A psychiatrist’s views on the conversion practices bill

A psychiatrist writes of the pressure on clinicians to adopt the affirmative medical patthway, the climate of fear about challenging this, and the difficulties in discussing the issue in professional circles, whether at work or in professional bodies.

Gender identity is a contested concept, without agreement amongst clinicians or society as to what it means or how it arises.  This problem is highlighted in the Interim Cass Report. 

Despite this, there is pressure on clinicians to affirm and provide treatments effectively on demand, which is outside usual practice.  Normal clinical debate is being discouraged. However, many clinicians are concerned that an affirmation pathway causes harm.

The leadership and policy teams of medical institutions including the Royal Colleges and the BMA have largely uncritically accepted the concept of gender identity and an affirmation only approach. This institutional capture is likely out of line with the views of ordinary members – policy making at these institutions is vulnerable to hijack by vocal minorities.

I have been trying to promote discussion of the Interim Cass Report within the BMA and within the Royal College of Psychiatrists via my roles within these institutions – this is proving difficult. 

I have found that many would like discussion but are afraid of speaking up.  In March, the BMA consultant conference passed a motion to promote respectful discussion of Hilary Cass’s report. The Royal College of Psychiatrists is in my view still trying to avoid responsibility by avoiding this discussion (because this topic is so difficult everyone tends to want someone else to sort it out) but locally I have found my colleagues are increasingly concerned in 1:1 discussion.

I work in general adult psychiatry but sometimes my patients have had gender confusion alongside other issues.  15 years ago, I remember my clinical team discussing a gay male patient with a new trans identity.  We discussed alternative explanations including the impact of his other mental health conditions and possible difficulty accepting his sexuality. 

In contrast, last August, the referral of a female patient with many difficulties including gender confusion led to paralysis in the team discussion as everyone was afraid of saying the wrong thing.  Due to pronoun confusion, some of the team thought she was a male wanting to be female rather than the correct way round.  This young woman had suffered sexual abuse and had had her child removed due to her complex mental health issues so her sex was relevant.

Psychiatrists already cannot do their jobs properly in this area in the current climate and cannot rely on their institutions or their union to back them up if they face complaints.  The Conversion Practices Ban Bill risks exacerbating this.