I went to the Tavistock as a young person - AMA

[MAW1993]

I attended the Tavistock from 2008 to 2011, beginning when I was about 15. I made this post because I saw the many questions people asked on a previous AMA. Unfortunately, the OP was uncomfortable answering some of them, and I felt there may be a need for an AMA with someone who can be more open.

In terms of phalloplasty, there are some significant risks associated with it and high rates of complications. However, 'failure' in the sense of a loss of the graft is rare and strongly associated with smoking, and most complications are managed at later stages of the surgical process. Furthermore, there is a lot of misinformation and scaremongering about phalloplasty, based on either old cases or incomplete procedures.

Of course it is also imperfect, and there are many things that would be better about it in an ideal world. However, there has been little development in surgical techniques since I first started transitioning or before that. Some trans men are holding off from surgery in the hopes that a miraculous alternative will be discovered, but I think that is very unlikely and so it unwise to pin all my hopes on it.

I spent 7 years thinking about the procedure before asking for my initial referral and consultation. The team that do it in the UK are very transparent about what is, and is not possible during the consultations and with their online literature. For me, the limitations associated with it are far more acceptable to me than how I feel as I am. The delay to my surgery due to (unrelated) ill health was a massive blow, and I am bitterly disappointed to still be so far from even beginning the process.

I appreciate others will feel differently, and know many trans man do not undergo this or any other genital procedure. However, I can only do what is best for me as an individual. I don't feel able to continue on as I am now, despite the overall improvements I have felt since my other procedures.

I'm sorry to hear about your complications from surgery. I have been very fortunate to have suffered no complications from my mastectomy, and only some short term bleeding from my hysterectomy. I have suffered complications from other surgeries in the past, but again they were very important to my wellbeing and so I do not regret having had them.

Unfortunately I think the current climate around “trans issues” means that no one will go anywhere near any full scale studies into causes at present. Because the results could support the idea of some medically reversible or psychological origin.

This would currently be a huge hot potato since trans activism (the very public stuff) doesn’t allow for the idea of attempting to undo trans ideation or sex characteristic dysphoria.

This is a huge shame as it means genuine sufferers don’t have any path open to them except living with the trauma or undergoing the great difficulty op has and does go through.

Eek sorry op this is not a question unless you would like to comment, I was replying to your post mentioning studies.

Fair enough, you've clearly given it a huge amount of thought.

I wonder, though -- is anything going to be 'good enough'? Do you see yourself as stopping after this, or will there always be one more step you could try, one more change you could make?

I don't accept that sex dysphoria is an intellectual issue. I have met plenty of smart and plenty of stupid trans people, like anyone else. Furthermore, in my experience it was clear that the emotional distress was the end product, rather than the cause of the sex dysphoria.

By intellectual, I meant a mental health issue, sorry, that was clumsily worded. I'm trying to be sensitive, but I expect you can agree that dysmorphia is a mental health issue.

What I've not yet understood is why people treat a mental health issue with physical adjustments.

I see that you go on to talk about hormones and brains structure, which I suppose is seeking a physical locus for the mental issue?

I've just been listening to something on dysmorphia - which is not treated by attempting to change whatever aspect of the body is the perceived issue, until we come to dysmorphia related to genitals or sex organs, and for some reason this is treated differently, by suggesting the body should be changed.

You may find Gina Rippon's work interesting on 'gendered brains', btw.

https://www.amazon.co.uk/Gendered-Brain-neuroscience-shatters-female/dp/1847924751

tl;dr, brains are fabulously and famously elastic.

Thank you for your understanding. I really hope there will be better treatment options for people in the future. However, if the current climate around trans issues in the UK persists, I think it is more likely that efforts will be made to simply withdraw care, as has occurred for children.

I'd like to see more studies that look for the causes and examine treatment options, in order to best guide clinical decisions. That said, I think it is important to say that none of the studies I have mentioned are without value. Evidence defined as being of weak quality is often the first step in the process of understanding something, and seeing whether a theory is reflected by reality. For example, case studies are amongst the weakest form of research, and yet are critical to the identification and treatment of emerging or rare diseases, such as with the HIV/AIDs and COVID pandemics. What needs to then follow is further research, which use larger sample sizes, with longer follow up, and is designed in a way that most minimises bias (whilst being suitable for the subject matter).

It's also worth bearing in mind that weak quality evidence is used throughout medicine to make strong recommendations of the best known management of conditions, whilst awaiting further research. The risk of leaving a condition untreated is balanced against the risk of using a treatment, particularly if there is uncertainty over the longer term effects. Many treatments used in current practise are justified on this basis, and particularly for groups in need of urgent care whilst being underrepresented in clinical research.

The way in which the hierarchy of evidence is being applied to support the restriction of medical transition, is not being replicated in these other cases, however. The motivation behind that double standard warrants consideration IMO.

