Safeguarding LGBT+ adolescents
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l245 (Published 31 January 2019) Cite this as: BMJ 2019;364:l245Linked Opinion
NHS staff are in a perfect position to be advocates for LGBT+ people when they most need it
All rapid responses
The purpose of this article is to highlight the complex psychosocial factors affecting LGBT+ young people and propose ways in which the non-specialist healthcare professional can help to safeguard them. This response goes into detail about the treatment of transgender/gender non-conforming young people despite this not being discussed at all within this article. Our article is specifically aimed at healthcare professionals who care for young people outside of specialist gender identity development services. The role of the GP or the paediatrician is not to make a diagnosis or initiate treatment for transgender/gender non-conforming young people but rather to safeguard the young person from the risks outlined in our article and ensure appropriate steps are taken. Our recommendation is in line with international best practice: that transgender/gender non-conforming young people are referred to gender identity development services where they can receive appropriate support from a highly specialist multi-disciplinary team.
With regards to the terminology used, our definitions of ‘cisgender’ and ‘transgender’ are in line with those used by the World Health Organization and the World Professional Association for Transgender Health. We do not conflate intersex people and transgender people - indeed, we specifically highlighted them as a separate group. We whole-heartedly agree with the point raised on the harmfulness of surgery on babies and children with ambiguous genitalia, who cannot give consent. However, we have not discussed this here due to the limited scope of our article.
We urge readers to focus on the purpose of our article – to equip generalists with the knowledge to be able to safeguard a vulnerable group of young people. It is the responsibility of all staff caring for young people to be aware of these risks and act accordingly. More information on the care of trans and gender non-conforming young people is available from the gender identity development service (www.gids.nhs.uk).
Competing interests: No competing interests
We read the Practice Pointer ‘Safeguarding LGBT+ adolescents’(1) and the Rapid Responses with interest. We are grateful to the authors of this article for raising a number of important issues. The Memorandum of Understanding on Conversion Therapy in the UK(2) is a multidisciplinary and unequivocal rejection of this damaging practice. GLADD (The Association of LGBT Doctors and Dentists) is a signatory of this landmark document, and we welcome the UK Government’s commitment to prohibiting this therapy(3).
Under the Public Sector Equality Duty(4), all UK health organisations must pay due care to the needs of their patients with protected characteristics and promote equality. In order to help provide consistency, NHS England produced the Sexual Orientation Monitoring Information Standard(5). Very few parts of the NHS have adopted this or are routinely asking or recording sexual orientation. Yet this would lead to a better understanding of health inequalities, improved targeting of preventative healthcare measures, and ensure equitable access to services. Until care providers understand the communities they serve, the well-documented inequalities experienced by LGBT+ patients are likely to persist.
1. Salkind J, Bevan R, Drage G, Samuels D, Hann G. Safeguarding LGBT+ adolescents. BMJ 2019;364:l245 https://www.bmj.com/content/364/bmj.l245
2. Memorandum of understanding on conversion therapy in the UK, Version 2. 2017. https://www.psychotherapy.org.uk/wp-content/uploads/2017/10/UKCP-Memoran... (accessed 18-Feb-2019)
3. UK Government Equalities Office. LGBT Action Plan 2018. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... (accessed 18-Feb-2019)
4. Equality Act 2010. https://www.legislation.gov.uk/ukpga/2010/15/contents (accessed 18-Feb-2019)
5. NHS England. Sexual Orientation Monitoring Information Standard. 2017 https://www.england.nhs.uk/about/equality/equality-hub/sexual-orientatio... (accessed 18-Feb-2019)
Competing interests: No competing interests
The article Safeguarding LGBT+ adolescents (1) was interesting but the authors did not cover the range of current thinking and used confusing, inaccurate ideological concepts such as "assigned" sex (2,3). Determined at conception, objectively observed and recorded at birth, sex characteristics at birth are almost always aligned with chromosomal sex. It is crucial that doctors are clear about embryology as prenatal sex determination is the basis for sex-selective abortion (4). When intersex features exist, these indicate a medical condition; factual attributes are not assigned. Intersex should not be confused with transgenderism; it is now accepted that medical intervention to ‘correct’ genitals is associated with poor outcomes and should have clear clinical indications (5).
