Dr Polly Carmichael
Developments and dilemmas
36– 46 minutes
… and you can see here that the increase in numbers in the number of sex assigned females coming forward is reflected in terms of the gender of the young people being referred to the clinic.
I’ve put this slide in because what the Dutch found who started early intervention about 15 years ago [inaudible – ‘could be longer’?] is that having embarked on physical interventions, really almost none of the young people felt that they wanted to stop. So I think, you know, once a young person has gone to the early intervention clinic, it’s very unlikely that they will then decide that they don’t want to continue down a physical route.
So we’ve had a few who have continued treatment elsewhere or who’ve [inaudible] ... one who has changed their mind and again, I guess that at that point in time they decided not to continue with physical intervention rather than change their mind, and one discontinued due to personal circumstances.
We do a lot of work with families - often we find with younger ones that one parent may be very very supportive, very keen for this intervention to take place, and the other holds all the anxiety and worry about whether this is the right way forward. And I think that work is very important and useful really in terms of the young person [inaudible] as well with the family so that all the different viewpoints are heard.
So the rationale for the blocker. So we said that very few people actually stop once they’ve [?commenced on?… ] the blocker. So ideally you’d be thinking that in some way people [are?] choosing to do that or as the Dutch and ourselves say, we have carefully selected young people who go forward with this treatment. What one’s trying to to do is obviously support young people who are in that percentage who would be continuing.
But of course, no tester[?] if you like is 100% accurate, so either we’re not including some people who would benefit […] or the treatment itself has some impact on the outcome. I’m not making a comment about whether that’s good or bad, I’m making an observation about the data. So the blocker is put forward as a diagnostic intervention, it’s a time to explore and understand and consolidate, and it’s also put forward as a fully reversible treatment. But, really, we don’t know fully what it’s impact is in terms of the developing brain and we don’t know if the [?sum?] it changes things that may have been pre-programmed to go another way.
So, I think you know it would be disingenuous to say it is fully reversible, nothing is fully reversible. And I think it is important that we do more research, really, to understand the impact of these treatments on developing brains.
So the timing of the blocker, not before Tanner stage 2 is a bit of a nod in that direction, and I guess that is based on the fact that we knew that the data suggested that the majority of those coming forward prepubertally didn’t necessarily elect to go forward for physical treatments, so it was thought that perhaps the influence of [inaudible?] sex hormones at puberty may in some way be important in terms of an individual’s identity development.
So how much, how much is enough? We don’t know,but that’s why it’s Tanner stage 2, so the person has experienced some of their own puberty.
So, I think we’re all the time balancing evidence and practise, so on the one hand there’s perhaps a [few?] that behaviour and emotional difficulties young people experience are largely secondary to gender dysphoria and that if you can treat that distress around gender … with physical interventions then those difficulties will go away.
But the truth is we have very little published long term outcome data, and the Dutch really are the only group who have published perspective data looking at the impact of physical treatments, and their data is a heterogeneous group including people of different ages, so those from 12 up until early adulthood.
So we have been looking specifically at those starting the blocker in the early stages of puberty. What we have to know is that there is not a consensus amongst professionals, and there are concerns around impact on health, and even though there isn’t consensus, there are teams exploring the possibility of lowering age limits, particularly of cross sex hormones, although they acknowledge the lack of long term data, and I guess this is very much a reflection of the way people think about and conceptualise gender has more impact really on the way in which care is delivered than does any evidence base, and I think what we really need to be doing is getting the evidence base to catch up with that.
So in most case of childhood GD, the wish to transition to a different gender will have abated by the end of puberty [inaudible] the Dutch team. figures of how many continue to experience gender dysphoria vary and they are very [?rightly?] contested.
So the I think the take-home message is that the impact of the changing context of gender diversity and how it is expressed needs to be taken into account and understood.
We need to acknowledge there is a heterogeneous group that isn’t like you know like a blood test or a diagnosis, this is people’s identity, their sense of themselves, and we have a very mixed group coming forward to the service and as a health service we need to have a model that takes into account all these different presentations.
So in terms of the context. I think gender identities are diversifying without a doubt on this [?inaudible?] a brief look at this slide – [Jen?] I know you’ve covered this in much more detail than I could. But it is amazing really how much things have changed over even the last 5 years really and more and more the case. We’re seeing many more different gender identities, if you like, coming forward and being expressed.
Support and information is much more readily available. Social media, as I’ve said. Political interest and lobbying. The Women and Equalities’ first legal meeting was on gender, and we got some very strong things to say following that about provision for young people experiencing gender diversity.
The age at which young people are socially transitioning is really getting much earlier. As I’ve previously mentioned many [?are moving?] on stealth. And I think what’s emerged are newer approaches to care now there’s about to be a memorandum banning ? therapy. and in a way this is sort of how the debate … polarised, this idea of [comparative?] v affirmative, which is a newly emerging approach.
I think we’ve accused of being [comparative?] I find that deeply insulting and inaccurate if anything we’ve been really affirmative not [comparative] and so I think we need to be really careful to actually be clear what we’re talking about and what things actually mean because how things get translated into practise are sometimes very different and certainly in terms of the affirmative approach we’ve seen now very young children [ technology interruptions … inaudible] we’ve seen very very young people who’ve fully socially transitioned age 3 or 4, and there’s one particular case where the parents who’ve obviously [got] the best interests of their child at heart, and are wanting to be protective for their child and do their best by them but what they wanted from us really was to get in contact with the school to address a hate crime. And the hate crime was that another young child had misgendered this very young child who’d socially transitioned at school.