THERE is no area of medicine more ethically complex than paediatrics, especially at a time when the health and wellbeing of our children and young people is – quite rightly – given more focus than ever before. And yet there is a worrying lack of scrutiny around treatments administered within one small but growing area of child health.
The Gender Identity Development Service (GIDS), based in London, is the UK’s only specialist service for the treatment of children who may be transgender. Last year 2590 young people were referred there; a decade ago, it was fewer than 100.
That last statistic is thought-provoking. Why has there been such an increase in the number of children referred to GIDS? Why do so many more young people now believe they are transgender than 10 years ago? What sort of treatments are available and how successful are they?
These questions are primarily of relevance to the children seeking help and their families, of course. But they have wider significance, too, both in terms of how children are cared for by the NHS and how society deals with the increasingly high-profile – and thorny – issue of gender identity.
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And this is where things get difficult. Not only do we apparently have no answers to these questions, but if the reaction to some of the clinic’s own staff is anything to go by, even asking them is deemed to be transphobic.
Last month two former members of staff at GIDS, psychologist Dr Kirsty Entwistle and senior psychiatrist Marcus Evans, a former governor of the health trust that manages the service, spoke publicly about their reasons for resigning. In an open letter, Dr Entwistle told of children as young as 11 being given puberty-blocking hormone drugs, their families reassured that the effects are reversible, despite there being no clinical evidence about the long-term impact of the medicine, and concerns being raised about side-effects on brain and bone marrow development, not to mention a possible link to self-harm.
Dr Entwistle also believes children with mental health problems caused by trauma are being pushed towards gender transition; so are young people on the autistic spectrum and with complex social phobias, according to Mr Evans. He added in a BBC interview that after waiting months, sometimes years for a referral, vulnerable and distressed children and their parents often arrived at GIDS with a fixed idea of both the problem and the solution, sometimes supported in their view by transgender pressure groups, which went unchallenged by doctors. Scrutiny is a routine and fundamental part of any medical practitioner’s work, yet clinicians who questioned these approaches, he alleges, were routinely accused of being transphobic.
Each one of these individual allegations is serious and would surely merit an investigation. Taken together, however, they create an alarming scenario: vulnerable, damaged children rushed into drug treatment that could have a profound and irreversible impact on the rest of their lives.
How can it possibly be transphobic to ask that all medical treatment given to children should, at the very least, be evidence-based and administered only if it fits the medical and welfare needs of the individual child in question? How can it be transphobic for a doctor in possession of a full case history to question whether a child is transgender?
The very fact that it is also being repeatedly alleged that doctors are making clinical decisions based on a particular political agenda, or are afraid to speak up against it, should be enough to warrant an investigation. Surgical units in other areas of medicine have, after all, been shut for less.
And yet the only action taken at GIDS – where a total of five staff have reportedly resigned from their roles – has been an internal review carried out by its own medical director.
It is clear that a full and independent investigation into the clinic and its approach is required, not to mention more research into the short and long-term effects of puberty-blocking drugs. Mr Evans, meanwhile, suggests a slowing down of treatment programmes to give all those involved – clinicians, families and young people – time to reflect. He also wants an external body to oversee treatment, creating a barrier to protect clinical staff from political pressure. This all seems eminently sensible, does it not?
What’s also required is academic research into, as well as open and honest discussions more widely around, the reasons children and young people are – or believe they are – transgender, or wish to explore their gender identity. There are doubtless a host of factors at play, encompassing physical, emotional and psychological change, not to mention political, media and peer pressures, all of which influence teenage and indeed adult identity.
We need to better understand the interaction of these complex strands so we can help and support our young people through all their struggles. We also need to be able to ask pertinent questions without being accused of transphobia. As the toxic and polarised debate around adult trans issues highlights, however, this isn't going to be easy.
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