Trans Ethics with Florence Ashley – The GenderGP Podcast S2 E6

 
Transfeminine jurist and bioethicist Florence Ashley, joins Dr Helen and Marianne to discuss ethics in the context of medical treatment for transgender people.
 

Topics covered in this episode include:

- The ethics of diagnosis for trans people
- The relevance of assessments and why they are dehumanising
- The value of experience in directing decisions on the treatment of trans youth

 

Florence Ashley is a transfeminine jurist, bioethicist and academic. Her focus is on therapeutic approaches to transgender youth and the legality of conversion therapy.

Follow Florence on Twitter @ButNotTheCity

 

Links
- https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/
- https://www.florenceashley.com
- https://www.florenceashley.com/uploads/1/2/4/4/124439164/ashley_thinking_an_ethics_of_gender_exploration_-_against_delaying_transition_for_transgender_and_gender_creative_youth.pdf
- https://gendergp.com/bmj-carl-heneghan/
 

 
The GenderGP Podcast
Trans Ethics with Florence Ashley – The GenderGP Podcast S2 E6
 

Hello, this is Dr Helen Webberley. Welcome to our Gender GP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr. Helen Webberley:

Hi everybody, and welcome to our podcast today. We have myself and Marianne as usual. And today I'm very excited to invite Florence Ashley, who is a bioethicist and Masters of Law candidate at McGill University in Montreal. Florence contacted me because she'd written an article talking about psychiatric assessments in trans patients. And I was very interested in what she wrote. So I'm really excited about opening up some of the sources she's had in her article. So Florence, can you tell us a little bit about yourself and your background and your interest in this field?

Florence Ashley:

So you know I do law and bioethics. I did my law degree at McGill University, and now I'm doing my masters. A lot of my focus is on law and bioethics, and especially health law as it relates to Trans Healthcare. So my master's topic is a big old regulation of conversion therapy, you know. And I'm working on laws that prohibit it, and I'm going to continue in the same topic for my doctoral work. But at the same time, I also write on a host of issues in line with bioethics relating to trans people, like peer-reviewed journals. And I have gotten interested in the question of gatekeeping and stuff like that but from an ethical perspective; because a lot of the discussions have been very framed in a naïve version of evidence-based medicine that doesn't leave a lot of room for ethical discussions beyond the evidence of harm through studies. And I think that we need to broaden our discussions to include a lot more than what is the nitty-gritty of the evidence. But also how do we interpret and how do we do the uptake of that evidence? And also how do we think about those issues from more philosophical and critical perspectives?

Dr. Helen Webberley:

Okay. Brilliant. Well you know, you're just the person I would really love to talk to. I have to say. So much of what you said that rings true. I'll just pick up on that last thing that you said talking about the lack of evidence, and how the thirst for evidence and how it would lean heavily on evidence doesn't give us a chance to discuss broader social areas around this. And we're all saying if there isn't any evidence to say that doing this is going to be beneficial or harmful, how can we possibly introduce a treatment that might be beneficial or harmful.
And what we forget to do is talk to the people who are actually in the chair in your office or in the consulting room with you. And because we're so caught up with this lack of evidence—I mean certainly he...

 

Transfeminine jurist and bioethicist Florence Ashley, joins Dr Helen and Marianne to discuss ethics in the context of medical treatment for transgender people.

 

Topics covered in this episode include:

– The ethics of diagnosis for trans people

– The relevance of assessments and why they are dehumanising

– The value of experience in directing decisions on the treatment of trans youth

 

Florence Ashley is a transfeminine jurist, bioethicist and academic. Her focus is on therapeutic approaches to transgender youth and the legality of conversion therapy.

Follow Florence on Twitter @ButNotTheCity

 

Links

– https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/

– https://www.florenceashley.com

– https://www.florenceashley.com/uploads/1/2/4/4/124439164/ashley_thinking_an_ethics_of_gender_exploration_-_against_delaying_transition_for_transgender_and_gender_creative_youth.pdf

– https://gendergp.com/bmj-carl-heneghan/

 

 

The GenderGP Podcast
Trans Ethics with Florence Ashley – The GenderGP Podcast S2 E6

 

Hello, this is Dr Helen Webberley. Welcome to our Gender GP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr. Helen Webberley:

Hi everybody, and welcome to our podcast today. We have myself and Marianne as usual. And today I’m very excited to invite Florence Ashley, who is a bioethicist and Masters of Law candidate at McGill University in Montreal. Florence contacted me because she’d written an article talking about psychiatric assessments in trans patients. And I was very interested in what she wrote. So I’m really excited about opening up some of the sources she’s had in her article. So Florence, can you tell us a little bit about yourself and your background and your interest in this field?