No, what would be left to change?

This is another way in which sex dysphoria and body dysmorphia, whilst sharing characteristics, also differ. No amount of cosmetic surgery will relieve the distress of most patients who suffer from body dysmorphia. Trans people have surgery to change their sexual characteristics, and then by and large go on to have a greatly improved quality of life.

Obviously some people do ending up regretful and more unhappy than before they transitioned. However, systematic reviews (which provide the highest quality of evidence) utilising large sample sizes have consistently found the rate of regret for surgery to be around 1% for trans women, and less than 1% for trans men.

I don't believe that regret or detransition should be covered up, or people who go through that should be maligned and left without support. But I think the inclination to use their experience to deny a treatment that results in vastly improved psychosocial functioning in 99% of patients is unjust.

That’s all so helpful. Thank you again for the time you’ve given to this thread.

Do you think that any of the destransitioning is due to transphobia and deciding that it’s preferable to live with gender dysphoria than tolerate transphobia day in day out?

What made you realise at such a young age that males have penises and you didn't? Did someone expose themselves, or worse, to you?

What do you think made you believe that not having a penis was a negative rather than having a vulva was a positive?

You say that the rate of regret for gender reassignment surgery (I'm not sure if that's what I should call it) is 1% or less. Do you know how this compares with other types of surgery (e.g. knee replacement)?

I think it’s fairly normal for toddlers to see their parents naked and to know that boys have penises and girls have a vulva. I think assuming abuse from that knowledge is quite the leap.

Hmm, OP is now casting doubt on the Cass review. I'm taking some of this apparent reasonableness with a bit of a grain of salt. I wish you luck, OP, but I also do think that the nature of the need to get informed consent to anything, especially in children, requires a full understanding of the risks involved. I really don't think that the issue of the last few years is that people have talked about the risks of puberty blockers too much and the benefits not enough!

I outlined a key difference between sex dysphoria and body dysmorphia above - physical intervention does not improve functioning for patients suffering the latter, but does for those suffering the former.

Sex dysphoria can clearly cause mental health issues. It is also possible that it is purely a mental health condition. But there simply isn't the evidence base to state that as it stands. The best available evidence we have paints a more complex picture with prenatal, genetic and developmental factors all being associated with, but not necessarily causative of, sex dysphoria. We need more and better quality research to be able to ascertain any causal relationships.

I spoke about the findings of the research that is available, to the best of my knowledge and with recognition of its limitations. I am not sure why you characterise that as 'seeking a physical' cause. I would be happy to review any research you could provide that evidences the assertion that it is a mental health condition in addition to what I spoke of above.

However, even if we are to accept the claim that it is a mental health condition, that does not preclude the possibility that transition is appropriate for some patients. The evidence base for its role in improving quality of life and functioning is strong for people with persistent sex dysphoria. There is also strong evidence to suggest that talking therapy has an important role to play in determining its suitability for a patient, and some limited evidence that it can also lead to desistance or lessening of symptoms in some patients.

The use of physical interventions to treat established mental health disorder is also not without precedent. Similarly, patients must be screened for suitability and less invasive approaches should be the first course of treatment. For example, very rarely deep brain stimulation (a form of brain surgery) is used to treat depression and OCD, with some stringent criteria. These are that the illness must be severe, and that it must be resistant to front line treatments, such as psychological therapy and pharmacotherapy.

In relation to the male/female brain debate, it is known that there are regions of the brain that are sexually dimorphic from early development, and that sex steroids play a role in regulating synaptic pruning. Also known, as you said, is that the brain is capable of widespread neuroplasticity throughout our lives and particularly in our younger years. Significantly, the brains of men and women are far more alike than not on average, and inter-person differences are seen regardless of their sex. For the few regions where sexual dimorphism is observed, we have no understanding of the degree to which this influences identity or behaviour, if at all.

As such, I certainly don't believe in 'female brains' that make you like cooking dinner and raising children, or 'male brains' that induces football watching and beer drinking. But I do think the fact that structural differences have been observed in the brains of trans people (in both sexually dimorphic and monomorphic regions) warrants further investigation.

I must be honest that as someone who has not detransitioned, I think it would be unfair for me to speculate on the motivations that lie behind it and probably inevitable that I would apply my own experiences in a way that could be completely inaccurate to them.

That said, I do have some friends from when I first transitioned and had more engagement with the wider trans community, and know two people who did detransition at some point. One did so after trialling social transition, and feeling like it was not the right choice for her. She did not have any hormonal or surgical treatment and I am not aware of any concerns relating to her gender / sex since. The other decided he would be happier living as a gender non-conforming man after having taken hormones for a few years.

I never experienced sexual abuse as a child. My brother and I are very close in age, and so would share a bath as young children.