We agree about not conflating sexual orientation and gender identity when making compassionate and therapeutic responses especially for those vulnerable to, or actually experiencing, abuse. Within families and communities upholding strict religious or ‘honour’ tenets, variations may be considered serious affronts. Individuals may experience extreme psychological pressures and physical violence tantamount to torture in an effort to change them. This undoubtedly requires safeguarding. It is long-accepted that conversion therapy for homosexuality is ineffective, damaging and unethical. The Royal College of Psychiatrists has explicitly supported a ban (7). As working with people with gender dysphoria requires a different model of understanding, it remains legitimate to listen, assess, explore, wait, watch development, offer skilled support, deal with co-morbidities and prior traumas, and consider use of a variety of models of care. While respecting individuals’ right to a different viewpoint, it is neither mandatory to affirm their beliefs nor automatic that transition is the goal, particularly when dealing with children, adolescents and young adults. These risk closing the ‘open future’, as well as life-long physical problems including lack of sexual function, infertility and medical dependency. With 85% desistance amongst referred transgender children (8) and increasing awareness of detransitioning (9, 10), unquestioning ‘affirmation’ as a pathway that leads gender dysphoric patients to irreversible interventions cannot be considered sole or best practice.
More good-quality research trials are required to provide reliable evidence of clinical and cost-effectiveness of a range of approaches, including patient selection. These will surely include exploration of underlying unhappiness with the goal of achieving body/mind reintegration. In contrast to previous medical scandals that pathologised homosexuality, something different may be happening here. In effect, transitioning children who would otherwise have grown up lesbian, gay or bisexual may introduce another form of conversion (6). A well intentioned but permanent medical pathway for all is unlikely to achieve the best long-term outcomes. Confirming disgust in natal sex or external sexual organs, especially for those with prior childhood trauma, risks medical collusion with, or reenacting of, abuse.
References
1. Salkind J, Bevan R, Drage G, Samuels D, Hann G. Safeguarding LGBT+ adolescents. BMJ 2019;364:l245 https://www.bmj.com/content/364/bmj.l245 (last accessed 5 February 2019)
2. Byng R, Bewley S, Clifford D, McCartney M. Trans health needs more and better services: increasing capacity, expertise, and integration https://www.bmj.com/content/362/bmj.k3371/rr-0 (last accessed 5 February 2019)
3. Byng R, Bewley S, Clifford D, McCartney M. Gender questioning children deserve better science. Lancet 2018; 8;392:2435
4. Neogi SB, Zodpey S, Negandhi P, Gupta R. Use of Sex Selection Techniques for Social Reasons: A Menace. Indian Pediatr;54(2):99-101
5. Cools M, Nordenstrom A et al. Caring for individuals with a difference of sex development (DSD): a Consensus Statement. Nature Reviews Endocrinology 14, 415-429 (2018)
6. The Royal College of Psychiatrists Statement on Sexual Orientation PS02/2014 April 2014
7. Ristori J, Steensma TD. Gender Dysphoria in Childhood. Int Rev Psychiatry . (2016) 28 (1): 13-20
8. Butler G, De Graaf N, Wren B, Carmichael P. Assessment and support of children and adolescents with gender dysphoria. Arch Dis Child 2018 https://adc.bmj.com/content/early/2018/04/26/archdischild-2018-314992 (last accessed 5 February 2019)
9. Mills L. A letter to young trans people. https://www.transgendertrend.com/letter-to-young-trans-people/ (last accessed 5 February 2019)
10. Turban JL, Keuroghlian AS.Dynamic Gender Presentations: Understanding Transition and "De-Transition" Among Transgender Youth. J Am Acad Child Adolesc Psychiatry. 2018;57(7):451-453.
Competing interests: No competing interests
Firstly I wanted to congratulate the authors for their article – it has the hallmarks of a fantastic practice pointer: accessibility and a clear message. We are all seeing more patients from across the gender[1] and sexuality spectra[2], yet are unprepared from our undergraduate or postgraduate medical education on how to deal with this.
There is a very good article from Dudar et al[3], where there is quantitative data suggesting the (positive) impact that including LGBT issues in OSCEs or MCQ questions has on medical students. Over in the UK, I am aware of a LGBT steering group within the BMA that has recently been set up, to discuss such issues at a more national level (contact the BMA’s Equality, Inclusion and Culture Advisor to join).
