Trans aged 18

Is there a specific attack on trans rights for young adults? After the disastrous case of Bell v Tavistock, restricting puberty blockers for 16 year olds, is there a move to reduce treatment for older teenagers? How might such a campaign work? A lot depends on what “adolescent” means.

Aged 18, ideally, you have a strong relationship with your parents, and anti-trans campaigners make much of the fact that brain maturation continues until age 24.

The UN formally defines adolescent as aged 10 to 19. This Lancet article says “understanding of continued growth has lifted [the] endpoint age [of adolescence] well into the 20s”. A lawyer might want a precise definition. A doctor would consider the good of the actual patient. A gender psychiatrist should balance the potential harm of changing sex characteristics where a patient might revert against the harm of delaying a trans person’s transition.

The NHS has changed the name to Children and Young People’s mental health services, from Children and adolescent mental health services. Most patients “transition” to adult services aged 18, but some do at 16 and there may be some flexibility. This means it is usual in Britain to treat an 18 year old as an adult.

WPATH does not provide a definition of adolescent, but the WPATH standards of care state that adolescents diagnosed with gender dysphoria are far less likely than children to detransition. Many adolescents do not report a history of childhood gender nonconforming behaviour, so parents may be surprised.

On the assessment of adolescents, WPATH says,

Assessment of gender dysphoria and mental health should explore the nature and characteristics of a child’s or adolescent’s gender identity. A psychodiagnostic and psychiatric assessment – covering the areas of emotional functioning, peer and other social relationships, and intellectual functioning/school achievement – should be performed. Assessment should include an evaluation of the strengths and weaknesses of family functioning.

The change from fully reversible interventions, including puberty blockers, to partially reversible interventions, including cross sex hormones, should not occur until adolescents and their parents have assimilated fully the effects of earlier interventions.

Testosterone makes the voice deepen. Oestrogen causes gynaecomastia.

The Mail had an article which is little more than “anti-trans campaigners say trans is bad”. GenderCare, operated by Dr Stuart Lorimer, who also sees NHS patients, was allegedly prescribing cross sex hormones to 18 year olds after one consultation. The Mail says,

There is no suggestion that Dr Lorimer or GenderCare, which sees individuals from the age of 18 and charges up to ÂŁ300 per appointment, have contravened any medical guidelines. But parents and campaigners are concerned by the speed at which drugs that can have serious health risks, including blood clots, strokes and infertility, are being prescribed to potentially vulnerable young people.

A stroke would be a severe consequence, which is unlikely.

The Mail produces two parents who say their 18 year old offspring had a hormone prescription after one consultation, and a group of parents hostile to transition whose spokesperson says treatment for people in their early twenties is unsafe. It’s not news. It could indicate that after Keira Bell there is an attempt to roll back treatment for older people, even up to 25.

A campaign to limit treatment for 18-25 year olds has no potential loss for the anti-trans campaigners. The more such views are expressed, the more people might think they seem reasonable. However to succeed, it needs to overcome profound barriers. The main one is the NHS definition of adult, as a person over 18.

Could a doctor prescribing hormones to an 18 year old presenting as trans be liable for damages in court? The legal test is in Bolam v Friern Hospital Management Committee. A practice accepted at the time as proper by a responsible body of medical opinion skilled in the particular form of treatment in question was not negligent merely because there was a body of competent professional opinion which might adopt a different technique.

That is, the very existence of WPATH is enough to protect doctors following their standards from negligence claims. There are prodigious, well-funded attempts to chip away this protection, and the Bell case advances them, but for the moment there can be no particular attack on 18-25 year olds’ treatment.

The other possible attack is on professional competence through the General Medical Council. Doctors must:

  • Work in partnership with patients.
  • Listen to, and respond to, their concerns and preferences.
  • Give patients the information they want or need in a way they can understand.
  • Respect patients’ right to reach decisions with you about their treatment and care.
  • Support patients in caring for themselves to improve and maintain their health.

In providing clinical care doctors must:
a) prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs.
b) provide effective treatments based on the best available evidence

Again, there are significant difficulties in making an ethical case against doctors prescribing cross sex hormones, and arguably no particular case, yet, referring to 18-25 year olds.

