A justice project as well as a therapeutic project
I’m reading a 5k word piece by Bernadette Wren in the LRB last year. In the first part, at least, she comes across as highly aware of the questionable nature of and risks attached to the gender ideology. Around halfway she gets to the controversies.
I will offer only a few brief reflections on some of the issues over which GIDS has been most vociferously attacked. The first contention is that there wasn’t enough research evidence to enable GIDS to offer medical therapies to young people with confidence. This is an important challenge, but it relies on an idealised conception of medicine as offering effective and safe interventions, based on a wide range of randomised-control studies with extended evaluation. The problem with this view is that many paediatric medical interventions are not backed up by such studies, but depend on confidence in the existing, broader knowledge base (often from studies on adults) and are justified by the concern to relieve suffering.
But is trying to swap a person’s “gender” actually a medical intervention at all? Is it medical at all?
Very many mental health treatments (medical and psychological) are poorly evidenced by these standards, including those routinely offered at the Tavistock to both children and adults. But compassion demands that we provide forms of treatment that are grounded in theory and in the experience of well-trained and accredited professionals, and which correspond to the values of the patient. Put simply, many questions around treatment are not settled by science alone, because scientific knowledge is itself social knowledge. When we devise treatment plans, we inevitably work within what society considers a just response to suffering; our research is based on culturally derived ideals about what constitutes a worthwhile life; treatment decisions reflect prevalent notions of self-determination, including of the rights of minors.
But is trying to change someone’s “gender” really a treatment? Or is it something else? I think I get what she’s talking about, but I also think “gender” swapping is snake oil, and very damaging snake oil at that.
A second point of attack is that the service was in the grip of an ideology, one that has taken hold in government, academia, medicine and the law. I disagree. GIDS’s patchwork of pragmatic, values-based commitments, its agnosticism about causality and its hesitancy over the absolute normalisation of gender transition in young people, strike me as far from ideological.
Well, she knows it from the inside and I don’t, but there is for instance Keira Bell, so…
What is true – and perhaps the ideology attack is trying to get at this – is that GIDS, from its modest start, was a justice project as well as a therapeutic project. By justice, I mean it aspired to widen the circle of people whose experience of the self is listened to with respect. This meant not automatically deeming a child’s atypical gender identification problematic, and not striving to modify that identity in the direction of a more orthodox body/mind relationship. It also meant not evading the fact that trans, non-binary and queer people have been (and often still are) dismissed as knowledge holders within healthcare systems; that they are subject to ‘epistemic injustice’, since society as a whole lacks an adequate interpretative framework to understand their experiences.
Ah. Perhaps this is where the problem resides. The thing is, there are good and compelling reasons not to take “a child’s atypical gender identification” at face value, or to “affirm” it, or to amplify it with hormones or blockers or both. There are good and compelling reasons not to take a child’s experience of the self at face value. Children are children. Their brains are still developing. There’s a lot they don’t know, and a lot they don’t understand. A justice project that overlooks that or pretends it’s not true is going to make mistakes.
In the recent release of a survey that claimed that 80% of children on puberty blockers wanted to go on to transition, there was a great deal of crowing that it’s a valid way to treat pre-teen dysphoria. But, as you say, their brains are still developing. I daresay that inhibiting their brains from developing is one of the features of puberty blockers, and I can’t see how one can make a different decision than to transition due to the sunk cost fallacy. They have gone this far to ruin their sex lives, why not go all the way in the hopes that they would finally be happy?
Gender is something that few adutls understand, how are we supposed to expect that children, (and developmentally delayed adults) will understand well enough to make informed decisions?
From the article:
This is a fair point, but I think an incomplete one. Part of that “judgment” has to be a weighing of the risks of treatment as well as the risk of non-treatment.
In the case of “talk therapy” (which I seem to recall reading doesn’t really have great scientific support for achieving demonstrable outcomes, with the possible exception of cognitive behavioral therapy), the downside is that some time and money are spent on ineffective therapy sessions. So we really can take the attitude of “I dunno, try therapy, maybe it’ll help.”
Pharmaceutical mental health treatments can have more serious side effects, but are typically resolvable by discontinuing the medication.
I don’t think the same can be said of puberty blockers, much less cross-sex hormones and surgical interventions. At least, the evidence is minimal or mixed at best, and there are strong common sense reasons to suspect that, e.g., going through puberty at 20, is going to have some downsides. If the state of medical knowledge is “we just don’t know,” it’s not at all clear to me that the answer should be “and therefore we give this treatment.”
