Do You Need Support Around Your Gender?

In February 2022 Dr Hilary Cass issued her interim report of an ‘Independent review of gender identity services for children and young people’.

There is, however, an assumption underlying this misconceived publication, evident in the very title: that gender identity and the related idea of gender dysphoria are valid concepts for which ‘services’ may be needed.

Although Dr Cass is careful to say that ‘the language used [in the report] is not an indication of a position being taken by the Review’, she points out that it is ‘focused on the clinical services provided to children and young people who seek help from the NHS to resolve their gender-related distress’ or who ‘need support around their gender’. I suppose we shall have to wait for the full report for her to get off the fence.

What is gender-related distress? It means that a child or young person has a feeling that he or she is in the ‘wrong’ body. That is to say, a boy or girl suffering from this kind of distress is unhappy because he or she is not a girl or boy, respectively.

Children and young people may suffer distress for all sorts of reasons: family strife, bullying, difficulties at school, poverty, racial discrimination, being in trouble with the law, bereavement, physical and emotional neglect or abuse, etc., and they need the best help that is available to protect them and help them deal with or come to terms with their problems, whatever these may be. Indeed, this recognised in the report since we find:

The majority of children and young people presenting [with gender dysphoria] have other complex mental health issues and/or neurodiversity [autism].

What is gender dysphoria anyway?
The expression ‘children and young people with gender dysphoria’ (my emphasis), repeated several times in the report, reinforces the assumption that such an entity exists in nature – although no objective criteria have been discovered to support it. This deficiency, however, does not give Dr Cass pause in pursuing the notion of gender dysphoria as a disorder. Indeed, she defers to the wisdom of a 947-page tome known as DSM-5.

DSM-5 is the fifth (2013) edition of the American Psychiatric Association’s publication, Diagnostic and Statistical Manual of Mental Disorders. In a not entirely tongue-in-cheek fashion it’s sometimes called the Bible of psychiatry. It’s important to understand that the 298 mental conditions discussed and defined therein are derived from the deliberations of various committees: there is no identifiable state of the brain that corresponds to any so-called mental disorder. Therefore, such disorders, or they may be called conditions or behaviours, are of necessity entirely subjective. Furthermore, if one talks of disorders and diagnoses in this context, by definition it means one is dealing with an abnormality for which specific treatment may be required, but this is another evidence-free assumption.

Now to the diagnostic criteria for gender dysphoria in children as set out in the report; they are copied from DSM-5 (abbreviated and emphasis added):

A marked incongruence between one’s experienced/expressed gender and assigned gender…A strong desire to be of the other gender…A strong preference for cross-dressing…A strong preference for cross-gender roles in play.

And for adolescents and adults we have the following criteria (abbreviated and emphasis added):

A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics…A strong desire to be rid of one’s primary and/or secondary sex characteristics…The condition [again implying an abnormality] is associated with clinically significant distress or impairment.

The repeated qualifiers ‘marked’, ‘strong’, ‘clinically significant’, and suchlike testify to the subjective nature of these diagnoses. And who is to make judgements about the strength or significance of these feelings?

We also find the following observations:

Most children and young people seeking help do not see themselves as having a medical condition; yet to achieve their desired intervention they need to engage with clinical services and receive a medical diagnosis of gender dysphoria…they may feel very certain of their gender identity and be anxious to start hormone treatment.

However, they can then face a period of what can seem like intrusive, repetitive and unnecessary questioning…We have heard that some young people learn through peers and social media what they should and should not say to therapy staff in order  to access hormone treatment; for example, that they are advised not to admit to previous abuse or trauma, or uncertainty about their sexual orientation.

In other words, it’s a mess.

What should we do instead?
It would be better to abandon diagnostic labelling in relation to children and young people (and in older people for that matter) in this situation, and use a descriptive or narrative-based approach. Thus, instead to talking, for example, of a child with gender dysphoria or gender incongruence, we should help the child in a supportive and non-judgemental fashion explore the source(s) of his or her unhappiness and not take at face value the child’s fantasy that he or she is in the wrong body.

Furthermore, it should be made clear to the child or young person that it’s impossible for hormonal manipulation, with surgery if undertaken, to transform them into the opposite sex. Such interventions are experimental, fraught with risk, are largely irreversible, and may lead to regret for the rest of the person’s life.

The naked body does not lie.

Text © Gabriel Symonds