Tavistock. Part Two: Clinical Dilemmas

Talk by Polly Carmichael.

Part Two on the tension between different approaches for dealing with “Gender Dysphoria”.   Hopefully part one provided some background for any neophytes. Tavistock Clinic: Part One.

Dr Carmichaels speech is : here  The summary is taken from a transcription provided by Mumsnet volunteers; for which I am very grateful.

The  talk took place in the following context:

  • 4500% rise in the number of referrals, to the Tavistock, over a decade.
  • Rise in females (reversing sex ratio in less than a decade)
  • Tavistock pilot to place younger children on puberty blockers.

This change in protocol followed work done by Dutch Gender Identity Services.  As you will see, from my earlier blog, the Tavistock were under some pressure to revise their treatment protocols to allow earlier medical interventions.

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The evidence from introducing puberty blockers, at an earlier age, has resulted in children invariably progressing to cross sex hormones and entrenched on a medical pathway.  The pro-medicalisation Lobby argue this is because they are 100% accurate in identifying those children who would persist.  The alternative perspective is that the act of blocking puberty somehow locks in the Gender Incongruence. If this is correct we are medicalising those who would have desisted and, historically, many of those would simply be gay. I cover this here The Woke Gay Conversion Therapy?

There are many people working in this field who have raised this as a concern: 9AAEBE78-2449-4E00-B2BE-9351E9599D90

We don’t know whether these children would have desisted and reconciled to biological sex.  The pro-interventionists have another  perspective. They argue this is evidence the screening is working and it may be unfair to the children not put on this clinical pathway! This is also the argument used against setting up a control group. From the perspective of the Tavistock it would be unethical to leave a cohort untreated if they meet the diagnostic criteria for intractable Gender Dysphoria.  I do wonder if anyone has thought to include parents, who oppose medical intervention, to see what the long term outcome is for our children?

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Another startling admission is that we simply don’t know what the long term implications are on developing brains. 👇This is a clear admission this is an experimental treatment.  Have politicians,and parents,  been persuaded to take this risk because activists claim our children are at a high risk of suicide?  Have activists managed this by leveraging questionable data on likely suicide? (I blogged about this here Suicide in the Trans Community)

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This paragraph is important because there are still documents out there calling this intervention a “pause”.  Indeed here is Polly herself from the CBBC children’s programme “Becoming Leo”. 36D86977-4F65-4CD8-AF4C-2A7E48DF5E3F

Many people working in this field have postulated that going through a natural puberty  resolves gender incongruence in the majority of cases. Dr Carmichael is clearly aware of this research and emphasises that the treatment, at Tanner Stage 2, means that these children will at least have had a partial puberty.

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She concedes the paucity of long term data on outcomes. She also anticipates concerns  about competing mental health diagnoses.  In this way the “Gender Dysphoria”, it is implied, has to be treated to resolve these other difficulties. This neatly avoids any suggestion mental health issues underpin the “Gender Dysphoria”, or desire to find a label/treatment.

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The framing of this discussion is entirely reliant on whether you believe in an “innate gender”.  If you do believe a child can be born in the wrong body it  necessitates treatment.  If you believe gender is a social construct then societal sex stereotypes are the problem.  These seem to be irreconcilable belief systems.  Worth having a look at how Mermaid’s diagnostic criteria works.  Would anyone not meet the diagnosis threshold given this criteria?

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Dr Carmichael , below, frankly admits that the evidence has yet to catch up with practice. She further acknowledges there is no consensus and there is concern about the long term health impact. The only way this treatment can even approach an ethical justification is if you are confident that:

a) Gender Identity is innate

b) The Tavistock have a reliable system for targeting irreversible treatments only on children who would, in any case, have persisted. 

c) You believe data that suggests there is a suicide epidemic in trans-identified youth. {This makes intervention a life saver & justifies pharmaceutical interventions}.

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So what has effected this change?  Political Interest and Lobbying.  Let us not forget the role of the Women & Equalities Committee. Since it morphed, from a  Women’s committee, it has been successfully colonised. In its original incarnation it focussed on women’s issues.  As predicted, women’s concerns have been pushed to one side with a wider focus on “Equalities”.