In other words, holding these people who make extraordinary claims which rely on subjective certainty to the same standards as everyone else who makes extraordinary claims which rely on subjective certainty isn’t fair. Our normal skepticism is an inadequate interpretive framework because it won’t lead to a properly submissive attitude towards knowledge holders who need our agreement before we can give them the help they need.
Society also lacks an adequate interpretive framework to understand the experience of people who have been abducted by aliens.
Screechy,
I’m not quite sure what you mean by this. Are you perhaps under the impression that taking puberty blockers pushes the body’s puberty clock further and further back, with the result that puberty will resume when the blockers are discontinued? If so, I’m not sure this is the case. My understanding – which could easily be wrong – is that the pubertal duration isn’t pushed back, it is used up. I’d love to hear further on that point from e.g. fondofbeetles.
Holms,
I was just charitably assuming, for purposes of discussion only, the “best case” desistor scenario, that “normal” puberty would just begin whenever the blockers are stopped, and saying that even that is not exactly small potatoes: remaining prepubescent while your peers all mature and begin dating and transitioning (no pun intended) to adulthood, and then going through puberty as a college student, would be incredibly isolating and traumatic I would think.
I’m not claiming that puberty blockers are just such a simple “pause button,” and am not informed enough to comment, other then to say that I’m aware there’s controversy on that point and also concerns about bone development, etc. Obviously the case for puberty blockers is even worse if we question or relax that assumption.
Then you damn well better make sure that you engage in comprehensive tracking and follow-up, so that patients and practitioners who follow will have better grounds for making such decisions in the future. Letting your patients drop off the face of the earth once you’re done with them does not sound like a very careful or confident standard of care. “They were okay as far as I could tell by the time they were released,” might not be the gold standard of success you think it is. You’d think that such untried, experimental procedures would merit more care and long term contact, with patients, not less.
And how does this square with “First, do no harm?” What if it turns out that your theory is shit, and it collapses into a pile of incoherent wreckage of wishful thinking and lies upon the lightest of critiques and interrogation? Well simple: you shield it from any pointed questions and claim “success” if the patient makes it out the door under their own steam. How can someone be “accredited” in doing something that’s not possible? Even the claim of being able to turn straw into gold rests on there being some gold to examine at the end of the process. But men can never be women; women can never be men. All you’ll be able to produce is a crude resemblance that results in none of the actual functionality that is inherent in healthy, intact members of the target sex. And if this a) fails to produce the promised, impossible result (though this failure is hidden behind novel redefinitions of what men and women are), and b) makes things worse for the patient than they were to begin with, how does that make you an expert or specialist in anything but ruining people’s lives? There is no gold here, only misery.
It sounds more and more like doing “nothing” would have been better than doing what has been done, though I’m not sure how one handles a situation in which one of the “values of the patient” might be using the threat of suicide if they don’t get what they want.
And how, exactly is it a good thing to humour these people in their impossible beliefs? We wouldn’t do the same for anorexics, but say you’re trans or enbee, and it’s time to break out the scalpels.
And we certainly don’t prioritize taking their claims seriously when it comes to determining military budgets and designing air defence systems. Maybe there’s a lot less there to understand. Not that people don’t have intense, disturbing experiences or feelings they think are real. It’s the explanations behind them that need investigation. Taking explanations of these people at face value might not be the best thing for them. Looking for actual aliens is not necessarily the the most useful and therapeutically justified line of enquiry. Yet somehow the re-introduction of mind-body dualism, and gendered “souls” is supposed to be a serious solution for a “problem” being “solved” with dangerous drugs and sterilizing surgery.
This is great. I had to go out and do stuff after writing this hasty summary of Wren’s views and youse guys are shredding them.
A fundamental problem that I see is that what the patient purportedly desires, and the ostensible objective of medical and surgical interventions, is to be the other sex. The fact of the matter is that the goal is unattainable. Human beings cannot change their sex. That’s simply not something that can actually be on offer. It can’t be done. Some things can be done to physically or socially mimic the other sex. The only symptom is an internal discomfort. In reality, the best that can be achieved by “gender affirming” actions is a placebo effect. There is no real treatment, only a very costly sugar pill.
Which is why we’re subject to endless repetitions of “trans people are who they say they are” etc etc etc. The goal is impossible so instead of abandoning it we will do our best to imitate it and enforce our attempt via strict orders to the entire world to pretend the imitation is real, with severe social punishment for people who refuse to pretend.
It’s all working out splendidly, isn’t it.