The Misfortunes of Keira Bell (Continued)
What’s the difference between sex and gender?
It’s like a question that’s reputed to be asked of those wishing to qualify in accountancy: what’s the difference between residence and domicile? Residence is where you live; domicile is where you think you live.
Thus, sex is whether you’re male or female, and gender is how you ‘identify’, that is, whether you think of yourself as male or female, or as neither, or as something in between.
This question is once again in the news with a BBC headline: ‘Doctors can judge if under-16s can give informed consent to puberty blocker use, the Court of Appeal has ruled.’ This judgement reverses a 2020 High Court ruling that people under 16 lack capacity to give informed consent to treatment that delays the onset of puberty. The appeal was brought by the Tavistock Trust which runs the curiously named Gender Identity Development Service (GIDS).
The original case was brought by an unfortunate young woman called Keira Bell, who says she should have been challenged more over her own wish to ‘transition’ when referred to GIDS. She expressed her disappointment over the Court of Appeal’s decision and will seek permission to take the matter to the Supreme Court.
The Court of Appeal judges said they recognised the difficulties and complexities of the issue, but that it is for clinicians to exercise their judgement knowing how important it is that consent is properly obtained according to the particular individual’s circumstances.
This sounds all very fine and large, but if we look a little deeper into the question of so-called gender dysphoria and the use of puberty blockers in troubled adolescents, it’s not quite as simple as it may seem.
What is gender dysphoria?
The NHS website defines it thus:
Gender dysphoria is…a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity [which] may be so intense it can lead to depression and anxiety and have a harmful impact on daily life.
What is gender identity then? The NHS informs us that it’s the situation in which some people ‘feel their gender identity is different from their biological sex.’
Thus, it’s a sense of unease and a feeling of unhappiness about one’s body, even to the extent of wishing to change it to that of the opposite sex. We are reassured, however, that ‘gender dysphoria is not a mental illness.’ This being the case, it seems to me it would be better for people so affected to be offered help to come to terms with their reality. This is because there is a major difference between wishing one could be of the opposite sex and fantasising about it, and actually taking steps to try to achieve such a new identity.
Referral to GIDS
Referral to this clinic implies a decision to treat accordingly. If this is not the case, perhaps we could be told in how many young people who have been referred to GIDS is the decision made, either that they do not have the capacity to make an informed decision for this life-changing treatment, or who are told such treatment is judged inappropriate and who are then sent on their way.
Furthermore, the very name of the clinic implies that gender dysphoria is a disorder for which the appropriate treatment, after careful consideration and counselling of course, is experimental hormonal treatment (‘puberty blockers’), likely followed by lifelong use of cross-sex hormones and irreversible surgery.
Concerning the matter of informed consent, is it made clear to the patients, as it ought to be, that it’s a biological impossibility to change one’s sex? Every cell in the body (except the ova and sperm) is indelibly and irreversibly marked as male or female by the presence of an XY or XX chromosome, respectively. All that can be achieved by hormonal and surgical interventions is to change the external appearance of one’s body so that it will to a greater or lesser extent approximate to that of the desired opposite sex.
In the case of female to male transitioning, if normal puberty is prevented and testosterone later administered, one usually ends up as a person of short stature with a man’s voice and a beard who lacks a penis, who may have had her breasts removed, and who is almost certainly infertile.
The affirmative approach
Part of the problem is that the recommended approach, especially in America but also it seems at GIDS, to a person presenting with gender dysphoria, should be ‘affirmative’. In other words
…mental health professionals ‘affirm’ not only the patient’s self-diagnosis of dysphoria but also the accuracy of the patient’s perceptions…Affirmative therapy compels a therapist to endorse a falsehood: not only that a teenage girl feels more comfortable presenting as a boy—but that she actually is a boy. (Quoted from Irreversible Damage by Abigail Shrier, Swift Press 2001, pp 97–98.)
Further, accession to the request for a puberty blocker by a doctor amounts to collusion with an adolescent’s fantasies and projections. It takes at face value the patient’s belief that their unhappiness can be alleviated or abolished by embarking on experimental hormonal treatment.
The idea is to ‘buy time’ while the young person makes up his or her mind what they really want to do: continue as they were born (male or female) or change their outward appearance as far as this may be possible to become something they are not and never can be: the opposite sex.
Part of the pernicious business of affirming troubled adolescents’ views of themselves is shown in the GIDS referral form for GPs who are asked to tick the appropriate box, male or female, in response to an item worded ‘Sex assigned at birth’. This implies that sex is, indeed, something that is assigned and therefore can be reassigned.
Sex is not assigned at birth. As I mention in my previous blog about Keira Bell, almost invariably the first words uttered by the birth attendant are ‘It’s a boy!’ or ‘It’s a girl!’ as the case may be. In the vast majority of babies this is obvious from a glance at the genitals. The birth attendant does not say, ‘Well, here’s your baby. What gender would you like to assign to them?’ (About one in 5,500 babies is born with an abnormality and has ambiguous genitalia but I don’t discuss this here.)
Likewise, at the top of the GIDS referral form it says:
Young people referred to GIDS are frequently struggling with issues such as communication and relationship difficulties, bullying and discrimination, low mood and anxiety, and a number also self-harm.
Indeed, and these serious problems need to be dealt with and remedied directly, as far as this is possible. But the people who run GIDS evidently have already made up their minds that these unfortunate experiences ‘are often linked to a young person’s gender identity.’
Risks of puberty blockers in physically normal people
Before the idea of gender dysphoria was invented, it was possible in the UK for adults who believed they were in the wrong body to undergo a ‘sex-change’ operation on the NHS. But before this could happen they were carefully assessed by psychiatrists and had to show they could live successfully for at least two years as a person of the opposite sex by cross-dressing, etc. (I describe such a case in my memoirs, An English Doctor in Japan, YouCaxton Publications, 2020, p 39, available direct from the publisher or from Amazon.)
This is a different matter from the situation of disturbed teenagers who may project their unhappiness onto a belief they’re in the wrong body. They should be supported with psychotherapy or counselling to work through or at least come to terms with their conflicts and problems, and when they’re mature adults, if such dysphoria persists, they can be assisted to transition.
A drug such as leuprolide (Lupron), although not approved as a puberty blocker can be used ‘off-label’ to halt normal puberty. This amounts to interrupting healthy endocrine functioning based on the say-so of minors and in the absence of any objective diagnostic criteria. Puberty is not a state that can be turned off and on like a light switch, and using drugs for this purpose is experimental. The NHS says: ‘It’s also not known whether hormone blockers affect the development of the teenage brain or children’s bones. Side effects may also include hot flushes, fatigue and mood alterations.’
In my opinion, the drastic step of hormonal manipulation to delay puberty in physically healthy adolescents should not be undertaken.
Text © Gabriel Symonds
Picture credit: www.huckmag.com