Florence Ashley:

So you know I do law and bioethics. I did my law degree at McGill University, and now I’m doing my masters. A lot of my focus is on law and bioethics, and especially health law as it relates to Trans Healthcare. So my master’s topic is a big old regulation of conversion therapy, you know. And I’m working on laws that prohibit it, and I’m going to continue in the same topic for my doctoral work. But at the same time, I also write on a host of issues in line with bioethics relating to trans people, like peer-reviewed journals. And I have gotten interested in the question of gatekeeping and stuff like that but from an ethical perspective; because a lot of the discussions have been very framed in a naïve version of evidence-based medicine that doesn’t leave a lot of room for ethical discussions beyond the evidence of harm through studies. And I think that we need to broaden our discussions to include a lot more than what is the nitty-gritty of the evidence. But also how do we interpret and how do we do the uptake of that evidence? And also how do we think about those issues from more philosophical and critical perspectives?

Dr. Helen Webberley:

Okay. Brilliant. Well you know, you’re just the person I would really love to talk to. I have to say. So much of what you said that rings true. I’ll just pick up on that last thing that you said talking about the lack of evidence, and how the thirst for evidence and how it would lean heavily on evidence doesn’t give us a chance to discuss broader social areas around this. And we’re all saying if there isn’t any evidence to say that doing this is going to be beneficial or harmful, how can we possibly introduce a treatment that might be beneficial or harmful.

And what we forget to do is talk to the people who are actually in the chair in your office or in the consulting room with you. And because we’re so caught up with this lack of evidence—I mean certainly here in the UK it’s always been talked about and there’s no evidence. Therefore we mustn’t cause harm. It’s really hard to get past that, isn’t it?

Florence Ashley:

Yes, of course. And one thing which is weird is that there’s kind of a failure to distinguish between lack of evidence and a lack of what would be considered high-quality evidence. And you know, anecdotal evidence is still evidence, and it’s still weighty enough evidence to determine clinical approaches in the absence of other types of stronger evidence that run contrary to it. And I think one of the problems with a big discussion is that—well just look at what the evidence-based medicine BMJ article by Carl Hannigan has done, and you know it’s very like, “Oh well there’s no evidence,” or stuff like that. And the problem there is that there’s almost this sort of like fetishism of the Oxford measurements of quality of evidence and problems that also they fail to kind of position the lack of evidence within the reality that it is not possible to ethically conduct randomised controlled trials on this issue. At least not to with an active and a control arm. It could be possible between multiple active arms, but it couldn’t be possible between an active and a control arm for trans people, and you know this is something that’s like Marty Deutsch has highlighted, and the problem when making guidelines is you’ll never have randomised control trials, so we have to rethink our approach to evidence. In light of the fact that the gold standard in evidence is not something that we can get. Randomised control trials are both unethical and impractical in the sense of like not possible. The reason is that when you have a randomised control trial, you select a group of participants and then you randomly assign them to either a group that gets treatment and a group that gets a placebo. There are comparative control trials for two active arms, which were what I was talking about, in which case you have two different treatments. But here I’m thinking about really one that has no treatment versus the treatment arm. And in that case, first of all, it’s not possible because it needs to be blinded, so people need not know which arm they’re part of. Well, with hormones you know, because they have very noticeable changes on your body, and so it would become “unblinded” very quickly so it would completely avoid the blinding that is necessary to the scientific validity of that randomised control trial. But then there’s also the question of ethics which is: there’s this notion that’s called equipoise in bioethics, and it’s the idea that it would not be ethical to conduct at a randomized controlled trial and to give a treatment that we know to be inferior to the alternative treatment even if what you’re trying to measure is how worse it is. If you are certain that it is worse, it would be unethical to force people to get that one. And so that’s why we can’t conduct randomized controlled trial here because we have sufficient evidence to know that not giving those kids treatment would be harmful and dangerous as compared to giving them puberty blockers or hormonal treatment or allowing them to transition socially. And so there is the absence of this requirement of equipoise to do the trials. And you know there’s a little asterisk to add there; that the requirement of equipoise is still somewhat controversial in ethics primarily because of the role that plays in what we call the replication crisis—which is the fact that we’re not redoing our experiments to verify that they were right and not just a fluke, because of the fact that we think it’s unethical to redo them once we know that one treatment is better than the other. So so there is some controversy about whether equipoise should be a requirement for ethics, but it is one of the big reasons why it’s been very difficult to get randomized controlled trials. It’s because, well you couldn’t do it because it would immediately get unblinded, but also because there’s a lack of equipoise and so people don’t want to do it.

