I am very concerned with Welsh Government’s proposed affirmation-only model for gender dysphoria. Based on my clinical experience this seems to be a potentially dangerous approach. There is a presumption that all patients presenting with gender dysphoria are the same and that one solution fits all. This is not the reality.
Merely affirming ones’ experience of transgender identity is clinically unhelpful for many people as there are a considerable number for whom the presentation of feeling that they are in the wrong body may not be a fixed long-term one, indeed, it may be one which they later regret.
Further, rather than being a single condition there are many conditions; only some of which may be suitable for permanent fixed physical interventions such as hormones or surgery. In the service I ran, we saw patients with all sorts of gender presentations and, significantly, 26% of the adults I worked with were people who had previously had physical gender interventions such as hormones or surgery but who had later come to regret this decision; people who would now be considered detransitioners.
This 26% were not present in any follow-up studies: this is one area of medicine where no follow-up was undertaken. They were, and are, a silent population who had been given medical and social interventions which they had asked for at the time; services believed that giving them what they asked for was the correct intervention.
Out of a sense of shame, these patients often did not go back to their GP, psychiatrist or gender clinics, but they universally stated that what they wished they had received at the time was a more exploratory, inquisitive, therapeutic model to try and work out what was behind their newfound gender presentation rather than immediate ‘affirmation’. They frequently cited that their families, colleagues and clinicians simply went along with their self-diagnosis, rather than asking them what they meant by their wish to change gender – a wish which subsequently did not persist, and one which they later regretted.
There are also many other conditions which may present as a gender dysphoria but which may be due to other factors such as trauma, autism or conditions relating to sexuality. There is also a blurring of important distinctions between those who wish to appear as the opposite sex but do not wish to change their body – conditions such as transvestism and autogynephilic men who are excited by the acquisition of female genitalia.
The affirmation model alone is a short-sighted one. I understand how people who wish to do well by minority groups may feel that this is a supportive approach. However, those of us with extensive clinical experience in this field are very much aware that this ‘one solution fits all’ response is potentially dangerous and damaging.
This is especially so in the case of children for whom questioning most aspects of life – including culture, religion and their own identity – is a normal part of growing up. For some there may be internalised (or external) homophobia; for many children it is a manifestation of subversively and creatively exploring aspects of their identity.
Unfortunately, rather than allowing these children to creatively play with aspects of their identity, they are shunted into discrete categories and then put on a medical pathway which may be totally unnecessary and lead to further complications as an adult. Once children are given chemical castrating agents similar to those we gave to homosexuals in the Second World War (which we now know is wrong) and then given cross sex hormones the changes can be irreversible. The famous case of Keira Bell verses the Tavistock last year brought to the fore just how damaging such a trajectory can be for young people.
It is my hope that the Welsh Government will review its proposed affirmation only model for Gender Dysphoria so as to prevent what many of us predict will be a tsunami of young adults in the future who will come to regret the path they were encouraged, even pressurised, to take, and for whom there will be lifelong implications for their health, happiness and well-being.