Until we can be sure that staff from across the MDT are taught about such issues, it is vital for articles like this to be written and have the wide reach that the BMJ has.
[1] Great TED videos exploring the concept of the spectrum of gender: www.ted.com/playlists/459/the_gender_spectrum
[2] Kinsey Scale: https://kinseyinstitute.org/research/publications/kinsey-scale.php
[3] Dudar K.J., Ghaderi G., Gallant J., Dickinson J., Abourbih J. & Briggs M. ‘Queering the Medical Curriculum: How to Design, Develop, Deliver and Assess Learning Outcomes Relevant to LGBT Health for Health Care Professionals’. Amee MedEdPublish. 2018: 1-8. Open access on: www.mededpublish.org/manuscripts/1128
Competing interests: No competing interests
This article highlights the very real consequences of under-serving LGBT+ patients, and suggests pragmatic approaches to better address the needs of this population. However, education about inclusion needs to start at medical school to incorporate inclusive thinking from the beginning of shaping new doctors. When reflecting on current classroom and clinical learning experiences, this is almost entirely missing in today’s medical school curriculum.
The most recent Stonewall report on the treatment of LGBT+ people in healthcare found that almost a quarter of NHS staff have witnessed negative attitude towards LGBT+ people (1). Perhaps even more worrying is that 1 in 20 have witnessed poorer care delivered to patients based on their sexuality (1).
Currently, LGBT+ education at medical school does not go beyond reducing sexuality to a risk factor for STIs; medical students are conditioned to assume HIV-related immunosuppression when reading a scenario with an MSM patient for a multiple choice question and to therefore assume any purple rash is Kaposi’s sarcoma, or pulmonary symptoms are due to PJP. Although it is important to consider the risk of certain sexual behaviours, the absence of any other training on the needs of LGBT+ patients skews attitudes and perpetuates negative stereotypes.
Medical students need to be exposed to a diverse range of LGBT+ patient experiences. Instead of MSM being synonymous with promiscuity, learning how to consider the various social and economic struggles that will affect their health would be more helpful.
UK curricula need to address the deficit and include teaching in both preclinical and clinical stages of education, as suggested in this article. This will ultimately lead to both a more diverse workplace with less discrimination, as well as better patient care, bringing us a step closer to the NHS’ goal of serving each and everyone of us.
(1) Somerville C. (2015). Unhealthy Attitudes. The treatment of LGBT people within health and social care services. Stonewall.
Competing interests: No competing interests
The importance of an appropriate understanding of the literature
In their response to the present article, Susan Bewley and colleagues point out that the Royal College of Psychiatrists has supported a ban on therapies aimed at changing sexual orientation, but that “working with people with gender dysphoria requires a different model of understanding” (1). However, it should be noted that therapies aimed at changing gender identity have also been strongly opposed by the Royal College of Psychiatrists. Indeed, despite occasional claims that attempting to change sexual orientation and gender identity are ethically very different, professional associations and guidelines have largely concluded that both are unethical. In the United Kingdom, a memorandum of understanding against conversion therapy for gender identity was signed by 13 leading healthcare groups including the British Psychological Society, Royal College of General Practitioners, NHS England, and NHS Scotland (2). In my work, which focuses on trans reparative therapy, I have recorded over 49 professional associations which oppose attempts to change or discourage trans outcomes (3).
To these statements opposing reparative therapy must be added the growing consensus over the affirmative approach for trans people. The approach has been endorsed in most guidelines drafted in the last few years and has garnered the support of the Australian and New Zealand Professional Association for Transgender Health, American Academy of Pediatrics, the Pediatric Endocrine Society Special Interest Group on Transgender Health, and The Lancet to name but a few (4,5,6). In other words, Bewley’s characterisation of the current state of science and professional knowledge is inaccurate.
Professor Bewley and colleagues' reliance on the 85% desistance metric is also mistaken. Firstly, this number has been severely challenged by the academic literature (7,8,9). As critics have highlighted, most children included never asserted a trans identity, questionable assumptions were made regarding the up to 40% of youth lost to follow-up, and follow-up wasn’t sufficiently long to adequately capture youth who repressed their identity until later in adulthood. The 85% figure is wholly unreliable.
