Thread.

A number of new psychiatry papers in the BJPsych Bulletin have been published in the UK challenging the assumptions and evidence base around affirmation treatments for gender dysphoric children.

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In particular, the insidious idea that to not affirm 'gender' in children is like conversion therapy for homosexuality is pulled apart as ideological and unscientific.

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In the first paper, (Griffin et al) where my good friend Prof Byng, the excellent @susan_bewley have contributed, the ideological and pseudoscientific stance of the @rcpsych on 'trans' conversion therapy is taken head on.

[full text] https://www.cambridge.org/core/journals/bjpsych-bulletin/article/sex-gender-and-gender-identity-a-reevaluation-of-the-evidence/76A3DC54F3BD91E8D631B93397698B1A/core-reader#

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We get a good history of how ideas of 'transexualism' (‘a desire to live and be accepted as a member of the opposite sex, and an accompanied discomfort of one's anatomic sex’) have drifted into the more diffuse concept of 'transgenderism'.

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We see the shift from seeing transsexualism as being a psychiatric disorder to being transgender as a matter of 'personal identity.' This has been compared to how society no longer see homosexuality as a disorder.

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However, this paper challenges this comparison as a set of conflations and ambiguities in language and concepts.

Indeed, it is great to see a paper like this take care to set out and define its terms...

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The central challenge is to take on the @rcpsych idea that "Conversion therapy is described as ‘any approach that aims to persuade trans people to accept their sex assigned at birth’." The psychiatrists is now supposed to accept a self-declaration of being trans enough...

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for "a patient to expect their doctor provide a range of complex medical treatments, with no evidence of dysphoria being required." and "that full medical transition is an ultimate goal in gender-diverse patients, rather than considering a range of possible goals"

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Crucially, the idea is raised that this is a medical treatment that appears to prolong the main symptoms and result in a lifetime of medical intervention. And that, less invasive approaches appear to have much better outcomes.

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"As there is evidence that many psychiatric disorders persist despite positive affirmation and medical transition, it is puzzling why transition would come to be seen as a key goal rather than other outcomes, such as improved quality of life and reduced morbidity. "

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And is warns against elevating regressive ideas of gender over the reality of sex, by treating as meaningful that it is possible to have an inner identity of being a man or woman.

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"One cannot possibly know how it feels to be anything other than oneself. Medicine may be in danger of reinforcing social norms and reifying a concept that is impossible to define over and above material biological reality"

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This is a paper that challenges the newly emerged orthodoxy that being transgender is some sort of innate state for people and that to view it as such "closes down opportunities for doctors and patients to explore the meaning of any discomfort."

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It calls for a more plausible hypothesis that "that one's gender identity is flexible, informed by one's culture, personality, personal preferences and social milieu." We should not be trying to deny the material binary of sex by creating a new rigid binary of trans/cis.

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This is wake-up call for the @rcpsych to rethink. "Those providing and interpreting the scanty evidence from published research need to be independent and impartial, using best-quality measures rather than ideology"

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The second paper is by Marcus Evans - the former Associate Clinic Director of the Adult and Adolescent Departments, Tavistock and Portman NHS Foundation Trust clinic

16/ https://www.cambridge.org/core/journals/bjpsych-bulletin/article/freedom-to-think-the-need-for-thorough-assessment-and-treatment-of-gender-dysphoric-children/F4B7F5CAFC0D0BE9FF3C7886BA6E904B/core-reader

Marcus Evans ( @marcusevanspsyc) is one of the many therapists working at this clinic who have resigned over concerns over the quality of treatment there.

17/ https://quillette.com/2020/01/17/why-i-resigned-from-tavistock-trans-identified-children-need-therapy-not-just-affirmation-and-drugs/

This new paper (Freedom to think: the need for thorough assessment and treatment of gender dysphoric children) explores similar themes about the lack of any good evidence base for the affirmation approach for children who present there and the use of puberty blockers.

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Evans quotes Carl Heneghan ( @carlheneghan), Oxford University's Professor of Evidence-Based Medicine and Editor-in-Chief of the journal BMJ Evidence-Based Medicine who called this treatment an ‘unregulated live experiment on children’.

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Evans looks at gender dysphoria as having a close relationship with body dysmorphia. Surgeons are used to patients who present wanting surgery to "erase a psychological difficulty" and we should view gender dysphoria in a similar way.

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This is a shocking view to those who see 'trans' as being an innate quality of an individual. These papers are calling on us to revisit this is we want to actually get good clinical outcomes and better lives for people with such psychological distress.

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"The fantasy that the body can be rapidly sculpted as a way of being rid of profound psychological problems needs to come under much closer scrutiny. "

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These papers are timely with the government looking at banning 'conversion therapy'. For homosexual conversion therapy, we have a sound evidence base that such conversion is futile.

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We also have a well developed social acceptance now of homosexuality being "normal, acceptable variation of human sexuality".

We have no such understanding for the ideological conceptualisation of 'transgender'.

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In fact, the idea that gender nonconformity should somehow be medicalised is regressive and against all progressive thought and that we should instead help and allow children to "reconcile their identity with their biological sex".

The recommendation from the paper is worth reading.

/Ends