What would Freud have thought of this?

Keira Bell is a young woman who has bravely revealed her story to the public in the hope of saving others from getting into a similar heart-rending mess. Her problem was what is called gender confusion—but it turned out that that was only on the surface.

When she was 16 she was started on puberty blockers (hormones to delay puberty) which she took for two years. Then she was treated with the male hormone, testosterone, and ended up having a double mastectomy. But as time went on, doubts began to arise and she stopped the treatment when aged 22. Unfortunately, by that time the damage was done: she had a man’s voice and facial hair, and no breasts.

Feeling that she had been let down by her doctors, she brought an action against the Tavistock Clinic and the Portman Trust (the two London clinics dealing with gender identity problems) in the High Court. The three senior judges agreed with her and ruled that  children under 16 are unlikely to be able to make an informed decision to ‘transition’ to the opposite sex.

I’ll let her continue in her own words from a 2020 BBC interview (paraphrased and with emphasis added):

‘I was about 14 and things had been bubbling under the surface for years because I had felt different but it wasn’t very prominent until my early teen years and I think it was more a problem that society had than I had with myself because I felt pressured to change.

‘The process of changing from female to male is very difficult, though initially I felt relieved and happy. But as the years went on I started to feel less and less enthusiastic. It depends whether you want to dig yourself deeper into this hole or choose to come out it and have the weight lifted off your shoulders and just live naturally as how you truly are.

‘I didn’t feel too strongly about the need to change until I found out through the internet that it could be done. Then I visited my GP and started in the process that built up the urgency for change. At each step I felt the need to change in order to feel better, because each step didn’t really make me feel better.

‘When I went to the clinic at first I felt it was saving me from depression and suicidal ideation. At the time I felt it relieved all that mental health condition of gender dysphoria. It’s something you need to work through—it’s not something that you should rush into.

‘I would have liked to have had some sort of intensive therapy—that would have made a big difference.

‘When you are that young you don’t really want to listen to anyone, so I think it’s up to the institutions like the Tavistock Clinic to make sure you understand it’s a life-altering path that you’re going down and it’s not guaranteed to work.

‘No one was there to say any different and as a teenager I was allowed to run with a fantasy. It has affected me in the long run—I’ve only just stepped into adulthood and now I have to deal with such a radical burden.

‘I identify just as a human being. I now accept my sex which is female.’

An interview she had with the Spanish feminist platform Tribuna Feminista continues the story (emphasis added):

‘As a 14-year-old, Keira Bell started experiencing severe discomfort with her body. She did not fit into stereotypes about femininity and thought that the problem was her body. She hated the idea of growing into a woman.

‘Instead of questioning the underlying problems, such as depression, self-hatred, and low self-esteem, with compassion and care, the NHS’s gender clinic for children advised this teenage girl that she was indeed male, and that the best treatment for her dysphoria was to immediately begin blockers which would stop her puberty development.

‘Following three one-hour appointments, Keira Bell was put on a pathway that began with puberty blockers at 16, cross-sex hormones at 17, and resulted in a double mastectomy by the age of 20. We do not know enough about the long-term impact of puberty blockers and cross-sex hormones on children’s cognitive and reproductive development, but Keira knows that this medical treatment did not resolve the dysphoria she was experiencing.’

After the High Court judgement Keira Bell made the following statement:

‘I’m delighted at the judgement of the court today. If it had been made for me before I  embarked on the devastating and experimental puberty blockers my life would be very different today. My hope that this judgement will shine a light on this harmful experiment on vulnerable children and young people. These drugs seriously harmed me and they have harmed many more, particularly young girls and women. This judgement exposes a complacent and dangerous culture in treating children and young people with gender dysphoria. I would like for there to be better mental health services to help those dealing with gender dysphoria to reconcile with their sex. And furthermore I call on society to accept those who do not conform to sex stereotypes—not to push them into a life of drugs and concealment from who they really are. That means stopping the homophobia, misogyny, and bullying of those who are different.’

Gender Identity Development Service
The department at the Tavistock Clinic that deals with these matters is the curiously named Gender Identity Development Service (GIDS). A spokeswoman says that only very few young people embarking on transitioning regret this decision. But even if they do regret it, they may feel by then that it’s too late and decide they just have to make the best of it. Keira Bell may be  an exception, but who really knows? Moreover, it should be noted that referral to this institution implies a decision to treat accordingly, that is, with puberty blockers and cross sex hormones.

As for the ‘Development’ part in the name of this clinic, if gender is defined as the awareness of oneself as being male or female, this has usually occurred by the age of five, but how many children thereafter go through a persistent phase of questioning their gender? The bias in favour of treatment at GIDS is further evident in the wording on their website where they talk of ‘people assigned male (or female) at birth.’