Dr. Helen Webberley:

It’s so difficult, isn’t it? Because we have that paper from Paul Hennigan in the BMJ and you know I don’t know what the outside of the UK is like, but people look to the BMJ. GPs and doctors and nurses in the UK will be looking at the BMJ and trusting what is written there. And that article has the potential to do a lot of damage. And basically what he was saying is, as you’ve said so clearly, Florence, is that we haven’t got enough evidence. So how do we know that it’s safe to treat these children? But when you’re asking for more evidence, what you’re actually saying is, “OK, let’s take a thousand children, and we’ll give 500 of them treatment, and we won’t give the other five hundred often treatment, and we’ll see which ones do better.” And you just couldn’t do that. It would be so unfair. It would be so unsafe. And what we forget is that we have, as well as we have evidence, we have what we know is best practice. So we can see clinics that have been working over the last 10, 20, 30 years who have been using these treatments and we’ve seen that they’ve been very safe. So as well as calling for this concrete rigid evidence that you’ve been describing, by not taking into account best practice and by not referencing any of the international guidelines that have been produced recently, you know we’ve done a real disservice to publish something so potentially damaging in the BMJ, I have to say.

Florence Ashley:

Yeah I don’t know if you saw, but I published a response blog post on the bioethics that net blog, which is the blog of the American Journal of Bioethics. And one of my points was that while assessments of safety are very much value-driven, but also I feel like there was also a lack of expertise in specifically trans health that made it difficult for people like Carl Hannigan and his co-author to properly assess the evidence used. So for instance, they use t scores matched by gender assigned at birth for bone density in the– think it was a zinc study—and well the problem with that is that only when you use t scores and you have something that kind of like delays puberty, well as the rest of the peers go through puberty they get bone mass naturally, so of course you have a lag compared to them. So your age match is wrong, but then also you have to consider the difference in age, bone development based on gender, and the fact that they’re being matched with gender assigned at birth has implications because the people are being compared to, well if you’re being compared to cis women, while cis women go through puberty earlier and so they have this gain of bone density earlier on. So when you’re comparing over a time span of late adolescence into early adulthood, your data based on t scores are very weak. But then also there’s the question of well, “Why are you basing that that on relative bone health? Surely what we want to know is, are they more at risk of osteoporosis? Are they more at risk of bone breakage? That’s not going to be something you get from relative metrics, that’s something you get from absolute metrics. You have to look at, “Well, okay, your bone density is like x amount.” Is that an amount that is known to correlate with more fractures? And the answer seems to be no unless you think that 16-year-olds are particularly are at more risk of fractures. So it’s a weird kind of like a lack of perspective. Same thing with like when they do hematocrit, which has to do with the concentration of red blood cells in the blood. Well, the data is like, “Oh, well trans masculine youth get much higher hematocrit.” Well yes, of course when they take testosterone they go into normal male range hematocrit, which is significantly higher than that of the normal female range. And so there’s nothing weird about it nor anything necessarily dangerous about it. And this is not to dismiss the fact that you can have dangerous hematocrit levels that are in part due to testosterone, as is the case in the general population. But you know these figures very much need to be contextualized, and I feel like that the BMJ article didn’t contextualize. And then I also feel like they weirdly went again against the conclusions of the systematic reviews that they rely on, the systematic reviews are like, “Yes this is sufficiently safe. We need more data. This is fairly convincing evidence of safety.” And then you have them going like, “nope, we have no evidence.” This is unreasonable and experimental practice, and you’re just like, “Well, why did you rely on them but then give a completely different assessment? and on what basis did you do that.”

Dr. Helen Webberley:

