VD: Well, let’s talk now to Dr Polly Carmichael who is the Director of the Tavistock clinic, NHS clinic in London. Thank you very much for coming on the programme.
VD: How can you be absolutely sure when a child or teenager comes to your clinic that they do genuinely want to live as the opposite gender?
Dr PC: I think the first thing to say is this is a really complex area and the truth is you can’t ever be a 100 % sure about a lot of things and certainly in this area you can’t be a 100 percent sure.
Having said that, our assessment process is wide ranging. it’s over a long range of time.
We look at the development of gender, we look more widely at relationships and how young people are doing in school and so on. And, moreover, less than half of the young people who actually come to the service would ever be referred to the clinic. And for those that are, they continue to meet with psychosocial professionals, to explore their gender and importantly think about a whole range of pathways.
VD: Right. let’s talk more specifically about what happens if someone does come to your clinic then. How many therapy sessions would you have with a young person before puberty blockers would be part of the conversation?
Dr PC: ok, so we work according to NHS specifications. We are a commissioned service and in the specifications it says 3-6. I think in reality…
VD: That’s an hour long?
Dr PC: That’s an hour long, maybe longer sometimes, with two clinicians, I guess that’s around giving young people a space, but also giving their parents a space.
VD: And over what period of time would those 3-6 sessions be?
Dr PC: So… it would vary. it’s all individual, it’s case by case but over a period of six months or so. But I think it’s important to say that the reality is one outcome of the assessment period is not infrequently, ongoing exploration and thinking
VD: rather than at the end of that period prescribing puberty blockers
Dr PC: Yes
VD: 3-6 sessions, each about an hour long, 2 clinicians over a period of about six months - does that strike you as not enough therapy and over too short a period?
Dr PC: So, I think if it were that after that period everyone was being referred to clinic, then I think there would be rightly questions. But the truth is often it’s much longer than that. And indeed, I think we are well aware of some of the concerns that have been coming out more recently around large increases in numbers of referrals, there have been concerns about more assigned females being put forward for services. And I think within that, if anything, we are more cautious, more careful.
We also have a network model, so young people come from all over the country. And we convene professionals meetings locally and many of the young people we see have co-occurring difficulties and so it’s most appropriate really that any therapeutic input happens locally.
VD: Right. How can a child or teenager give their full informed consent to taking puberty blockers? That’s what critics suggest they can’t and Kiera Bell is one of them.
Dr PC: Yeah, so… Obviously people over the age of 16 are able to give consent. And the consent process we have is a robust one, it’s a process, it’s not an event. it’s not one occasion where you obtain consent. But I think it’s involved in numerous discussions around thinking about all the different pathways. If an individual is pressing for any physical intervention there would be extensive discsussions around their hopes for that, their expectations, ensuring they are realistic. There would be discussion around potential side effects, known side effects, unknown ones, unknown unkowns. And all of this before a young person even gets referred to the clinic. And then formal consent would be taken within the endocrine clinic. The first visit would only ever be a full discussion from a medical doctor around the treatment. And education and so on.
And so formal consent would never be taken until at least the second meeting.
VD: Right. Again, is that too soon. And again, how can a 13 year old really give formal consent for taking puberty blockers, taking cross sex hormones?
Dr PC: Well, a 13 year old isn’t giving consent for taking cross sex hormones. There’s a lot of misinformation and
VD: Lets stick with puberty blockers, lets just stick with that. Sorry, that was my mistake
Dr PC: No, that’s fine. But I guess… blockers… sorry – you were asking about informed consent. I think young people are able, My view is they are able to give informed consent. They are given full information round the intented action, the potential risks and so on. Over time, on more than one occasion. I think there is also evidence in general, that young people can develop, if you like, specialist areas of knowledge, beyond their developmental stage, if you like. when there’s been work around that particular area. I think that’s evidence that comes from pediatrics in general.
VD: Right. Do you mean why, because they are going online and joining forums so they have knowledge?
Dr PC: I think that’s very different. The knowledge that they obtain within the clinic is a robust knowledge based on the evidence. That’s not always the case online.
VD: Keira Bell was 16 – so she was able to give informed consent as a 16 year old, Regrets. she says that your clinic did not challenge her enough. Do you accept that?
Dr PC: I think we do challenge, without a doubt. My heart goes out to Kiera. I think Kiera is incredibly brave and speaks really well. I think it’s really important that individuals can come forward. there’s a place for them and there’s a place to discuss this. But this needs to be kept in a context. The detransition rate is, across studies, very low, 0.3 to about 3%. And also detransition means many things. So, for most, the reason that is given is around a lack of social acceptance, the loss of family and peer support. So, I think, whilst it is really important to think about that, we also need to hold in mind the many people who go forward and can lead a full life with support around their gender identity.
VD: My son, this is from a viewer, my son started with the Tavistock when she was at the time 13 years old. They’ve spent years cancelling before treatment and the only argument I have is that at nearly 24 years, he is still awaiting the final treatment. This caused depression and anger with things not moving quickly enough. I understand this but I wish my son to feel complete and happy with himself.
In terms of the puberty blockers, you will know that those who criticize the use of them in young people say this is experimental treatment that can have life long consequences, you are using a drug which is most commonly used to or licensed to treat advanced prostate cancer in men and to chemically castrate male sex offenders. And to halt very early puberty, it is not licensed to treat gender dysphoria in children, that is true , isn’t it?
Dr PC: So, I’m not a medical doctor but I think you will find that many drugs used in pediatrics are not licensed for use in children.
VD: Do you have any worries about the long term effect on individuals, psychologically , on their brain development, on their fertility? We don’t know what they can do to people.
Dr PC: Well, the blocker has been used for over 30 years so I think , there is actually quite an evidence base. Clearly it is really important, as numbers increase, awareness increases, that there is more research. But I think you have to weigh this up against the effects of not intervening. We are talking about young people whose sense of themselves does not match their physical body and the distress associated with that is often huge.
VD: Finally, let me ask you why you think there has been an explosion in referrals of young people to gender identity clinics. In 2009 -10 there were 77 referrals; 2018-19 – it’s gone up to two and a half thousand. That is a 3263% increase. it’s astonishing. Why?
Dr PC: Well, that’s a really difficult question. I guess there are multiple reasons for it. We need to hold in mind, as much as we are talking about transgender people much more, actually, this continues to be a marginalized, stigmatized group. And so, part of that, I think is likely to be greater awareness and that can be nothing but positive. But, of course, we are also aware that there may be changes in the demographics and that we need to be, if anything, more cautious. And I think, as a clinic, that is exactly the approach we take.
VD: thank you very much for coming on the program. We appreciate your time this morning, Dr Poly Carmichael, Director of The Tavistock. Thank you.