Polly Carmichael is the clinical director of the Tavistock GIDS service and Professor Gary Butler is the clinical director for the UCLH endocrine clinic that prescribes any medication after the Tavistock clinic has completed its assessments. Both Carmichael and Butler were the key witnesses in the Tavistock versus Mrs A and Bell case which concluded that young patients may not be old enough to consent to treatment.
There are three areas where the court found it surprising that there was no evidence readily available from GIDS to back up their clinical practice. The concern was that if information wasn’t available on issues that affected treatment then how could the clinicians be convinced that the patients could safely consent?
How much did the lack of information affect the outcome and judgment? And why was the information not presented when it existed in publications by Carmichael and Butler themselves?
ONE – The court asked for evidence and opinion with regards to patients on the autistic spectrum. The court were told there was none, yet Carmichael published a study on this very matter in 2015 where she showed that around half of the patients referred to GIDS also had some autistic traits.
TWO – The court asked for evidence of positive outcomes which were not forthcoming yet, again, a key publication by GIDS which confirmed effectiveness was published in 2015. The study found that there was improved global psychosocial functioning which confirms the effectiveness of puberty suppression for gender dysphoric adolescents.
THREE – The court asked for opinion as to why the numbers of birth-assigned females was increasing, and were given no explanation. Yet Carmicahel published her opinion on this in 2018.
This article will examine each of these key elements in turn:
One – Autistic spectrum
The determination said:
34. The court asked for statistics on the number or proportion of young people referred by GIDS for PBs who had a diagnosis of ASD. Ms Morris said that such data was not available, although it would have been recorded on individual patient records. We therefore do not know the proportion of those who were found by GIDS to be Gillick competent who had ASD, or indeed a mental health diagnosis.
35. Again, we have found this lack of data analysis – and the apparent lack of investigation of this issue – surprising.
Publication:
Brief Report: Autistic Features in Children and Adolescents with Gender Dysphoria Skagerberg, Elin ; Di Ceglie, Domenico ; Carmichael, Polly. New York: Springer US. Journal of autism and developmental disorders, 2015-08, Vol.45 (8), p.2628-2632
The aim of the current study was to look at Social Responsiveness Scores in children and adolescents with GD attending the Gender Identity Development Service (GIDS)
The ‘professional correspondence’ section of the patient files including, for example, referral letters and assessment reports were systematically read and information concerning an ASD query or a diagnosis of ASD by a professional was recorded.
The current study explored the presence of autistic features, as measured by the SRS, in young people with gender dysphoria attending the GIDS in London as well as the number of young people with gender dysphoria with an ASD diagnosis or an ASD query.
In summary, the findings from the present study show that approximately half of the young people with gender dysphoria attending the GIDS show autistic features.
Two – Evidence supporting their use
The determination said:
71. However, the lack of a firm evidence base for their use is evident from the very limited published material as to the effectiveness of the treatment, however it is measured.
Publication:
Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria Rosalia Costa, MD,*† Michael Dunsford, PsyD,* Elin Skagerberg, PhD,* Victoria Holt, MRCPsych,* Polly Carmichael, PhD,*1 and Marco Colizzi, MD†‡1 *Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, Tavistock Centre, London, UK
This longitudinal study was conducted at the Gender Identity Development Service (GIDS) in London.
The aim of this study was to assess GD adolescents’ psychosocial functioning in follow-up evaluations. Based on previous literature [2,9] and our clinical experience, we hypothesized a poor general functioning at baseline, an improvement after psychological support, and a further improvement after the beginning of the GnRHa.
Two hundred one GD adolescents were included in this study.
Psychological support and puberty suppression were both associated with an improved global psychosocial functioning in GD adolescents.
In conclusion, this study confirms the effectiveness of puberty suppression for GD adolescents.
Three – Birth-assigned gender
The determination said:
32. Further, in 2011 the gender split was roughly 50/50 between natal girls and boys. However, in 2019 the split had changed so that 76 per cent of referrals were natal females. That change in the proportion of natal girls to boys is reflected in the statistics from the Netherlands (Brik et al “Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria” 2018). The defendant did not put forward any clinical explanation as to why there had been this significant change in the patient group over a relatively short time.
We help teenagers who have nowhere else to turn
Publication:
Sex Ratio in Children and Adolescents Referred to the Gender Identity Development Service in the UK (2009–2016) de Graaf, Nastasja M ; Giovanardi, Guido ; Zitz, Claudia ; Carmichael, Polly New York: Springer US. Archives of sexual behavior, 2018-07-01, Vol.47 (5), p.1301-1304
The current study aimed to examine the sex ratio in the number of children and adolescents referred to GIDS over the past 7 years and to investigate whether any gender differences can be found in terms of psychological functioning and age at referral.
The steep increase in birth-assigned females seeking help from gender services across the age range highlights an emerging phenomenon. It is important to follow birth-assigned females’ trajectories, to better understand the changing clinical presentations in gender-diverse children and adolescents and to monitor the influence of social and cultural factors that impact on their psychological well-being.
Between January 1, 2009, and December 31, 2016, a total of 4506 young people, aged between 1 and 18 years, were referred to GIDS.
In the current context, with increasingly more birth-assigned females referred to gender services presenting with psychopathology, could we argue that influences of socially constructed views of “femininity” and “masculinity” and the way these are being displayed on social media may have an impact on the increase of birth-assigned female referrals, especially for those who do not feel they fit this stereotype?
With regard to psychological functioning, a significantly greater percentage of adolescents had Internalizing problems in the clinical range compared to children, χ2 (1, N = 1696) = 12.02, p < .001. For this comparison, however, there is a sex difference: the difference between children and adolescents is significant only for birth-assigned females, χ 2 (1, N = 1127) = 11.17, p < .001, and not for birth-assigned males
Although there was no conclusion, the fact was that the difference in birth-assigned gender had been counted, examined and reported upon.
Conclusion
If there is to be a successful appeal, the clinicians who lead the care for gender dysphoric patients on the NHS must prepare their case properly and be prepared to give the information that may reassure the courts.
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