It wasn't really a case of thinking 'penis and scrotum good, vulva bad'. When I would look at my genitalia I would get a visceral feeling of shock and discomfort. It is very hard to describe. I think the closest I could come to it, is to ask you to imagine that you wake up tomorrow morning with a completely different face, or in the body of the opposite sex. It would be shocking and jarring to you, not necessarily because you think the new body is a bad one, but because it isn't your body. I would look down and expect to see male genitalia, and could not understand why that was not the case. I feel the same visceral gut punch now.

I can't say I did off the top of my head 😂. I'm aware that some joint replacement surgeries are harder than others (knee being one of them), so I looked up the statistics regarding hip replacements instead. A quick google for total hip replacement put the figure at 4.8% but that was quite a small study.

I'm not sure where you're getting this from? If you're talking about the discussion on evidence related to transition and the aetiology of sex dysphoria, I'm sorry if I didn't make it clear but I'm talking about adults. The evidence base for children is far more limited, and the use of drugs such as puberty blockers is a much more recent invention.

What I have criticised is the government, media and NHS England's response to the Cass review. Cass made it clear that the waiting lists and lack of support has resulted in appalling failures for at-risk children. I think the recommendation of regionalised care, integrated into other children's services, is a far better model. However, those regionalised centres are very far from being ready to open and meanwhile NHS England has shut down the only existing clinic for children to be referred to. Whilst my experience of the Tavistock was pretty awful, thousands of at risk being children and desperate families have been left with no help of any kind.

But of course, Gender Identity Disorder was classed as a mental health issue up until very recently indeed. 2013 is when the DSM 5 came out, I think, with it reclassified.

WPATH members were involved in getting GID renamed and reclassified.

Are you aware of WPATH and their work, OP? What do you think of them, as an organisation

'When I would look at my genitalia I would get a visceral feeling of shock and discomfort. It is very hard to describe. I think the closest I could come to it, is to ask you to imagine that you wake up tomorrow morning with a completely different face, or in the body of the opposite sex.'

But no child is born with this response, OP. It's been learned.

In your example, a person would only feel shock at a new face if they had learned to see a different face first.

If you will read my previous comments you will be aware of my own previous concern regarding transgender issues. However, with all due respect, the OP has referred to specific research and been very clear about the limitations of it too.

I have yet to see anything other than opinion from you.

You say ‘no child is born with that response, OP. It’s been learned’. Would you like to provide a single piece of evidence that points to that being anything other than your opinion? Where did OP learn this from by such a tiny age? Which member of OPs loving family taught him this? What on earth could they have said to OP that triggered a life long horror in relation to his genitalia? He never claimed that the analogy was perfect, only that it was the closest one he could think of.

Honestly reading this has me just as incensed as reading ridiculous posts from TRAs. Everything based on opinion, conjecture, and a refusal to listen to another or consider the possibility that things can exist beyond your narrow range of experience.

OP has been so gracious here and you’re now just using this as an excuse to spew your personal diatribe. None of your questions have been in the spirit of an AMA. You have no interest in getting to know OP, or make any effort to understands his life. Your true agenda is to try and prove OP wrong. He has never claimed to have all the answers about transgender issues in general, only to answer questions about his own life openly and honestly.

How sad that what has been a wonderful and respectful space has once again descended into this. You have an endless number of threads where you can engage in this behaviour and everyone will clap you on without a single moment of critical evaluation. This is an AMA, not your personal playground in which to play devils advocate about the personal choices an individual has made to try and find a modicum of happiness and relief in a world that has been cruel to them from birth.

Babies are born with a few innate, instinctive responses. Distress at their body is not one of them, unless they're in physical pain.

This isn't really a very controversial observation, and it certainly doesn't warrant such a vitriolic attack. 'Spew', indeed.

I've no idea where or why or how OP learned this response. I'd be curious to hear OP expand further, but that's up to OP.

Hear hear! I think that OP has dealt amazingly with the questions asked and doesn't deserve the questions that seem to come from a place of bad faith. OP is harming nobody, is not trying to lie to either himself or others about who he is, and does not believe that his trans status entitles him to erode others' rights. That's good enough for me and @Terref needs to back off.

So everything but reflex actions is learnt behaviour? I’d venture that it’s slightly more complicated than that, and that most human responses are multi factorial in origin?

A lot of things were previously classified as mental disorders in the diagnostic manuals. Including homosexuality and promiscuity. There are many conditions in the DSM / ICD that are organic in origin and aren’t technically mental illness - neurodivergent conditions, for example.

Now for my much longer answer, that directly links to the recommendations made by the Cass review.

With regards to puberty blockers - if you believe that there has a balanced consideration of the risks vs benefits in recent discourse, then I would call your attention to the quality and quantity of evidence that is now being demanded for their use in any form. Contrast that with the quality and quantity of evidence showing that talking therapy is suitable as the sole treatment of severe and unwavering sex dysphoria from childhood. And let me be clear, that that is the population I am referring to in any commentary of puberty blockers. In the Cass review they are referred to as 'children with gender incongruence', with the children who fail to meet this definition referred to as 'children with gender dysphoria'.