Yeah I mean those two things that you’ve mentioned there, Florence, one is the bone density and the other one is is the full blood count—the blood test. I’m just gonna break that down into slightly simpler language because these are things that I hear parents worrying about a lot. And so so very often, trans children maybe at the beginning, middle and then or throughout their treatment whether that’s with blockers or with hormones, will be encouraged to have bone scans to check for bone density. And I think what you were saying which I totally agree with is that you can measure bone density and you can get a number you can get a value, which is, say, for example, six. And you can compare that with someone else who might have a value of, for example, eight. But what do those values actually mean? Are we actually seeing that trans children on treatment have more bone fractures because their bones are thinner? And no we’re not. So what do those numbers actually mean? And the other thing that you mentioned is that the hematocrit, which is that white blood cells, and the fact that trans boys or trans men have a higher hematocrit than we would expect. So we start treatment, and their hematocrit increases and people are like, “Oh my goodness. That might be dangerous. You might get them to sticky blood and what have you.” But what you’re saying, and again I totally agree with, is that actually, that’s what testosterone does. And if you measure a cis girl with a cis boy, his hematocrit will be higher than hers because that’s what testosterone does. And it does it to cis children when they go through puberty, and it does it to trans children when they go through puberty. Except that what we have is there are people who would like, I feel and this is a valid opinion, well this is an opinion rather than a fact, I feel that there are people who would like to find difficulties with treatment in order to perhaps prevent it in order to be completely and utterly safe. And so people will say be careful because of bone density because you might have a bone density scan that is less than if you didn’t have treatment or be careful because your hematocrit your blood cells might be thicker than they were before. And they use it in an in a way to prevent trans people from having access to treatment, and these things are scary. They are scary. And what we need to do as professionals you as a researcher and an ethicist and a lawyer and myself as a doctor is to explain these things clearly to people, in a way that uses evidence and also uses patient experience, and then balances those things with the good outcomes. Because actually, we know that if we treat trans children, they have happy lives. They go back to school, and they join society, and they don’t hurt themselves as much, and they have better mental health scores. We know that there are very good things about treatment that we can also measure, and those things get forgotten, don’t they? In these studies, they want to show you that t scores or bone density might be reduced.

Florence Ashley:

Absolutely, and you know you saw it in that in that in the BMJ EBM one, which was kind of like dismissing the mental health aspect on account of mental health scores being very subjective. And I’m just like, “Well, I mean, sure that’s true. But that doesn’t mean that we should completely dismiss that when the whole point of the treatment is to improve mental health.” Well I mean maybe we need to nuance it’s not the whole point of the treatment, but it is one of the big motivations for treatment. And I agree with you that people are just trying to find ways to oppose it. And I’m curious to see what’s going to—so I do know that they are preparing the BMG EBM, which was a blog article and they’re preparing it for submission as a peer-reviewed article. And we will really see whether there was good faith there because they are aware of my response. They have declined to publish it. They’ve like ghosted me for a number of weeks but then I made some pressures through other channels, and they eventually answered, and they were like, “Oh well, thank you for that. And I encourage you to publish it. But we won’t publish it on our blog.” But then I put it in the blog of the American Journal of Bioethics. But we will really see if the good faith was there based on whether the peer-reviewed article even tries to address the critiques that I have made, right?

Because if they don’t, then that suggests that they’re not particularly interested in that kind of normal collaborative process of science. And so I’m I’m really curious to see how that will turn out. I can’t say I’m particularly hopeful, and I am concerned that the resulting publication will have a lot of the same biases, and kind of a lack of introspection about what kind of stuff safety assessments are. But we’ll kind of see.

Dr. Helen Webberley:

I guess I agree. And you know we have done a lot of work gender GP with advocacy and writing to big institutions and organizations to say, “Hang on a minute. That’s not right, or we don’t feel that you’re doing this right. We feel that you could do this better in this way.” And very often we’ve been blanked, but that doesn’t stop us. And we have to use the power of the people, the trans community, and their experiences. We have to use the power of professionalism in our different specialities, and we have to keep trying we have to get these people to listen to us, because everyone’s talking about safety and if there is one thing we know, it’s that there is a very high incidence of mental health issues of self-harm and suicide amongst trans people of all ages. That is a big safety issue. So I applaud you for your persistence, and you know, we’ve been working on a similar project which I’ll put on my website, and I’ll share with you. I want to move on actually, if I may, to the topic of assessments which I’m particularly interested in when we were first developing the Gender GP model where we kind of use the traditional medical models. Which is, you know, introduce yourself to the patient to take a history, to do some kind of examination, whether that’s a physical examination or a mental assessment examination, any investigations that might need doing such as blood tests. Then you put all that information together, and you sit with your patient, and you create a management plan. And that’s traditionally how medicine and the doctor-patient relationship works. So when we were developing our model I kept getting stuck, and Marianne will know what I’m talking about—we kept getting stuck on this word assessment and diagnosis because I just kept feeling that it was insulting to assess somebody for their trans identity or to give somebody a diagnosis, you know, like it fell on our shoulders to diagnose somebody as being trans. And so early on in our development of our model, Marianne and I, and I talked about this. I said I don’t want to use this word assessment anymore. I’m not going to use it. And so we started using the concept of an information-gathering process. So instead of assessing somebody, which we didn’t like, we gathered all the information from the person that wants our help, and we share our information with the person that we know wants our help. And then we join together and make that management plan. And Marianne I’d like to bring you in here. How do you think that that’s been received by the trans people that we’ve been helping along their journey?

