Margaret McCartney: Medicine must do better on gender
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1312 (Published 26 March 2018) Cite this as: BMJ 2018;360:k1312
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Dr Margaret McCartney in her “No holds barred” comment section “Doctors must do better on gender” 31 March-7 April rather decries what doctors have had to do when confronted with pleas for help with an infant with a disorder of sex development (intersex) or a child or adolescent presenting as transgender. With the former, we have learned over time that early interventions such as surgery may cause more harm than good and the rights of the individual to make a choice are being recognised, but the rearing of a child with physical sexual ambiguity is still regarded as being problematical by society.
On the other hand, as Dr McCartney recognises, society is becoming more accepting of gender fluidity, gender change and even non-defined gender states (non-binary). The rise in numbers of young people wishing to change gender does not mean all are going to, and even if self-declaration of gender in a Gender Identity Bill is permitted, one would hope that social as well as physical gender variations will be better tolerated. The prevalence of true child and adolescent transgenderism in the under 19s in the UK based on those physically transitioning in our national Gender Identity Development Service is currently around 1 in 18,000. The preponderance of birth-registered females seeking to transition to male is still unexplained. Although referral numbers have increased enormously in recent years, it appears that there may be a levelling out now and fewer seem to be requesting hormonal interventions. Certainly, very few of those presenting under 10 eventually end up on hormone treatment, but around 40% of those presenting in mid-adolescence do (1). Requests for hormonal interventions will only be supported after extensive psychosocial assessment and a paediatric review (1). We doctors are criticised on one hand for being too stringent in our acceptance criteria, yet on the other are thanked by the majority of young people and their families in how we approach this important decision making process – experienced from my direct patient contact. Irreversibility of physical interventions and loss of fertility unless conserved is stressed on multiple occasions. Despite this, over 90% of our young people will then continue on to adult services (1) and early long-term follow-up of this relatively small number suggests most remain fulfilled in their transitioned gender. They do not regard our input as ‘shameful’. We are continuing to investigate outcomes, supported, not stymied by ethics committees. Doctors do need to be guided by society’s values on gender and contribute to the debate. I would hope that as tolerance of gender variation increases, that hormonal or surgical intervention is not regarded as the absolute requirement to be transgender in one form or another, and that those opting for physical treatment feel supported not harmed.
1. Butler G, De Graaf N, Wren B, et al. Arch Dis Child Epub ahead of print: 27.04.2018. doi:10.1136/archdischild-2018-314992
Competing interests: No competing interests
We read with disappointment Dr Margaret McCartney’s ill-researched piece on transgender health. While we agree with Dr McCartney’s sentiment - that doctors must do better - we wonder why the BMJ did not commission an expert in this field who is also a trans doctor to write about this area - for example, Dr Kate Nambiar.
There are a number of basic inaccuracies that must be corrected. She writes that ‘Many children will grow up without reassignment surgery’. In fact, all children grow up without reassignment surgery – current NHS policy is that patients must be 18 to receive gender affirming surgery. Access to hormones depends on consistent, insistent, and persistent gender dysphoria, and as with any other medical treatment, any person who is Gillick competent can consent to their own treatment.
Furthermore, the claim that the Office for National Statistics (ONS) may make declaration of sex voluntary is untrue. The ONS are currently consulting on how to improve the precision of the census by the inclusion of an additional question – to imply this is because the census ‘offends transgender people’ is baseless, appealing to a reactionary fear of ‘political correctness gone mad’. Further, amendments to the Gender Recognition Act will remove unnecessary administration from the process of getting a new birth certificate. It has nothing to do with the right to access gendered spaces1. To make a false statutory declaration of gender identity is – and will remain – criminal.
Dr McCartney’s concern about research into de-transition seem to be a reference to the case of James Caspian - a hypno-psychotherapist who was denied ethical approval to research the experiences of detransitioned people as part of a master’s degree at Bath Spa University. Certainly, more research is needed in relation to de-transition (and re-transition) – but by experienced researchers, not students starting out in research – and one highly publicised case says little about the UK research environment in general.
The process of accessing medical transition is arduous. Partly this is due to lack of resources – waiting lists are two years long at most adult clinics. However, the medical assessment is overwhelmingly focused on preventing regret via barriers to those who wish to transition. We also know that outcomes of medical transition are overwhelmingly positive – for example, a study assessing every case of reassignment surgery performed in Sweden between 1960 and 2010 found the percentage of patients experiencing any regret totalled 2.2%2 . We question whether a focus on preventing ‘regret’ has withheld or delayed a lifesaving treatment from many people. The point about rape crisis centres is also misleading. As an example, rape crisis centres in Scotland have been trans inclusive for several years without problems. Women’s organisations have issued a joint statement of support for Gender Recognition Act reform (see below).
