Melissa Midgen, Child and Adolescent Psychotherapist , The GIDS (Gender Development Ientity Service), The Tavistock and Portman NHS Foundation Trust reviews Transgender Children and Young People: Born in Your Own Body, edited by Heather Brunskell-Evans and Michele Moore
Newcastle upon Tyne, Cambridge Scholars Publishing, 2018, 232 pp., £61.99 (hardback), IBSN (13): 978-1-5275-0398-4
The editors of this groundbreaking book, Heather Brunskell-Evans and Michele Moore, deserve both our congratulations and our gratitude for compiling such a comprehensive selection of arguments which together provide an analysis of the complex phenomenon that falls under the term ‘trans’, an analysis that is very different from the narrative currently capturing the minds of young people and professionals alike.
They bring together a variety of dissenting stakeholders to enlighten and educate us on the pitfalls inherent in the affirmative model which asserts that gender is a self-identified feeling unrelated to biological sex. These dissenting voices include academics, activists, parents, commentators and clinicians who have all arrived, from their different involved locations, at positions of profound concern; a position collectively identified as ‘gender critical’.
It is essential to understand that ‘gender critical’ is entirely unrelated to ‘transphobia’ – the easy, careless accusation leveled at those of us challenging the so called ‘gender-affirmative’ approach which demands that, for children and adolescents who claim their biological sex is at odds with their felt gender identity, the process of both social role transition and the attendant physical intervention should go unchallenged.
It is perhaps worth stating at this point that I write this review from the position of being a clinician at the only NHS commissioned gender service for children and young people. Many scores of hours have therefore gone into the formation of my thoughts, ideas, concerns and dilemmas. These are forged out of the crucible of the gender service alongside much reading, thinking, talking and debating with colleagues and professionals along the way. My relationship with this book therefore inevitably emerges out of my personal clinical submergence in the world of gender in all its guises.
This topic is one that ignites passions with people inhabiting polarised and strongly felt positions. As things stand we do not have sufficient evidence or understanding to know whether there are children born into the world intrinsically ‘trans’, in ‘the wrong body’ as it were. We do know that there are many adults who live happily and successfully as trans adults. However the complexity of presentation of the children seen at GIDS, the difficulty and pathology found in their histories, suggest that for many of them at least there are reasons for their body dysphoria other than an inborn ‘trans’ nature.
It is logical to infer that some of the children and young people we see in GIDS will grow into adults whose gender dysphoria is such that the only reasonable ‘solution’ or treatment is a social role transition followed by medical intervention. However, it is both my experience and the argument posited throughout this book that the current socio-cultural situation is one which has permitted an inflation of the idea, and that we are indeed co-creating the very notion of the ‘trans kid’. The authors also identify the profoundly regressive nature of what ironically has rapidly become the liberal dogma of embracing medicalised approaches to the enduring problem of patriarchal gender norms – the demand that boys must act one way and girls another – that constrain our lives.
While each chapter is a discrete piece in itself, offering an individual viewpoint, the accumulated impact ensures that all the issues I recognise and worry about from my own
clinical practice are referenced. So we are provided with a distillation of the current trends: the role of the internet and the potential for social contagion, radicalisation and grooming; the increase in born females identifying as trans and the associated high occurrence of co-morbid ASD; linked to that the late presentation of these females and the absence of explicit acknowledgment of the turbulence of puberty and turmoil associated with the dawning of same sex attraction; the unintended consequence that a so-called progressive movement in fact reinforces gender stereotypes by suggesting for example that feminine acting boys are in fact girls (a prejudice I have named as ‘effemiphobia’); the role of the highly politicised support groups in perpetuating inaccurate figures of the prevalence of self-harm and suicide; the ‘moral distress’ experienced by those professionals attempting to offer alternative formulations with neither the opportunity to provide psychological treatments nor the permission to discuss these dilemmas for what is undoubtedly a highly distressing set of symptoms; and the constraints placed upon those professionals by the looming spectre of accusations of conversion therapy.
Bechard et al. (2016) carried out a cohort study of referrals made for adolescents into a gender identity service which showed a high level of co-morbid psychological difficulty as well as psychosocial vulnerability. They concluded that this supported a ‘proof of principle’ for the importance of a comprehensive psychological assessment extending its reach beyond gender dysphoria. This chimes with a previously published paper from Finland (Kaltiala-Heino et al. 2015) which identified the phenomenon of an over representation of particularly complex adolescent females presenting at gender clinics.
The service I work in is referenced throughout the book and it is disconcerting to read this when the GIDS voice itself is absent so that a variety of alternative clinical voices are also absent. I am unable to state why this might be: whether or not the service was approached and declined, or whether the editors felt that approaching the service would imperil the publication of the book I do not know. I can imagine that an approach to our service might have felt unthinkable as from the outside GIDS is perhaps perceived as speaking with one voice, whereas in fact we are a hugely diverse and heterogeneous team encompassing a variety of theoretical positions as well as clinical disciplines. Nevertheless, as is made clear in the introduction, the contributors felt their endeavour to be sufficiently risky that meetings were initially organised using pseudonymous online identities.
This book is not perfect and veering from such different styles and voices can grate. However, overall I appreciate its capacious attempt to encompass succinctly the most pressing issues which need to be faced. Practitioners who wish to be efficiently inducted into the gender critical discourse could do much worse than read this as a robust introduction to the key challenges in our field. However, the gender novice would need to explore more clinically derived material and open themselves up to all sides of the debate, including perhaps a first person perspective and the argument for affirmation, as well as data-generated papers arising out of research both from our service and our colleagues in gender services across the world (particularly our close colleagues working in the Netherlands). To understand the historical and clinical context out of which GIDS came into being papers by Domenico de Ceglie would be valuable and exploring the publications of Bernadette Wren, Polly Carmichael and Sarah Davidson would provide the more mainstream GIDS approach.
However, as Lisa Marchiano urges here in her chapter entitled ‘The language of the psyche: symptoms as symbols’ we need to take these children seriously but not literally, and:
Teens for whom gender exploration is a descent to the underworld of depression, anxiety and rumination need us to meet their ordeal with the spaciousness of symbolic understanding, rather than the rigidness of certainty. (p.120)
Bechard, M., VandeLaan, D.P., Wood, H., Wasserman, L. & Zucker, K.J. (2017)
‘Psychosocial and psychological vulnerability in adolescents with gender dysphoria: A “proof of principle” study’. Journal of Sex & Marital Therapy, 43(7) pp.678-688.
Kalatiala-Heino, R., Sumia, M., Työläjärvi, M. & Lindberg, N. (2015) ‘Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development’. Child & Adolescent Psychiatry & Mental Health, 9(9) doi:10.1186/s13034-015-0042-y.
Melissa Midgen was trained in child and adolescent psychotherapy at the Tavistock Centre and in adult analysis at the Society of Analytical Society. She works at the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust
The Tavistock Centre
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