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The quote below👇 touches on the real change in the landscape surrounding “Transgender” children. Dr Carmichael acknowledges that some children are being socially transitioned at pre-school age. This is also a reference to the growing condemnation of “watchful waiting” , now badged as a practice akin to #GayConversionTherapy.  The memorandum of understanding (MOU) she references commits to a ban on therapeutic work to resolve Gender Incongruence.  BACP (British Association for Counselling and Psychotherapy) & the BPS (British Psychological Society) have signed up to a ban on Gender Identity “conversion”.  The Royal College of GPs has also signed this MOU.

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The fact most desisters  are predicted to be gay  seems to have escaped their notice. Counselling, to reconcile to biological sex,  is now officially condemned by these, erstwhile, esteemed professional bodies.  As of May 2020 there are is a  further move to outlaw any therapy to address “Gender Dysphoria” by, once again, conflating it with Gay Conversion Therapy. See here Gender Identity Conversion Therapy

There’s a huge amount to unpack here. 👇

401C86F5-0FAD-422C-B5C1-170B87F2D93DDr Carmichael is not happy  the Tavistock  are being accused of not being sufficiently affirmative.  She does appear to be trying to raise awareness of the changing nature of the child referrals.  Her interpretation of the parents, mentioned above. does not accord with my own perspective.  Socially transitioning a three year old and then attempting to report a young child for the Hate Crime of misgendering another child!  Is  this the behaviour of parents who are simply being protective! If I was relaying this story, verbally, my incredulity would be at such a high pitch only dogs would be able to hear me!

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In the section below there are a lot of erms as Dr Carmichael hesitates over the admission the treatment compromises fertility . She is anxious about this, but not for the reasons you might expect. She is concerned about  young people who defer medicalisation to try to salvage their reproductive health. The reason for this is they may not “pass” ,if they delay long enough to have a chance at parenthood.  This is not an uncommon viewpoint. One practitioner in this field praises the children who are kind enough to see themselves as future child adopters.

Sacrificing fertility is quite a significant thing to ask children to consent to and yet her concern is one of “presentation”.  Polly is aware this is indicative of that great sin of “binary thinking”. {Its almost as if she knows, on some level, there are only two sexes!}  No doubt Polly would consider me a “biological essentialist” but, like many women (and men),  I was in my thirties before I desired children. I would not have made a mature  decision, to place my fertility at risk, at age 12.

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And that last sentence! Actually wondering how the Tavistock can support children to feel comfortable enough to live with their bodies!   Klaxon Klaxon Klaxon!! This is what parents would like to know!  Shouldn’t the first line of treatment be body-positive?  In less than a decade we seem to have normalised  a bodily dis-associative disorder and completely over-turned decades of work, especially for the female body.

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Another thing that is hard to keep up with is the removal of any reference to mental health issues. The diagnostic criteria for Gender Dysphoria has now officially been re-classified to remove suggestions it is a Mental Health issue.  I sense Dr Carmichael really wants  to find a way to talk about co-morbidities here. However  activists have successfully  rebadged Gender Dysphoria as a naturally occurring variation and references to mental health are removed from the official diagnostic manual.

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How many of these children/teens placed on an irreversible pathway may have benefited from some good therapeutic exploration of their motivations?  Therapeutic Interventions to resolve Gender Dysphoria

This is a good summary of what the impact of this Conversion versus Affirmation model does to practitioners in this field.  I diverge on many points with Dr Carmichael but she is right that we are favouring medical solutions to resolve psychological issues. The lack of psychological support has also been raised by Tavistock staff who have now left and are whistleblowing.

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To balance the pressure for medical intervention we need a diversity of voices. These should include detransitioners,  It should include parents of children struggling with this “condition”.  It should include people who understand the concept of an iatrogenic “illness”.  It should include people who have expressed concern about what we are doing to young people. We need a countervailing voice to Lobby groups like Mermaids, Stonewall and Gendered Intelligence.

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The above is not a bad summary.

  • We need more empirical data, less opinion.
  • We need to look at contextual factors. (School teaching on Gender Identity, for one)
  • I disagree about taking a lead from young people.  Detransitioners have taught us that.

We need to urgently take measures to make certain we are not  medicalising children who could have lived a life without hormone dependency and surgical interventions.