Could NHS funding be withdrawn? Local commissioners make their decisions on what to offer patients, based on medical need not Daily Mail campaigns. This would be an attack on all adult gender services, not specifically 18-25. Even Liz Truss was talking about increasing provision of gender clinics, though that turned out to be a re-announcement of new clinics previously announced.

There will be increasing noise about gender services for adults in their twenties. It is unlikely to have an effect on the treatment specifically of 18-25 year olds.

Issues around gender

I am reading the World Professional Association for Transgender Health standards of care. There are overlapping issues around transgender.

First, there is the cultural concept of how a man should be, and the character of the person who does not fit that concept. Then, there is the enforcement on the person of the cultural concept, by family and peers. Then, there is the amount to which that person tries to hide difference, even from themselves, and the distress arising from the difference. Some people will not be bothered that others apparently object to their gender presentation, some will take it to heart. Transitioning is one solution to problems arising from these issues.

WPATH say Being Transsexual, Transgender, or Gender Nonconforming Is a Matter of Diversity, Not Pathology. Well, yes. Doctors might get involved because of the distress, or because the person wanted medical help with transition, but not to make the person conform to gendered expectations. We suffer stigma, so abuse and neglect from family and society, which can cause anxiety and depression.

WPATH say Treatment is available to assist people with such distress to explore their gender identity and find a gender role that is comfortable for them …What helps one person alleviate gender dysphoria might be very different from what helps another person. I feel treatment should also be available for the person who does not present with distress, because they have decided to transition. Aversion is an emotional response- “I find my genitals unpleasant”- but people might show dignity, and not wish to express that emotion as distress. However the diagnosis in DSM is gender dysphoria, or distress.

Find a role comfortable for the patient- transition is only one of several possibilities.

The standards of care are based on European and North American experience, and there is a wide diversity in cultural construction of gender around the world. Doctors elsewhere should apply the principles of the SOC being sensitive to the local culture and to patients’ needs. These principles include the following: Exhibit respect for patients with nonconforming gender identities (do not pathologize differences in gender identity or expression); provide care (or refer to knowledgeable colleagues) that affirms patients’ gender identities and reduces the distress of gender dysphoria, when present; become knowledgeable about the health care needs of transsexual, transgender, and gender nonconforming people, including the benefits and risks of treatment options for gender dysphoria; match the treatment approach to the specific needs of patients, particularly their goals for gender expression and need for relief from gender dysphoria; facilitate access to appropriate care; seek patients’ informed consent before providing treatment; offer continuity of care; and be prepared to support and advocate for patients within their families and communities (schools, workplaces, and other settings).

gwen-john-dorelia-in-a-black-dress

Mistakes and disorders

My lot are not the only women who get mistaken for men. If you are over 5’6″ or your hip to waist ratio is less than 1.4, it has probably happened to you at least once; but we are the only ones who, when we politely explain there is a mistake, are regularly disbelieved.

Once, oh happy memory, I was reverse-read. There I was in jacket and tie and trench coat, going to the other office. As I left the bus, I sang out “thank you” in a light voice, and the busdriver said “Orright Love” then looked round and said, “Sorry, mate”. I walked off floating on air. And once, when presenting male, I visited a friend, and afterwards her ten year old son asked her, “Was that a woman?”

Today, four women were talking loudly about wigs. This did not necessarily refer to me, but it might have done. My friend thought this showed success: if they comment on your wig, they would comment on your being T if they noticed it. And I do not think it meant they would have noticed it was a wig, but for the fact that they saw me leaving the wig shop. I would rather be able to grow my own hair, but feel less moved to whinge about my wigs than some people whinge about their hair, so am happy enough with wearing wigs. I liked the new one when I put it on, and it’s really growing (!) on me.

I am delighted that the World Professional Association for Transgender Health has decided that gender non-conformity is not a “disorder”. It is just part of the natural diversity of human beings. Their new standards of care are discussed and excerpted here. I have known that I am not mad for years, but I am glad the professionals have at last admitted it.