Marianne Oakes:

My experience with them is that they feel relieved when they realize that what we’re doing is just hearing their story and using it to facilitate their journey rather than assessing their level of trans. It doesn’t make sense that we’re not trying to say you know that you’ve scored 80; therefore, we can give you this treatment. What we’re doing we’re just listening to their stories collating all the information. And I think it’s refreshing. I think that would be the way I would describe it. If I can just mention though as well because just I was listening to all the talk about the research and I sometimes recall research. I have to read a lot of psychological research. And the one thing that they know, it’s about how you cut the cake. So depending on who’s reading the research, it will depend on what outcome we want and how they want to interpret that. I think it kind of links to this, Helen, because I think we got caught up in the old model originally until we felt uncomfortable. And if it was making us feel uncomfortable, imagine what it’s doing to the patients. So research was only down the road if you’re not careful.

Dr. Helen Webberley:

Definitely, definitely. And I love your like your concept of you know, who’s cutting the cake and how big a piece do you want—and do you want the one with the Maltesers on it or the one that’s got the sprinkles on it. You know, and you can choose, can’t you? You can choose how that cake is presented on that plate, on who wants it.

Marianne Oakes:

That’s the concept, depending on how you cut the cake, depends on how it looks. And that’s what research is, and rightly so. You know I wouldn’t want to dismiss all research because of that, but it’s how it influences the people then responding to that. And like I say even I was guilty of being drawn into that persistent and consistent idea.

Dr. Helen Webberley:

Florence, Marianne and Abby and I went to meet Johanna Olsen-Kennedy and her team in January in Los Angeles. And to and to hear the way that they approach the care of trans children was so illuminating. Absolutely beautiful, listening to them, to the affirmative way that they talked about providing care and support to children and their families. And one of the things that they said was if you think if your child and tells you that they are trans then they probably are. I loved that sentence, but I was scared to use it because in the UK we’re not quite as honest as Johanna’s clinic in terms of acceptance and treating trans children. So I was quite scared of using it, but we did a live event with Johanna and Aydin and Darlene, and we used that. That you know if your child says that they’re trans, then they probably are. We used it as our tagline, and of course, it attracted some attention. But then when I heard you in your article saying that actually, we shouldn’t be assessing people any more than we assess any a person for any other medical condition. And I just thought, “Brave woman, well done. Thank you. Because these things need to be said.” So tell us a little bit about your thoughts on that.

Florence Ashley:

Yeah, so I mean, my general approach is that generally, we shouldn’t be assessing gender dysphoria or whether or not people are trans. And that includes diagnosis although you know I have a whole lot to say on diagnosis. But you know the idea is like, “Well, okay, sure, there might be some cases where you’re presented with a clinical case, and you’re just like I feel like this person is not giving informed consent, is not making an informed decision.” and you know in that case there’s a question of assessing capacity. But as long as the person has the capacity to consent, and is mature enough or old enough to understand what’s going on, and not in a psychotic episode because that’s also something is like people will deny hormones or treatment to people who have mental health issues, even though those mental health issues have no impact on their capacity to give informed consent. But as long as you have the capacity, then giving informed consent should be more than enough. They know themselves. And of course, we sometimes make mistakes when we know ourselves. But it is still the best possible approach because, for one, assessments are demeaning, but also demeaning in a way that doesn’t actually lead to better decision making. Because if you’re telling someone, “Perform for me and I’ll give you what you want,” you’re not giving them room to voice their doubts and to do honest introspection and reflection, and exploration with you. You’re incentivizing them to lie and to tell you what you want to hear so that they’ll get what they want.

Dr. Helen Webberley:

You’re so right. I’ve seen enough people talk in forums, things like Reddit and what have you. You know someone’s got their appointment with the gender specialist coming up in the next few weeks, and there’s a kind of coaching process going on. They’ll be saying what should I wear, how should I wear it, how best can I wear my female looking clothing? What questions will they ask me? Can someone help me with that with questions and has anyone got any ideas on what kind of answers I should give? It is a bit like you know, coaching for the exam like you say know to make sure that they get the best chance of passing that exam. And the other thing that we see a lot of which makes me very sad—and I’m sure Marianne sees this as well, Marianne, I’m sure you do—is this idea that anybody who has mental health issues that aren’t under complete control, then you can’t have any treatment. But what we see so often is the gender dysphoria causing the mental health distress, and you’re quite right, and I’ve never really thought of it before. So yes, gender dysphoria causes mental health distress. But does that actually affect their capacity to make the decision that we’re actually talking about on the table at that moment, which is gender-affirming medical care? And if it doesn’t, then why are we restricting people just because they are feeling very stressed or anxious or depressed? Marianne, do you concur with that? Do you see that?