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The problem with this service is that it seems to be driven by people who see this as a social justice cause, They are excited at disruptive thinking, eroding or destroying social norms.  I will leave you with this quote from Bernadette Wren, who also works at the Tavistock. This is from the Transgender Equality Inquiry in 2015.  I sense that Dr Wren should have been more careful. Sometimes a social revolution doesn’t take the form you, naively, imagine it will:

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Tavistock Clinic: Part One.

Tavistock Clinic: “Gender Incongruence”  Clinical Pathways.

This is some background to a talk given by a member of staff from the Gender Identity Services  (GIDS) at the Tavistock. The talk is by Dr Polly Carmichael and provides  insight into clinical/ethical issues for Gender Identity Services.  I want to explore Dr Carmichael’s belief system and the alternative perspective of those of us who reject the Tavistock model.  Dr Carmichael reflects on the tension between “affirmative” approaches to children with Gender Dysphoria and what she labels “reparative” or “conservative”.   I will argue that parents resisting medical intervention are also “affirming”.  You can listen to the talk yourself  here

I aim to examine the ideological beliefs which underpin the treatment approaches at the Tavistock. It is also important to be aware of the , significant  pressure, GIDs are under from lobbyists. The last five years have seen slightly more coverage of parents, who are more critical/questioning of GIDs approach. This can only be a good thing.  For too long there has been an asymmetry in the media coverage which tends towards the “celebratory”.  Parents who are resisting the dominant narrative are less vocal because we don’t want to alienate our children. Where we do get contacted by journalists many of them retreat when they learn we are not pro-affirmation/ medicalisation.  There is nothing to celebrate about your child being a lifelong dependent on the Pharmaceutical Industry.  Where’s Ben Goldacre when you need a critique of the Gender Industrial Complex? 

AFFIRMATIVE APPROACHES:

Proponents of an “affirmative” approach believe that a child can be “Born in the Wrong Body”. They will often use phrases like “assigned at birth” to describe how  sex is determined. They argue the sex you are designated at birth may not match your “Gender Identity”.  Therefore you may, in fact, have an opposite “Gender” to the sex which you were “assigned”.  The theory of an innate Gender Identity mirrors established child development theory on the age  a child realises they are a boy or girl. For advocates of Gender Identity Theory this is seen as a sign that we all have an innate sense of “gender” and become aware of it at around three years of age. Therefore  if a child communicates some discomfort/distress, at being treated as a girl, or boy, they are deemed to be exhibiting  a conflict between their sex and gender. As this is a feeling , relying on an internal sense of self, the child will, it is argued, know better than their parents which “gender” they are. This argument sets the stage for empowering children/teens to act without parental consent. Something lobbyists are openly arguing should take place.  Those that subscribe to this belief  often use language around bodily autonomy to push for positive affirmation of the child’s “gender”. This may take social forms; such as allowing a new name, style of dress or pronouns which match the preferred gender. This can also take the form of medical interventions such as Puberty Blockers followed by Cross-sex hormones.  

ALSO AN AFFIRMATIVE APPROACH!

The alternative view, which I hold, is that nobody is born in the wrong body. A child becomes aware of the way they are treated, as a boy/girl, in a society which upholds sex stereotypes. They may reject societal expectations for  their own sex. This can happen to males or females. There  may be a particularly pronounced rejection of sex stereotypes in the homosexual community giving us Butch Lesbians,  or Femme Gay Males. The female child may reject dolls, and pretty dresses, in favour of her brother’s meccano, boisterous play and practical “playing out” clothes. Conversely her brother may like pink, sparkly clothes and prefer baking to football. Neither of these children are, at this stage, exhibiting “Gender Dysphoria” . They are rejecting restrictive sex stereotypes. They may be proto-gay adults, or someone with a condition, like Autism,which means they don’t find it easy  to “perform” the role expected for their sex. In teenage girls a rejection, of their natal sex  may be a flight from hyper-sexualised expectations of “femininity”.   Hell a discomfort with gender roles would apply to many girls from the seventies.  Many of us were dungaree wearing, tree-climbing girls and that was perfectly normal! 

