—“I’m not sure I’m straight”—to the conclusion: “I must be a man.”
Current figures are hard to come by in capitalist Poland, but a 3:1 ratio of women becoming men as against men becoming women has been suggested to me. So perhaps it was actually less about Communism, than more ingrained cultural issues. Anna Kłonkowska, a Polish academic living in New York, suggests interrogating the very words that Eastern Europeans use: “Slavic languages are highly gendered,” she explained. “There is no distinction possible within them between sex and gender: no separate words for these things. It is linguistically assumed that your anatomical features are the same as your perceived gender. It is not only the case with verbs (as in French) but also nouns and adjectives, and when you speak you express your gender in every sentence as well as the gender of the person to whom you are speaking.” Additionally, said Kłonkowska, “Cultural elevation of masculinity is built into the language: -transitioning female to male is seen as socially elevating whereas transitioning male to female is degrading.”
All of this makes conversation uncomfortable to anyone who is not quite sure where they fit in. Female to male trans people have told Kłonkowska that “their biggest concern” is “not really about the bodily alterations” but “merely being treated as male.” Unfortunately, in Poland, there is no way to have the one without the other. “Judges generally want to see some physical changes before they will allow the legal one. People say that they feel forced to take hormones so that a judge will see a man or a woman even though they are not unhappy with their existing bodies. Then afterwards they would give up taking the hormones.”
Whether the root cause is language, the legacy of Communism or patriarchal oppression, this is a story that needs to be understood at the level of society, not just the individual psyche. There is little doubt—as Janion argues—that there was traditionally “no cultural space for butch (ie more masculine) lesbians.” Transsexuality was perceived by the sexologists as a rare and difficult—but curable—illness. In this case it might have constituted a relatively attractive identity. After all, it turned a lesbian living with another woman into a success. Sexologists saw it as restoring “normal” heterosexuality. A similar trend can be seen in Iran, where gender reassignment surgery is encouraged for gay men who would otherwise be viciously persecuted.
“Whether someone will identify as trans or will be diagnosed as trans,” Janion argues, “will depend on what the other viable options are.” At which point it seems worth asking what, given the similar trend emerging in the UK and other western societies, might have changed to make so many youngsters born female feel so alienated in their own bodies?
A video of the launch of the recently constituted Detransition Advocacy Network sheds especially interesting light here on some young women’s struggles. The panel comprised of five women between 20 and 23 years old, plus the organiser, Charlie Evans, 28. All six are lesbians whose youthful feelings of self-loathing, self-disgust and social dislocation led them to make a decision to transition to male that they later came to regret, after varying degrees of hormone and surgical treatment.
Evans, in common with her panel-mates, now locates the source of her gender dysphoria as social (rather than personal)—and in particular in misogyny towards “masculine” women and lesbians. All six participants are now on better terms with their own lesbianism. “Gender dysphoria is the opposite of body positivity,” one of them says. But it was a harrowing and physically disruptive journey to have taken at such a young age. (All began their transition during puberty some time ago, and therefore have not been a part of the current controversy surrounding puberty-blocker drugs.) One man in the audience, audibly distressed at what he was hearing, asks: “How is it possible that you have had no one in your lives to tell you that it was OK just to be yourselves?”
There are broader questions here for UK society in 2020, and about its attitude to girls. It is hard not to feel that social media and porn have recently been conspiring to create a rigid and ultra “femme” idea of what a beautiful woman should look like. Whereas once Jamie Lee Curtis, with her short hair and athletic build, was considered a sex symbol in Hollywood, these days the Kardashians’ femininity can feel almost as homogenised as it is commoditised. And its shallow markers—nails, lashes, bling—frequently blur the distinction between the world’s most desirable women and drag queens. Keeping up with the requirements of womanhood, as they are understood in these times, imposes a time-sapping burden, and all those (most of us) who are not prepared to devote a large portion of our day to our appearance end up feeling alienated. Detransitioners might well be merely exposing the tip of an iceberg of social-media generated misery.
Phoebe Jones (not her real name) is a lesbian attracted to masculine women who mourns the shrinking of her dating pool. “I’ve always tended towards dating masculine-of-centre women,” she tells me, “I’ve never seen these women as having less of a claim on womanhood than I do… Their self-acceptance was important to me as it allowed me to celebrate them.”
But it’s not always easy. One lesbian friend was raped by a classmate when she came out. Another “was cripplingly insecure in clothes but confident naked. I gently pointed out to her that her body wasn’t the problem. She breast-bound and tentatively used gender neutral pronouns. We became good friends. Now she sees herself as a woman and a lesbian and still looks like a boy. I get the feeling she is comfortable being desired as such these days, and desiring too.”
This success story speaks of a relatively “masculine” woman learning to find her psychological comfort publicly and privately—something far too rarely reflected in the media in the era of Love Island. Such happy negotiations of identity remain largely unacknowledged—to the detriment of others who are still stuck with the anguish that preceded the happy resolution.
“Increasingly on dating apps,” explains Jones, “masculine lesbians use they/them pronouns… If anything, it almost seems more common now than just being a proudly butch lesbian, particularly in younger women.”
Jones is at pains to point out that she does not have a problem with people transitioning, “if they are old enough and have had appropriate therapeutic support. But when it comes to adolescent girls wanting to transition, I find it very sad… I had terrible mental health as a teenager and if the same kind of agonising and reckless drive towards destruction and away from discomfort is shared by any of these girls, I can’t help but mourn the trend to assist them in taking this drive to the logical extreme rather than helping them learn to live with themselves. I mean, to help them learn to cope with their internal contradictions for at least long enough that a decision to transition is an adult, reflective and thoughtful decision.”
Many outside and indeed within the UK’s Gids service fear that, far from freeing people from the constraints of “being in the wrong body,” over the last 10 years the Tavistock has—with the best of intentions—been giving effect to some of society’s unkindest (if internalised) prejudices. What a tragedy it would be, if in trying to learn from the historic misstep of gay conversion therapy, we are allowing a rushed regime of transitioning young people that will one day be remembered in an equally controversial way. History does not repeat itself, but it does rhyme.