Marianne Oakes:

Completely. I was just thinking when you were talking, there’s something about if we can encourage people to tell us the truth to tell us exactly what’s going on for them, then what we can do is choose the best pathway for them to transition and have the best outcome. If we set the model, so they’ve got to lie to us, we will never know that that pathway was the right pathway. You know I mean that I was listening to what Florence said, and I’ve been through the gatekeeping model as you know. And I did have to comply with their wishes, and they did not know the full truth about me. And so how do I know that I’ve got the best medical pathway now?

Florence Ashley:

Yes, absolutely. I mean I was actually interviewed for a piece on detransitioners, and you know as you can imagine I have all sorts of feelings about doing a piece about that. But one of the things I’ve been highlighting as well, you know detransitioners are being used to argue against informed consent in favour of heavier assessment, and I’m like, “Well, is there any evidence that the assessments work?” because first of all, they’re looking at stuff like did you have gender dysphoria when you were young, and then there are a lot of them are looking at stuff like “are you wearing dresses?” Stuff that is still completely irrelevant, for one. And you know I’m always thinking back to like Walt Heyer who’s now very, very vehemently anti-trans and has detransitioned in the 90s. But you know, this is a person who had transitioned in the 80s, at a time when there was like heavy gatekeeping and lot of like seeking to discourage people from being trans. The heyday of reparative therapy. And this person still went through a process, transitioned, and then eight years later realized that they weren’t trans and this wasn’t for them and detransitioned. So if the assessment process can fail to do what it’s supposed to do, which is to figure out who’s really trans from who’s not, and avoid the transition well then why are people arguing for it in the first place? And I think it ties back to what Marianne has mentioned which is, you know, if we encourage people to tell the truth, then maybe they’ll realize that it’s not for them at an earlier point in the process. Because if you do an assessment, that doesn’t mean that they’ll figure out who is going to be someone who will later detransition. And I don’t believe that even if people are honest, I don’t believe that they’re able to really tell in most cases. But I do think that if people don’t tell the truth because they want to get the care and you’re playing gatekeeper, then you’ll definitely not know. And I think that overall, it’s better just to create an environment where everyone feels like they’re not being judged at all, that they can tell the truth, that they can express their doubts and uncertainty and their worries without fearing that this will lead to a denial of care. Then they can actually explore and his worries these doubts these uncertainties with the providers, and make better decisions for themselves. And I think this is what really informed consent is about. It’s not just about making care easier to access. Yes, it is about that, but it’s also about giving people the tools to make the best possible decision for themselves.

Dr. Helen Webberley:

Yeah, absolutely. And that’s what I really believe, that the value of everybody in that room has the experience and the expertise in themselves and how they feel and how their heart their body and their soul feels. You know I may have the expertise in the medicine, and what medicines do or don’t do. Marianne might have that experience to pull out some of those feelings that the person is expressing, but is unable to know what to do with those feelings. And the expertise in that room together can make the best plan that can change you know and it can be a changeable plan. And that’s so how I want to see trans healthcare in the future. It’s interesting that you were talking then about the assessment and the distress that people feel because again in the UK, we have the model that children have to go through the big long assessment process before they’re out any access to any medical intervention. And very often it’s a very tricky time for them because if puberty is happening, we all know what puberty does to your bodies. Some people welcome it. Some people don’t. And when trans children are going through puberty that doesn’t feel right for them, and they know that these changes are going to last forever, and maybe these changes are going to make them identifiable as trans forever, so it’s so distressing for them. And it’s interesting. we were at an event in Bristol recently, and this idea was being discussed, so Johanna Olson-Kennedy was saying, “well why don’t you guys just give the kids the blockers at the same time you are going through your assessment process?” So at least they’ve got that feeling that puberty can stop while they go through the process of assessment. And Bernadette Wren from Tavistock Clinic, she said, “Well, we have a duty of care to these children. We have to be very careful.