Parents with this perspective seek to give our children time to reconcile with their biological sex /sexuality. For those of us with same sex attracted offspring we are particularly concerned at the number of gay males and Lesbians experiencing issues with their “gender”.  The mandated language would label my position as “non-affirming” however I would reject that language as a consciously (?)  negative framing.  We do “affirm” our children. We positively affirm our children’s Gender Non-Conformity, and support them to express themselves, as they wish, in their sexed body.  We work to alleviate the distress they feel and provide space, and time, for them to  reconcile to their sex/sexuality.  Our ideal aim is for them to  live a life free from dependence on synthetic, cross-sex hormones and surgeries.  I can’t think of any other situation where a parent seeking to avoid, potentially unnecessary, pharmaceutical dependence, for their child, would be depicted as a hateful bigot.  This happens, every day, to parents who challenge the prevailing orthodoxy.  

We know that this bodily incongruence persists for some adults.  We don’t lack compassion for their method of dealing with any bodily dis-associative disorder. However we believe that treatments which compromise, at best, fertility and may negatively impact on sexual function (& dating pools) are adult choices. We don’t think children and teenagers are mature enough to make these, irreversible,  decisions. We think it is parental over-reach to consent to these treatments on their behalf.  

TAVISTOCK  & LOBBY GROUPS (Mermaids) 

The Tavistock has been lobbied consistently by Trans Activists to move to interventions they describe as less conservative. I would label it as  as a more radical approach especially applied to the treatment of children.   Some of this tension is evident in these exchanges at the 2015 Transgender Equality Inquiry.  Here is a contribution from Bernadette Wren (Tavistock) in dialogue with Susie Green (Mermaids).   You can read this exchange Oral Evidence TE Inquiry 

You can watch the full thing here: TE Inquiry.

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Since this exchange the Tavistock has lowered the age at which puberty can be suppressed and already have some children who have progressed to cross-sex hormones.  This is part of a trial for which the results, to my knowledge, have not yet been formally released.  We do know it included 44 children and that nearly all have continued on the path to further medical intervention.  That is once you block puberty they invariably go onto Cross Sex Hormones. 

It is perhaps the case that the remaining staff at the Tavistock* have moved closer to  Ms Green’s position.  They have moved to a more radical set of medical interventions. This is where we are in 2020.  Puberty blockers are being given to children as young as 12.  Children as young as 4 are being seen at the Gender Identity Clinic.  

This is important context for Dr Carmichael’s talk which I will cover in my next blog. 

 

*You can confirmation  of this information on the Tavistock’s own responses to Freedom of Information Requests.   FOI Log

 

 

 

Multi-Sensory approaches to Gender Identity.

When I first came across this paper I was, initially, alienated by the standard Ideologically approved language.  I pushed past the “assigned at birth”, “gender identity” framing which is ubiquitous in this field, and it actually proved to be an interesting paper with some important observations.  It lasted, I think, about six weeks before activists got the final paragraph removed.  Here is that paragraph. 👇

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He is proposing more research to, potentially, identify less risky and invasive treatments that could mitigate “Gender Dysphoria”.  He also recommends caution, to the clinical community.  Were activists appeased by the concession made by the journal? No.  There followed a sustained campaign to get the paper retracted, which succeeded in April 2020. So why? What did the paper say that activists think needs to be suppressed?

EE898301-744C-4E71-B7EA-F4A92CB185E4D48905E9-A192-4C81-9AB0-04CB890DBD1AThe paper rejects the idea of “brain sex” which is the idea that a male can have a “female brain”.   That is a theory based on the claim  brain imaging showed transgender individuals have a “female brain”.  Critics point to the impact of neuro-plasticity; where the neural pathways are forged as an adaptive response to the external environment. Others highlight that these studies fail to control for homosexuality or even exogenous female sex hormones (synthetic oestrogen).  At best the jury is out on #LadyBrain theory.

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The paper considers a number of hypotheses about the causes of Gender Dysphoria. It concludes that the multi-sensory theory best explains the variety of types of Gender Dysphoria; the different ages of onset and whether sufferers persist in, or desist from,  identifying as the opposite sex.

The theory is that Gender Dysphoria, is a bodily dis-associative disorder,  caused by dynamic activity in functional networks.  He uses this theory to explore connections with high rates of anxiety and depression and some theories that persons with autism have an altered sense of their “body-ownership”.  (There is an over-representation of autistic people with Gender Dysphoria.  Autistic females are represented at eight times the rate of Autistic males. This is despite significantly lower numbers of diagnosed autistic girls).  Crucially the authors argue that their theory does not rule out the additional role of psychosocial factors.