I have never supported the 2014 move by the Tavistock from the research-only protocols to opening up the use of puberty blockers to populations for which there existed no evidence of their benefit. But I do support the original scope to use them in a subset of children who were particularly at risk and for whom talking therapy had failed to provide relief - under research protocols that would inform the development of evidence based best care practises. That is a view in direct alignment with the Cass review.

This is the same population that the Cass review makes reference to when stating that 'puberty blockers only have clearly defined benefits in quite narrow circumstances'. It is also clear in the report that the criticism being levelled is in regard to the use of puberty blockers in groups other than 'children with gender incongruence'. Cass does not criticise the use of puberty blockers in the original group, and in fact recommends further research on this basis. The review also finds that the treatment guidelines that have the best evidence base are the Swedish and Finnish ones. Both of those guidelines contain provisions for the use of puberty blockers - within children who meet the original criteria of gender incongruence and for whom there exists some evidence of benefit, but for whom we need better quality and longer term research.

The Cass review recognises that there is a stronger clinical understanding of prognosis for children suffering gender incongruence since childhood, than with those presenting in adolescence. Not all people suffering childhood gender incongruence will or should go on to medically transition. However, persistence into puberty was associated with long term sex dysphoria. Again, this is the group of children that could be eligible for the research project. To quote the report once more 'importantly some children within this group who remain gender incongruent into puberty may benefit from puberty blockers and will be able to enter the specialist component of the service and access the puberty blocker trial in a timely way'.

In respect to talking therapies, I believe these to be of great benefit. Not only can they help to determine the suitability of a patient for a specific treatment, they also are beneficial in and of themselves, whether used alongside other interventions or as the sole treatment modality depending on what the evidence suggests is most appropriate. However, what I do not support is the characterisation of them as the only treatment that should be provided for every child presenting with gender / sex related distress. The Cass report is clear on this too - 'the intent of psychological intervention is ... to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not.'

Finally when it comes to the escalation of treatment, the Cass review shares a very similar position to what I have advocated here. Distress should be addressed in the least invasive way possible. All children should receive specialist psychological support. Should that fail to facilitate increased psychosocial functioning and decreased distress then less invasive medical intervention, like the cessation of periods with contraceptive pills, should be used next.

However, the reality of the situation is that whilst NHS England has committed to following these recommendations and performing this vital research, they have closed down the only clinic through which this could have been facilitated. The regional centres, that I agree would be a vast improvement, are yet to be anywhere near ready to open. Clearly, children will not be able to access this research protocol, when they require the intervention of a service that no longer exists. Nor will children be able to access the specialised psychological support that is proven to benefit well being in all children referred for support. This utter decimation affects all treatment options, is in direct disagreement with almost every recommendation of the Cass report, and yet has been accepted by large segments of government, media and the general populace. Vulnerable children, who have already been failed time and time again, have been abandoned, and the Cass review used to justify this, despite it being diametrically opposed to such an outcome.

To conclude, for you to argue that I have in anyway cast doubt on the Cass review, you must have either failed to read it, my comments, or both. The report specifically warns against the weaponising and misrepresentation of both itself, and the children at its heart, by people whose views are informed by political ideology rather than evidence and expertise.

I'll leave you with a final Cass report passage to consider:
A failure to consider the cause, potential influences and contributory factors can lead to people taking polarised positions. Nuanced discussion is needed about how best to understand and respond to the children and young people at the centre of the debate.

I hope this clears up any concerns of me casting doubt on the review. I have avoided overtly factual arguments surrounding research on trans people as a whole, because I did not believe that to be the purpose of an AMA. Perhaps this is what has facilitated the characterisation of my position as one of apparent reasonableness covering underlying duplicity. I appreciate this response has a far less friendly tone, but I draw the line at the misrepresentation of my values and desire to see holistic and meaningful care provided to children living through what I once did.

Unsurprisingly, as a person who has lived my entire life with sex dysphoria, and experienced a vast array of 'services' aimed to cure it, I am aware of WPATH alongside the changing definitions and political narratives surrounding the issue.

No I do not agree with WPATH, who have made recommendations based on inadequate, contradictory evidence whilst ignoring findings that do not correlate with their position. I have further clarified my views on the evidence base and appropriate recommendations for treatment in the response I have just published to lemonstolemonade.

Thank you. I can confirm, once again, that the wonderful and caring family that I have spoken about in length never taught me that my female anatomy was shameful, sexually abused me, or taught me that a girl was capable of anything less than what she dreamed of. My parents were not perfect, just like us all, but their support of my aspirations and wellbeing was unconditional and unwavering.