She said, “We have got two or three examples of adolescents who change their minds and that they didn’t proceed with treatment for whatever reason.” And Johanna said, “Well, I understand that. And we have children too who’re fluctuating in the decisions on their journeys.” But she said, “Surely those two or three children went through your assessment process and got through it and passed in inverted commas in order to have treatment.” So, in fact, it didn’t even pull out the children who might not have a fully met upward slope progression all the way through. It doesn’t pull out those children who waver and are unsure about the best journey for themselves. So it kind of in itself it’s made a mockery of the very long assessments that these poor children have to go through while they’re very distressed.

Florence Ashley:

Absolutely. And I don’t know if you saw, but I actually read to critique of Rand’s approach in the latest issue in the special issue of Clinical Child Psychology and Psychiatry, to which Rand contributed. There was actually a special issue that was mostly based on people from the Tavi, and I kind of like addressed this part which is if we take her starting point of promoting exploration and also of, you know seeing gender as relational and dynamic and relationally-constructed which is something I do agree with, we still should see puberty blockers and social transition as the default. And we should rethink our approach to that because exploration is not something that should happen before transitioning as a sort of performance, but it’s something that happens through the transition. So before, during, and after. And even after transitioning, you’re still learning more about your relationship to gender. And I think this that this is important. And so, allowing puberty blockers in the very traditional sense of like, well this is giving them time to think and to explore well—it is true. We need to think of that and stop thinking of puberty blockers solely as a positive intervention. And also generally I do think that like it’s less an intervention than is puberty. But I think there’s also a failure to distinguish cessation of treatment from regret. And I think that’s a big issue in approaches that are sort of negative towards easier access to treatment, is that they assume that if the kids stop, then the decision to go on hormones was wrong for them and that they’ll regret it. But what we do see from case studies by Turban and Keuroghlian an (unclear 36:56) is that the people who do cease treatment are a lot of the time are actually grateful about the opportunity to take hormones, or to take blockers and explore their gender and their relationship to their gender into their body during those moments. And so the assumption that cessation of treatment means regret is kind of a huge stretch, and it’s important to have that in mind, that even though there are people who are going to regret, we shouldn’t assume that everyone who ceases treatment is a bad outcome. That has regret because that is not true.

Dr. Helen Webberley:

For me, it brings in the complexity of language and the fact that we’ve got to get this language right. And again we’re very careful. I don’t like the words detransition. Johanna uses retransition. And she says you can retransition as many times as you want to, and no one’s going to criticize or point a finger. Regret is so different to not being trans means, that isn’t what it is. When we developed the Gender GP journey and model of care, Mariam introduced me to the idea of the journey and actually whether your cis or trans, we all have a gender journey of how we feel about our gender and how we express our gender. And that was something you introduced wasn’t it, Marianne and taught me about it in your work.

Marianne Oakes:

This concept of the journey—it’s obviously a stereotypical metaphor within counselling services. Life’s a journey, but in terms of trans journeys, I think sometimes it’s the idea that it is the same outcome for everybody and that we don’t have choices along that journey is a misconception. And how can we work through our choices if we’re not allowed to start the journey? So, being given a chance to have medication might be the thing that helps you to make your mind up. I don’t think people stop being trans. I think once you question your gender, that’s going to follow you through life. You’ll never know if it’s the right decision or not. All you can say is I’m looking back and regretting. And if I’m not whether I continued on my journey or stopped, well I’m happy with where I am. (Unclear 39:32) So yeah the journey to me, I talk about finding places on the (unclear 39:38) where we feel comfortable giving blockers to a young person, and we feel comfortable, and we can keep in school, and we feel in control, and it might not require hormones yet. It might lead to a place where hormones are never required, then again, it might lead to a place where they are. It’s about finding your place on that journey and being comfortable at any one time. Unfortunately, I think the medical model, the gatekeeping in particular, drives you to a certain goal, whether you want that goal or not without any exploration of alternatives.

Florence Ashley:

Absolutely. I do feel like you know the medical gatekeeping model is very deeply intertwined with a very binary, transmittable view of being trans that you see trans people as a binary gender and as you know (unclear 40:40) fully transitioning and having a kind of weird sort of cisnormative view of what fully transitioning means, which is like you know very poorly adapted to the realities of trans people. Because for one, a lot of trans people are non-binary and non-binary should not be treated as a sort of exception or weird case in trans health, but also because just because you identify as a man or a woman doesn’t mean that you want a specific pathway of care and pathway of interventions. And I do think that there is an issue with the medical model pushing, and we see that in parents as well it’s like pushing for a specific way of being trans, and I think that’s antithetical to the ethos of affirmative care which is if you follow the person and if that person doesn’t want certain interventions, you shouldn’t be pressuring them to have them.