The paper makes comparison with other theories of Gender Dysphoria and this is what likely propelled activists to get it retracted.  The social justice theory is that all of these children (and adults) are simply “Born in the Wrong Body”.  They are deemed to be “correct” in feeling this way and it has become anathema to contradict this belief.

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Another aspect of this paper which explains the ire it generated, is the data on how, in many young children with gender dysphoria, it resolves by itself.  This data tends to be hotly contested, even though it is pretty much consistently the case that the vast majority, historically, desisted.

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As I have posted before , on this blog, why are we medicalising children when the vast majority would desist, reconcile to biological sex and many would simply be gay?  A reminder of an overview of the studies which generate these statistics Do trans kids stay Trans?

Note that desistance studies that post-date the administration of puberty blockers show a very different trajectory.  It has been noted that these children invariably progress to cross-sex hormones.  They appear to be locked into the trajectory to further medicalisation.  As many of those that desisted , historically, turned out to be Gay Males and Lesbians that raises an unpleasant spectre of Gay Eugenics.

This paper also doesn’t cover the issue of “Rapid Onset Gender Dysphoria” (ROGD)  This is a new phenomenon which, I have argued before, doesn’t seem unconnected to a rise in teaching , in schools, of the idea of “Born in the Wrong Body”.  We have seen a rise of 4500% in referrals to the UK main Gender Identity services and an inversion of the sex ratios.  Until this last decade referrals were mainly male.  Now females pre-dominate. Lisa Littman published a paper on ROGD and it also came under sustained attack, was withdrawn, further reviewed and re-published with only minor changes.  You can read about this controversy here Lisa Littman: ROGD

However this is a rapidly changing situation and this paper attempts to address shortcomings in our knowledge base in a considered manner.  It even uses the language of “Cisgender” and is careful not to refer to the activists least favourite theory of Autogynephilia.  The conclusions it drew were fairly gentle and should have been uncontentious.  What’s that you say?  We need more research?

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And for this the author has been hounded for months.   The retracted paper, after the “offending” paragraph was removed, is here 👉. Paper

 

Therapeutic Interventions to resolve Gender Dysphoria

This article shows how a good therapist can identify underlying issues and attempt to resolve Gender Dysphoria without medicalised responses to bodily discomfort.  The therapist is fluent in Gender Identity speak  but does have the courage to honestly interrogate what “Gender” means to the clients they see. It is important to  note that any therapist may, or perhaps will, feel compelled to speak in approved language to get published. Additionally our young people have imbibed the new lexicon so the therapist may need to speak in the approved language, to establish a dialogue with Gender Dysphoric youth.

The article: Psychoanalyst on Transitory Trans Identity   Author Alessandra Lemmas

Psychoanalysis pays attention to unconscious motivations in the formation of “identity”.  This is in marked contrast to Gender Identity proponents of a medicalised response. Lemmas talks of the need for  “a posture of implicit scepticism”  when dealing with claimed identities. This is in marked contrast to Gender Identity medical practitioners who prioritise a subjective sense of self and demand only “belief”.   This is an excerpt from a response to an article in the British Medical Journal about how to treat Gender Dysphoria. The response is from Dr Helen Webberly, currently suspended from the General Medical Council,  who is not alone in her stance: Helen Webberly . 

7497F32A-55A9-4C68-BBF4-F5ABE45B1E43The belief that people can, literally, be born in the wrong body underpins the lack of a therapeutic approach to young people presenting with Gender Identity Issues. Merely to suggest that this may be an incorrect, self-diagnosis, generates outrage that  we are denying the “lived experience” of the transgender community. Yet we know, as Lemmas, and many others, point out most desist, reconcile to biological sex and many are simply gay. 👇

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The author subscribes/pays lip service to the idea that sex is assigned at birth, rather than merely observed, as it is in 99% + cases.  She subshumes both Lesbians and Gay men underneath the “transgender” umbrella. The statistics on post-operative satisfaction accept the narrative from within the Gender Identity community with no acknowledgment of the methodological flaws with the phenomenon of “loss to follow up”. {This is where a patient loses contact with the Gender Identity Service they are using. Detransitioners say they don’t return to the services which, they feel, actively harmed them, so this cohort disappear from the “follow up”}

The three case studies, in this article, cover many of the issues raised by parents dealing with our gender Dysphoric offspring.  All claimed a transgender identity with no prior history  sound puberty. We are told about the huge spike in referrals to the UK’s main Gender Identity Clinics and a wider social context emphasising choice and very much of a piece with the atomising of the individual in neoliberal, capitalist, societies.

