‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties#
Clinical Child Psychology and Psychiatry
The authors are two psychologists at the Gender Identity Development Service (GIDS) in the UK. The authors present a case review of 12 gender dysphoric young people who met the following criteria:
- began reporting gender dysphoria (GD) at age 12 or older,
- actively requested medical intervention,
- ceased wishing to pursue medical interventions during the psychosocial assessment.
The average length of the psychosocial assessment was ten months and seven sessions. The average age was 14. Seven of the 12 had recent suicidal ideation and self-harm. Two cases had a recent suicide attempt. Seven had been diagnosed with Autistic Spectrum Condition (ASC), and the authors believe that others in this cohort would likely obtain an ASC diagnosis. Three were male, and nine were female.
The psychologists present in-depth reviews of two of the cases. Teasing and homophobic bullying were typical prior to the onset of GD. In both reviews, the adolescents were anxious about pubertal changes and were socially awkward with peers. In the case of "Louise" a girl who identified as a boy:
"...[she] spoke in very a matter of fact way about her understanding of hormonal interventions and was insistent that this was necessary for her to live in her body. She had already transitioned socially."
The psychologists continued to explore the background to her puberty related distress:
"...it was felt it may be helpful to offer Louise the contraceptive pill to manage periods for the time being (which she took up), as well as identifying ways to help her keep thinking about her experiences of her body and the process of growing up."
With her anxieties around puberty alleviated, Louise no longer wished to pursue opposite-sex imitation. But Louise worried that this would mean discontinuing session at GIDS and delegitimising her trans identity:
"In the following GIDS appointment, Louise’s mother informed clinicians that she was no longer interested in pursuing the GIDS medical pathway. Louise anxiously voiced her worry that communicating her decision could mean an abrupt termination of GIDS support. This was understood in the context of having formed a meaningful therapeutic relationship and possibly her worry that a sudden ending could also challenge the legitimacy of her status identifying as a trans man, where she found herself, in her words, ‘at home’ for the first time."
However, after 9 months of further sessions, Louise no longer identified as a boy and was able to reconcile her previous beliefs:
"...Louise took the lead to set the agenda for the meeting and shared that she had now started using her birth name again. She shared how she was still in the process of letting her wider family and social circle know that she would like them to start using feminine (she/her) pronouns again. She reflected on how throughout the assessment she felt she had been exploring her own sense of gender fluidity which had coincided with significant mental health difficulties. This had led her to feel that her (female) self had carried these painful experiences which needed to be got rid of; she reflected, ‘I felt that I had always wanted to put that poor girl in a box and put the lid on top’."
While not without its flaws, the extended psychosocial assessment approach at GIDS contrasts markedly with the approach reccommended by the Waikato Guidelines. According to the Waikato Guidelines, the role of the psychotherapist is to affirm the child's belief that they are the opposite sex and "assist" (ie sign-off) "in the informed consent process...while being clear that having mental health issues is not a barrier to accessing [puberty blockers]". There is no reccommendation to explore the reasons behind the child's distress. The Guidelines promote the theory that any co-morbid mental health issues are the result of "minority stress" and societal transphobia. This theory is out of step with Kozlowska et al (2021) which attributes mental health issues of GD adolescents to adverse childhood experiences, trauma and loss.
Clinicians following the Waikato Guidelines are encouraged to "be aware of the positive impact of puberty blockers...on future well-being" and "be mindful of the need to refer promptly".
Clinicians in New Zealand would likely have presribed Louise puberty blockers almost immediately. Without experiencing normal puberty the blockers could have increased the likelihood that Louise's feelings of distress would persist (Stein 2012).
Any suicidal behaviour would confirm the supposed neccesity of an immediate intervention, rather than indicating a lack of capacity to make long-term decisions about the potential impact of blockers.
If Louise had shown improvement, clinicians, following the Waikato Guidelines' practice, might attribute this to the treatment rather than to the placebo effect or to the medical professional's endorsement of an adolescent's fragile identity.
Louise's life as a permanent patient of the opposite-sex imitation indsutry would have been very different.
The study took place in a context where GIDS allowed children, rather than medical experts, to be in 'the drivers seat' in medical decision-making. The adolescents themselves decided if they would take puberty blockers and cross-sex hormones.