There’s plenty to discuss when it comes to trans healthcare. How do we find more efficient and resource-effective ways to deliver medical gender transition in the current NHS climate? What can doctors do to reduce the risk of suicide in trans people? What skills and competencies do GPs need to treat and support the 1% of their practice lists who are gender variant? Instead of dressing up prejudice as ‘concern’, let’s listen to trans voices and centre service delivery on the needs of the community.
Yours sincerely,
Dr Harriet Feldman MD, PhD
Dr Ben Vincent, PhD
Dr Catlin Gunn DPhil
1. https://www.engender.org.uk/content/publications/Scottish-Womens-Sector-...
2. Dhejne, C., Öberg, K., Arver, S. et al. Arch Sex Behav (2014) 43: 1535. https://doi.org/10.1007/s10508-014-0300-8
Competing interests: No competing interests
I was reading my assigned epidemiology textbook recently (Webb, Bain & Page, Essential Epidemiology 3d edition, 2017, Cambridge University Press, so quite a mainstream book) and came upon this statement on page 128:
"In this study it is unlikely that there is a problem with the time-directionality of the relationships with gender (AS THIS DOES NOT CHANGE OVER TIME)...." Emphasis mine.
My first thought was "how did this manage to sneak past the censors considering this was published as late as December 2017"? But my second thought "perhaps there are still a few academics and leaders out there who hold on to common sense and are not prepared to accept the new reality that one can change one's gender". It seems that most in prominent positions have either jumped on the bus (have embraced the concept), or will run alongside the bus (go along with it whilst not agreeing themselves, but not speak against it for fear of losing jobs, research funding, professional standing or registration), but few are prepared to stand in front of the bus and say that gender is one of the immutable things in life and that performing surgery does not turn you into a person of the opposite sex/gender but simply makes you look a bit more like one. And perhaps this is why we won't often hear the stories of those who choose to detransition - it is not what people want to hear in the current climate.
Perhaps medicine should get back to first principles - first do no harm! And then work toward helping people accept the reality of their situation rather than creating a new, alternate "reality". For in the same way that one wouldn't assist an anorexic person to lose weight, why should one assist someone to become something that they, in reality, cannot?
Competing interests: No competing interests
I appreciate Margaret McCartney's article. In addition to missing data regarding self-perception of satisfaction there is the problem that people who have a lot invested in a treatment will be disinclined to see it as unsuccessful. This is true of patients committed to alternative therapies, who have spent lots of money. Double blinding of trials can obviously exclude this bias. But this is not possible for transgender surgery, where the personal commitment is inevitably very high for multiple reasons - people who believe that their current experience of dysphoria is best met by radical surgery, the cultural context, the prolonged counselling and need to demonstrate a commitment to transgender lifestyle for example.
There is an additional myth that sexuality is fluid, when in nature, across species it is a biological fact at multiple observable levels throughout evolutionary history. If this is the case, which seems irrefutable biologically, then Gender dysphoria is a cultural and social construct. As such it is a personal choice and commitment which is not driven by biology, but by lifestyle preference. This again would distort and survey of self-satisfaction with the outcomes.
Competing interests: No competing interests
Or maybe we should ditch the concept of gender completely. It's an amalgam of spectra of personal preferences and psychological traits, with a line in the middle arbitrarily dividing each one into masculine and feminine. We comment on children doing things that don't tally with the shape of their genitals.
Girls can be called tomboys (considered a compliment), while it is implied that such boys will be gay when they become adult (which is intended to be an insult). Children should be allowed to explore and have fun together without assumptions being made about their future sexuality.
Many adults cluster around the centre of some of these traits whilst being at the end of others. Thus if they are used loosely, the terms non-binary and transgender could be used to describe many people.
Now we are developing much better understanding of gender diversity, we need to find other ways of describing these traits without automatically associating them with a particular sex or sexuality.
Competing interests: No competing interests
An excellent and well timed article.
I am very concerned about the increasing tendency to label the common crossover in interests between boys and girls as transgender tendencies. Children are exposed to far more societal stereotyping in terms of what clothes they should wear and toys they should play with than adults are and it isn't surprising many don't fit into the overly narrow box they are allotted.
Some studies on children showed differences in preferences and personalities between boys and girls, but others have shown a huge overlap with females being less than one standard deviation apart from males in all kinds of measures and less than a tenth of a standard deviation apart on many. There is also concern that researcher bias affected many of the studies which haven't been replicated.
I think that protecting transgender people from abuse and accepting them in society is important, but that the desires of transgender people have to be balanced against the desires of other groups who may want a different solution to the problem e.g a young male might want to join the girl guides because he identifies as a girl but that might mean some Muslim or Hindu girls can't then attend because their parents don't want them socialising with people with penises and it might cause problems with tent sharing on residential trips, . Also women's refuges might not want men identifying as women (many of whom still have penises) in the refuges especially if they look more male than female. Some men might also just pretend to identify as women to have access to vulnerable women.
I also think the physiological differences between men and women have to be given more consideration when transwomen are competing in sport. The upper permitted level of testosterone in women's sport of 10nmol/L is also ridiculously high, especially considering few female athletes have PCOS.