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The first case is illustrative of the complicity of transgender identity.  More on “Anita” below. 👇. As you can see Anita claims multiple identities encompassing male, gay & female as well as “drag queen”.  Already taking cross sex hormones but with no intention to progress to more surgical changes.

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The dialogue seems to settle on the idea that gender identity can be fluid and an exploratory phase. Nevertheless Anita is already medicalising, We leave this case here, though I will just add that I have never seen a satisfactory explanation of what “living as a woman” means. It seems to depend on circular reasoning /a retreat to sex stereotypes.
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Janes case is more complex and, arguably, requires a more robust interrogation since Jane seems to fully intend a full transition to “live as a man”.   The sessions are challenging and, on more than one occasion, the analyst reports the anger triggered by the exploration of underlying issues. What emerges is a young girl whose parents have traditional gender roles in the household. Janes perception is that her mother is a “hostess” with little power, standing in the household.  On being pressed much of Janes “Identity” seems built about rejecting all the signs associated with being a “girl” such as make-up and long hair.  Here are some of Jane’s thoughts on what being a girl means to her:

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Tellingly., Jane reveals that they did not feel they measured up to the expected level of attractiveness as a girl.  Even more revealing is an expression of same sex attraction. Not as a lesbian but as a male attracted to females. Another common theme in detransitioners is the yearning for passing privilege as a male and how this, in retrospect, seemed to become more unattainable as they sought to identify as male.

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Jane is also adopted and vehemently rejects any idea this relates to their gender identity issues, However it later emerges that the birth mother was from a culture which prized male children, in preference to girls.  This prompts some self reflection and the realisation / admission that maybe this was bound up with the idea that her mother may have kept a male child.

248B3FDC-75C6-4E19-963F-3C15E42131C3Janes situation resolved itself without medical intervention. She is in a same sex relationship and has found a way to identify as a strong woman in her on line world after previously observing that she felt “insubstantial” and, significantly, failed to garner the same respect when she was coded female.

The third case study is Alex, who is a female who identified as male at 16. Alex was not interested in being dissuaded from hormones and surgery, as is common with our Gender Dysphoric youth. Alex’s parents affirmed the new identity and accepted their daughter as a son. Alex, however,still wished to access therapy, but still underwent a double mastectomy at age 19.  Post surgery Alex was, initially “happy” but then became depressed and suicidal and revisited the sexual abuse that they had endured at age 10, and realised the link between the abuse and the desire to remove their breasts . A54C4CEA-6ED9-4124-9D69-F442DC35785ETellingly, the parents were not aware of the sexual abuse and it did made me reflect on their role as affirming parents and, if they had been aware of this history, would it have made them exercise more caution?  I do NOT say this to judge those parents.  Any one of us could have genuinely advocated for this stance in the belief, pushed relentlessly by our media and advocated by public bodies, that this is the right thing to do.

I am conflicted about the “woke” language. By espousing the idea that someone can born “in the wrong body” {which is the belief system underpinning  transgender ideology} the danger is our Gender Confused children are getting mixed messages.  On the one hand the implication is that they may be hard-wired with a conflict between sexed bodies and an opposite sex brain.  At the same time it is clear that some of these cases are complicated by sexual orientation, history of sexual abuse and family dynamics.  There remains no diagnostic test that can separate the influence of “neuroplasticity” from the notion of an opposite sex brain.  In an ideal world we would start from the clear premise that there is no solid evidence that there is a biological basis for this incongruence between sexed bodies and a “gender identity”.   That does NOT mean that Gender Dysphoria does not exist or that it cannot, in a minority of extreme cases, be extremely debilitating and, for adults, may lead to an inescapable desire for medical intervention.

Irrespective of these misgivings this is a good article and those of us dealing with Gender Dysphoric teens know how hard it is to navigate this terrain.  Some solid therapeutic work seems to have built up sufficient trust to garner some solid insights from these young people.  Of course I wish that self-awareness pre-dated significant surgery but for parents struggling with this, especially,  I do recommend this piece.