One is not assigned as male or female at birth. For the vast majority of babies this is an innate and obvious distinction: ‘It’s a boy!’ or ‘It’s a girl!’, as the case may be, are usually the first words uttered by the birth attendant. It’s not a matter to be decided by others: Well, here’s your baby—what gender would you like to assign to them?

The word ‘designate’ may be used similarly, but the sex of a baby is not something that is assigned or designated at birth: it’s almost always obvious and thus the baby, as far as its gender is concerned, is defined  by its genitals which in the vast majority accord with its chromosomal sex.

Hazards of sexual reassignment
Attempts to assign, or rather, reassign the sex of a child are more likely to lead to disaster than anything else. An example is the appalling case of David Reimer whose botched circumcision as an infant resulted in the complete loss of his penis. What to do? Well, bring him up as a girl! The parents were encouraged in this desperate venture by a psychologist called John Money. Unsurprisingly, the experiment, for such it was, failed, and the unfortunate young man eventually shot himself. This story is recounted in a book, As Nature Made Him, by John Colapinto (2000). A review in Elle puts the point succinctly: ‘Makes a convincing case that gender has less to do with the signals we send and receive from the world than with the ineradicable messages encoded in every cell of our brains and bodies.’

Further, as Thomas Szasz points out in his book, The Myth of Mental Illness, in relation to what was called hysteria, making this concept into a diagnosis implies it is an entity found in nature rather than an abstraction thought up by man.

In gender dysphoria, as it is now known, the abstract nature of this notion is evident a fortiori since it is no longer even called a disorder or mental illness. It used to be known as gender identity disorder, but was re-named to remove the stigma associated with the word ‘disorder’.

What, then, is gender dysphoria? It has been defined as the distress a person feels due to a mismatch between their gender identity and their assigned sex at birth. Thus, it’s a feeling of distress related to one’s biological sex.

Gender dysphoria, like all problems affecting the mind and whether labelled with a psychiatric diagnosis or otherwise, is of necessity entirely subjective. That is not to say that young people confused about their gender do not experience real distress, but the life-changing and lifelong treatment involved in transitioning surely means that this intervention should be the last resort.

I do not find it convincing that the spokeswoman for GIDS, mentioned above, emphasises that no one is treated without giving fully informed consent, and that great care is taken to ensure the young person is certain—as far as anyone can be certain of anything at the age of 16—that they really want to proceed down the path of transitioning.

Abolition of unhappiness
Puberty is a difficult—even turbulent—time for many youngsters. It’s easy and understandable that some project their difficulties onto the belief that they are in the ‘wrong’ body, and if only, by the pharmacologist’s art and surgeon’s skill, they could be changed to the desired other sex, all their unhappiness will be abolished!

The first step for someone thus troubled should be the offer of psychotherapy to try to work through, or at least come to terms with, their underlying problems.

In the case of Keira Bell it seems this essential step had been missed: help with her real issues which might have had little or nothing to do with her gender identity—but once she was on the transitioning path the expectation was that she would continue.

I further wonder whether the informed consent that we are told is always obtained includes explaining to the patient that the changes such treatment can bring about are only on the surface: it’s a biological impossibility to change one’s sex. Therefore, it’s correct to say, without any disparaging implication, that people undergoing such treatment can never become real men or real women, as the case may be.

Here’s why. In the nucleus of every cell of the body (except the eggs and sperm) there are 22 pairs of chromosomes and one pair of sex chromosomes. The latter consist either of two Xs in the female, or an X and a Y in the male. (The eggs and sperm have only a single set of 23 chromosomes, one of which is an X in the egg, or in the sperm, an X or a Y.)

Thus, every cell of the body of a man or woman is indelibly, inescapably, and permanently marked as either male or female, respectively.

When Ms J K Rowling, the writer of the wonderful Harry Potter stories, noted that a person who transitioned from male to female is not a real woman, she was merely stating the obvious. Nonetheless, this caused an outcry among some bigots who even resorted to burning her books.

(Around one in 5,500 live births shows a true intersex state, with ambiguous genitalia, and there are rare disorders such as Klinefelter’s syndrome in which the person has one Y and two X chromosomes.)

Experimental treatment
The effects of puberty blockers are said to be physically reversible: if the young person stops taking the blocker their body will continue to develop as it was previously. However, we don’t know the full psychological effects of the blocker or whether it alters the course of adolescent brain development. In other words, it’s an experimental treatment.

In January 2021 there were more than 4,600 people on the waiting list at GIDS for consideration for transitioning interventions. But perhaps it would be better, as a first step, for people with gender confusion to be helped, as Keira Bell wistfully put it, to ‘just live naturally as how you truly are.’

Text © Gabriel Symonds

The picture is a statue of Sigmund Freud with the Tavistock Clinic in the background.