I also agree with T Gillam that a baby's sex is observed at birth not assigned.
Competing interests: No competing interests
Thank you for this balanced view. The lack of research into detransition is worrying and means we as a profession risk failing people with gender identity issues. The whole area, even within the medical profession, is beset by anti-scientific thinking and prejudice. Even the Royal College of Psychiatrists uses inaccurate terminology like ‘sex assigned at birth’ (last I checked, sex was observed, not arbitrarily assigned). We need to be more careful.
Competing interests: No competing interests
Re: Margaret McCartney: Medicine must do better on gender
As ever Margaret McCartney uses her space as a generalist commentator to good effect, both speaking for many of us and raising the level of debate. Calm discussion is indeed needed to help us through this time. I will consider why debate amongst doctors is so limited, summarise my personal views and argue why as GPs we need to be able to engage actively with our patients about pros and cons of different pathways.
So much is packed into Margaret’s piece. Rightly so. Dealing optimally with rapid societal changes requires of us an analysis of all types of evidence, as well as hypothetical scenarios to develop a better understanding of how the biological, psychological and social influence each other. However I also appreciate that to avoid whole sale pro versus anti trans positions being taken each issue needs to be considered on its merits.
Even if we try to consider evidence in the round, when emotions run high, any perspective may generate offence. Fear of being criticised, shamed or even having employment threatened is a reason for keeping quiet. For those with a high profile, fear of being no-platformed is very real. Threats of physical or sexual violence are not uncommon on-line. Real violence to the trans community is well documented; and we have recently seen violence to a woman wanting to discuss potential problems resulting from proposed legislation about self identification. Being insulted online if you are openly trans-gender is unfortunately common place; being called transphobic or a TERF (trans exclusionary radical feminist) is to be expected if you suggest for example that a trans-woman is still biologically male.
As doctors wanting to demonstrate we are up to date an additional worry includes appearing ignorant. Keeping abreast with nomenclature in relation to gender identities and sexual orientation is a start, but we might feel we need to understand the neuroscience of sex and gender, as well as ‘queer theory’, to fully equipped to join the debate. The latter reverses our prior medical understanding, such that sex is not determined biologically, but instead gender is determined by an ‘essential’ internal quality and defines whether we are man or woman or gender fluid etc, and biological sex can be changed to fit gender.
My personal bias is that genetically driven biological sex (including intersex) is essentially fixed (even with surgery and hormones), that the gender we identify as is not always in line with our biology and can change (because our brain function is influenced by upbringing and societal culture); and that for some gender reassignment is an understandable goal in our societal context. While I see it as a courtesy to use preferred pronouns and names, individuals who formally transition or self identify as a new gender should not expect others to believe they have changed sex; and the latter should not expect to be automatically admitted to spaces designed to protect girls and women.
I worry that engaging medicine and the law in making gender transition easier, whether through reassignment surgery or self identification, is the wrong long term societal solution to the substantial problems of our highly gendered society in which men still have too many advantages and too often view pornography or use violence against women, girls and boys (as well as men and trans people). We need to consider the long term public health and population effects of laws which enshrine the right to determine how others see us, and which seem likely to further increase referrals for reassignment. I worry that a bio-medical response is increasingly expected for girls with ‘rapid onset gender dysphoria’, which could be seen as an understandable response of the brain to ongoing promotion of sexualised roles for women and new subcultures promoting gender fluidity, is potentially harmful. I worry that men transitioning to become ultra ‘feminised’ trans-women will accentuate problems for women. I worry that trans-people will get caught in a backlash. I therefore see the direction we are travelling along as wrong for girls, boys, women and men including those identifying as trans. These are my views now, and I may well be wrong. I support the human rights of trans individuals not to be discriminated against but see this as a situation where judgements are needed to balance the rights of several groups.
In my role as a GP I must focus my attention on supporting each individual, and largely leave aside my concerns about the whole population. I need to both listen to and try to understand the individual patient and provide generalist expertise to support them in decision making. While I am completely opposed to formal Conversion Therapy I have concerns about the revised Memorandum of Understanding endorsed by the NHSE and RCGP which is ambiguous about whether it is right for generalists (non experts) to discuss different ways of conceptualising gender dysphoria, the pros and cons of referral or watchful waiting, and the potential links between the full range of symptoms of mental distress and gender identity. These are all things that as GPs we might choose to engage with in a person centred encounter. To do this well, and as Margaret McCartneys says “do better on gender”, we need organisational support, up to date evidence and to use the skills we have developed in practising whole person care.
Competing interests: I supported my late sister through what I see as a successful transition. She said she learnt something of what it was like to be a woman, and did overcome much of her gender dysphoria. My wife is an online supporter of radical feminist campaigns for the right to talk about a womanhood that does not include trans-women, and the potential disadvantages of self-identification legislation. These are my personal opinions and not necessarily the views of the Faculty of Medicine and Dentistry or the University of Plymouth.