PATHWAYS Trial – The Search for the ‘Truly Transgender’ Child Continues
By Carrie Clark
Earlier this year, I was invited to present Genspect’s concerns about the NHS puberty blocker trial to a parliamentary committee. My fellow panellists were eminent clinicians and researchers, and when I came to write my talk I decided to leave the technical critiques about trial design and methodology to them. Instead, I tried to expose the flawed premise that lies at the very heart of the trial, namely the belief in the existence of the ‘truly transgender’ child.
In essence, the ‘truly transgender’ child is a young person who adults have given up on trying to help in a way that preserves their right to an open future. The decision to proceed with a trial feels like a tacit admission that health authorities see these kids as write offs, so incapable of natural growth and reconciliation with their healthy bodies that they may as well be made sexually dysfunctional and sterile. I don’t believe that any young person, no matter how psychologically distressed, no matter how insistent, deserves to be written off in this way.
Now that the final trial protocol has been published, and nothing short of costly legal action can prevent the unnecessary medicalisation of more gender distressed children, the text of my committee presentation seem more relevant than ever.
“Thank you for inviting me to speak about the ethics of the NHS puberty blocker trial.
Puberty is the natural cure for gender related distress. Prior to the introduction of puberty blockers, 80% of gender distressed young people experienced recovery after going through puberty. The figure is as high as 87.8% in some studies. By contrast, 98% of young people who take puberty blockers proceed to sterilising cross sex hormones, with a further proportion undergoing invasive, experimental genital surgeries.
So the first thing to say about the ethics of the NHS trial is that it will prevent natural recovery for the vast majority of participants, unnecessarily placing them on a path towards infertility, sexual dysfunction, brittle bones, urinary incontinence and a lifetime of medical dependency.
At root, the NHS trial is predicated on a belief that there is such a thing as a ‘truly transgender’ child, a child who will live a life of desperation and tragedy if they cannot cosmetically ‘pass’ as the opposite sex in adulthood. No rationale for blocking puberty remains that does not depend on this belief.
The Cass Review showed that puberty blockers do not buy time to think, do not improve mental health and do not resolve gender dysphoria. The only indication for their use that the Review identified was in suppressing the development of secondary sex characteristics, as a prelude to the use of cross sex hormones and genital surgeries in order to help a child superficially resemble the opposite sex in adulthood.
For supporters of the trial, the ethical question is not whether it is right to treat mental distress using invasive hormonal and surgical techniques, or whether it is ever acceptable for medical professionals to collude in a child’s belief that their healthy body is wrong. Incredibly, they regard these huge ethical questions as settled. I would argue that society hasn’t even begun to grapple with their implications.
Nonetheless, public debate about the trial typically takes the existence of the ‘truly transgender’ child as a foregone conclusion and focuses ethical questions on the assessment process, on using inclusion and exclusion criteria to accurately identify ‘transgender children’. So, how do we assess which children should assume the heavy physical burden of medical transition and the equally heavy psychological burden of living at odds with the reality of their body?
The truth is that we can’t. Assessment in this area can only ever boil down to a subjective assessment of how well someone conforms to reductive sex stereotypes, of how vehemently they assert a cross sex identity, or of how intensely they vocalise distress about their sexed body. In this way, a whole range of diverse experiences are easily misinterpreted and pathologized as evidence of intense and persistent gender related distress.
To illustrate this, I would like to tell you about a detransitioner I will call Julia, a service user at Genspect’s Beyond Trans support service. When she presented to a gender clinic at 12 years old, she was considered the ideal candidate for puberty blockers. She had been “insistent, persistent and consistent” in asserting a male identity. She was highly gender non-conforming, preferred boys toys, clothes and company and she hated her developing female body with a passionate intensity. She was started on blockers and proceeded to testosterone at 16. At 18, suffering painful atrophy of her reproductive organs as a result of testosterone use, Julia had a hysterectomy, and at 20, she had phalloplasty.
Now aged 26, Julia has had no less than 16 surgeries to correct complications arising from phalloplasty. She has difficulty draining her bladder, resulting in a permanent urinary tract infection which places her at highly elevated risk of sepsis. She has lived with chronic pain since her early twenties. She has never experienced sexual pleasure, has never orgasmed and has permanent pain in her surgically altered genitals.
But far worse than the physical side effects has been the realisation that Julia was never a ‘truly transgender’ child. She was a gender non-conforming lesbian, who struggled to come to terms with her sexual orientation and tried to escape homophobic stigma by becoming ‘heterosexual’.
The pain and suffering that doctors put Julia through, starting with a prescription for puberty blockers, was completely unnecessary. There is no such thing as a ‘truly transgender’ child and there are no young people for whom a lifetime of iatrogenic harm, of physical and psychological attrition, is a good or desirable outcome. There is therefore no ethical way to conduct this trial.
The resources allocated to the trial should be diverted into completing the data linkage study and finding out what has happened to the 9,000 children already treated with puberty blockers and cross sex hormones by the NHS. Funds also need to be made available to support people like Julia, who the NHS has a moral responsibility to care for.”
Carrie Clark is a member of the Killarney Group and sits on Genspect’s Advisory Board.
Puberty is Every Child’s Right.
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