There are a number of clear reasons why clinicians have grave concerns about the Conversion Practices bill.
Iatrogenic harm is harm done to patients by physicians.
If clinicians are fearful of being accused of conversion therapy, this will prevent them undertaking the necessary therapeutic work that can allow patients to develop an understanding of the reasons they want to identify out of their natal sex, and the chance to resolve these difficulties, thereby avoiding unnecessary medical interventions that can leave them infertile, and lifelong medical patients.
The Cass review is yet to publish its final report. The interim report is the most up to date review of the evidence and describes the deficiencies of the current gender service (GIDS), criticising the dominant ‘affirmation’ approach and calling for a more holistic approach. This means clinicians need to explore the reasons why someone has become distressed, dissociated or disgusted by their own bodies.
Cass highlights the risk of diagnostic overshadowing. This is key to the difficulties clinicians will encounter when supporting someone with gender distress, that could lead to them being accused of conversion therapy.
Gender dysphoria is usually co-occurring with mental illness, a history of abuse and attachment disorder, neurodevelopmental conditions like autism, and/or internalised homophobia.
When we see patients with gender distress – if we are not able to help them make psychological links (for example in a girl with autism linking feeling awkward, not fitting in and being bullied, and how this may link to her identification as non-binary), if we are not able to think with patients about cause and effect (for example a girl who has been sexually assaulted wanting to be male, in order to feel stronger and to avoid further assaults), if we are not able to challenge a patient’s assumptions (for example a feminine boy believing he must actually be a girl) – then we are not able to practice ethically, or actually treat patients’ mental health conditions.
There is already a climate of fear in Child and Adolescent Mental Health Services. Some CAMHS staff have a strong adherence to gender identity theory, are vocal, empowered and will criticise clinicians who try to offer a more nuanced understanding of a young person’s presentation. I have witnessed accusations of transphobia and seen clinicians feel attacked and ‘wrong’. There are always deep discussions about cases but the aggression and vilification I have witnessed are not usual practice. They do however have a chilling effect and prevent holistic discussions of cases within the multi-disciplinary team. It is the patients who ultimately will receive poorer care.
When doctors try and organise broader professional discussions, these efforts are shut down. Last year some psychiatrists began organising a conference for London higher trainees – speakers included Hilary Cass, staff from the Tavistock GIDS, a user group representing trans voices – yet because gender critical perspectives were also included, Health Education England and Great Ormond St Hospital medical education were lobbied heavily by trans activist individuals and organisations, and this conference was prevented from happening. We were told it would be reorganised, but over a year later and there is no sign.
We are struggling to have open discussions in professional forums – I have heard many examples of clinicians being afraid to voice their concerns because of the loud and domineering voices of activist doctors. One trainee spoke to me about her decision to not specialise in child and adolescent psychiatry, because of this issue. Others shy away from entering discussions as they fear the repercussions.
This year clinicians, with high levels of expertise, delivered training to NHS Trusts describing their holistic and gender exploratory approach which is aligned with Cass’s recommendations.
Following the training, the slides were leaked, and the training reported on social media accusing the Trust of ‘promoting conversion therapy lobbyists’, and naming and defaming the clinicians who were presenting. These slurs had a powerful impact on those clinicians, but more importantly their patients or potential patients who will likely see these slurs online, lose trust – the most important aspect of the therapeutic relationship.
Resolution of gender distress – which most would accept is a positive outcome for young people who are suffering – may come about if they receive a genuinely exploratory approach.
However, in treatment adolescents may rage against attempts to help them think about their distress. This reaction is par for the course and is experienced in many severe adolescent presentations. If their rage can lead them to accuse their therapist of breaking the law, some of them will do so.
Why would clinicians enter this field of work and put themselves at such a risk? The impact of this bill needs to be carefully considered if we are to prevent iatrogenic harm.