Even if the figure of 85% was reliable, it would not be relevant to the present discussion. Bewley and colleagues' intervention concerns trans adolescents, yet the reported percentage comes from studies on youth. Another study by the Dutch team, one of the main sources of the 85% metric, has revealed that all of the children who received puberty blockers continued to identify as trans and desire medical transition in late adolescence (10). The claim that a worrisome percentage of trans youth do not grow up to be trans may be questionable with children, but it is plainly false from puberty onwards.
Although youth who later cease desiring medical transition must be considered when developing our approaches to clinical care, Professor Bewley and colleagues' use of the literature is misleading. They cite a composite case report by Jack Turban and Alex Keuroghlian as evidence of increasing awareness of de-transitioning, but do not mention that the case study showed that youth who underwent hormonal treatment and later changed their mind were grateful for the opportunity to explore their gender identity through transition even if they ultimately found their identity to be in alignment with the gender they were assigned at birth (11). This result is in line with my own work which suggests that gender exploration operates not before transition, but through it (12). The idea that youth who de-transition must regret transition is an unwarranted projection of transantagonistic attitudes on gender variant youth, some of whom have experienced or are still experiencing body dysphoria. There is nothing disgusting about having a body that has been altered by hormones.
Open futures should, all other things being equal, be promoted. Social transition and puberty blockers open futures rather than foreclose them (12). Allowing a pubescent youth to undergo puberty does much more to foreclose futures than puberty blockers do. Puberty is symmetrical: whether you take hormone replacement therapy or merely stop blockers, your body is changing in partially irreversible ways. By the time hormone replacement therapy is on the table, the values of bodily autonomy and self-actualisation more than justify access; in case this does not suffice to convince, access to transition-related interventions have been shown to significantly improve mental health (13,14).
While I appreciate Bewley and colleagues' interest in trans youth health, it is important to be familiar with the relevant literature and take care not to misrepresent it before commenting in an academic forum.
(1) Royal College of Psychiatrists. Supporting transgender and gender-diverse people. PS02/18. 2018. Position Statement. https://www.rcpsych.ac.uk/pdf/PS02_18.pdf
(2) Memorandum of Understanding on Conversion Therapy in the UK, Version 2. 2017. https://www.psychotherapy.org.uk/wp-content/uploads/2017/10/UKCP-Memoran...
(3) Florence Ashley. Resources. https://www.florenceashley.com/resources.html
(4) Telfer MM, Tollit MA, Pace CC, Pang KC. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. Version 1.1. Melbourne: The Royal Children’s Hospital; 2018. https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/au...
(5) Rafferty J. Ensuring Comprehensive Care and Support for Transgender and GenderDiverse Children and Adolescents. Pediatrics. 2018;142(4): e20182162. https://pediatrics.aappublications.org/content/142/4/e20182162
(6) Gender-affirming care needed for transgender children. The Lancet. 2018;391:2576. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)31429-6.pdf
(7) Newhook JT, Pyne J, Winters K, et al. A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. International Journal of Transgenderism. 2018;19(2):212-224. https://www.tandfonline.com/doi/abs/10.1080/15532739.2018.1456390
(8) Newhook JT, Winters K, Pyne J, et al. Teach your parents and providers well. Canadian Family Physician. 2018;64(5):332-335. http://www.cfp.ca/content/64/5/332
(9) Olson K. Prepubescent Transgender Children: What We Do and Do Not Know. J Am Acad Child Adolesc Psychiatry. 2016;55(3):155-156. http://dx.doi.org/10.1016/j.jaac.2015.11.015
(10) de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276-2283. https://www.ncbi.nlm.nih.gov/pubmed/20646177
(11) Turban JL, Keuroghlian AS. Dynamic Gender Presentations: Understanding Transition and “De-Transition” Among Transgender Youth. J Am Acad Child Adolesc Psychiatry. 2018;57(7):451-453. https://www.ncbi.nlm.nih.gov/pubmed/29960687
(12) Ashley, F. Thinking an Ethics of Gender Exploration: Against Delaying Transition for Transgender and Gender Creative Youth. Clinical Child Psychology and Psychiatry. 2019. In press. https://www.florenceashley.com/uploads/1/2/4/4/124439164/ashley_thinking...
(13) What We Know Project. What does the scholarly research say about the effect of gender transition on transgender well-being? https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/%20what-d...
(14) Bauer G, Scheim AI, Pyne J, et al. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health 2015;15:525. https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-015-1...
Competing interests: No competing interests