Dr. Helen Webberley:

I think the other thing that the medical model does, and Florence, you refer to this when they were talking about your article, about the deeply personal questions that people are subjected to just because they are trans. And I remember when I was doing a referral letter for somebody who wanted a rhinoplasty, so surgery on their nose to feminise their nose—and I wrote a letter explaining that in my view this person was indeed identified as a woman and was likely to do so for the rest of her life and that having an operation on her nose to make it look more feminine would be of benefit to her. And that was for me is a referral letter which you would give somebody who needed some gallstones removed. This person has gallstones they’re stuck in the bladder. Right, and I recommend actually removing the gallbladder would be the right thing for this person because they are getting frequent attacks of pain if you compare the two. And then they wrote back to me because I haven’t included things like a forensic history. And I was staggered. Why ever would I ask this woman about her forensic history is when she’s wishing to feminize her nose? And you know, you mentioned Florence, the question the deeply personal questions that we should not be asking. Marianne, I guess you hear this a lot as well. I’ll open that up to both of you.

Florence Ashley:

That’s super weird to me. And also I think you just wonder what happens when people are being like so much more already so much more conservative than the standards of care? Because like this kind of stuff is not required by the standard of care letters which I really think are way too conservative. Although it is implicit in the assessment of it in the standards of care conception of assessment of gender dysphoria because of their like persistent well-documented (unclear 43:36). But it’s so weird, and that’s something that comes back a lot in terms of invasive questions like, “Why are you inquiring into my past?” First of all, I’m probably way uncomfortable with my youth or pretransition time, especially at a time where you’re seeking care which is often a very vulnerable moment, and you especially don’t want to feel like your past is being scrutinized in order to judge your present. But also it’s like why is that relevant? Are we still in this vision that the only valid form of being trans is early-onset gender dysphoria? I thought we had moved past that, and I fail to see how it’s relevant to who I am now how I was when I was a kid. I certainly am a very different person. So it’s a weird assumption that who I was as a kid is still relevant to assessment, and that ties back to the issue of assessments. They are not just dehumanizing, but they also ask questions that are very questionable relevance in the assessment process. And this ties back to the fact that we don’t really have anything that looks like an assessment process. We don’t really have questions to assess whether people are really trans, because they kind of do all the questions we can ask cannot rely on false stereotypes of what trans people are like.

And honestly, the only question you can really ask people in terms of assessing whether they’re trans is: “Are you trans?”. And they answer yes, then that’s kind of the end of your inquiry because there’s not a whole lot more you can ask. So there’s a kind of like a dual-layer of assessments or dehumanized, but they are also absurd in the sense that what the hell are you asking.

Marianne Oakes:

I am a counsellor who deals in feelings, and when people ask me about how it feels to be trans, I kind of explain it around the words to explain it. I always say it’s a deeper sense of self, and what that means to me, in second decisions in a simple way to explain it to somebody else is really difficult. I just wanted to go back to that idea of having to prove ourselves. And I was working with a client, aged 47, who’s been on for three years and decided they wanted breast augmentation. They went to see a surgeon, and they said you need a referral letter. So my client just said, would every 47-year-old who wants breast augmentation need a referral letter? He said, “Well, no, but your trans.” As the 47-year-old, my client knows themselves as well as any 47-year-old female. But they then had to go and get referred. They needed somebody else to say yes, this person is trans. They needed somebody else’s permission to have that surgery. And when I read about in processes being dehumanizing, I think that an obvious procedure for women to have to go through that is a perfect example of how dehumanizing it is. That we’ve got to have the opinions of other people as third parties.

Dr. Helen Webberley:

Yeah I mean just recently actually and they’ve been talking a lot about cosmetic surgery and the fact that it’s not very well regulated, and are people able to access it too easily? And all I think about is, “Wait. Yes, you can completely be able to access it all too easily, unless you’re trans, then you have to jump through so many hoops and pay so much money to private providers to give you letters of referral and what have you.” Which is completely unnecessary. You know it’s dehumanizing. It’s wrong; it’s disrespectful, and it does not equal treatment. And actually, once you were talking then about the one question—I love your bravery and I think I think I’m brave and sometimes I think I’m being brave and I speak you—that we need to assess somebody, “Are you trans?” beautiful. But I’m a doctor, I’m under investigation by my General Medical Council who regulate doctors. And one of the criticisms that they are accusing me of which is under investigation is not a thorough enough assessment. And actually like you say the WPath standards of care which are a go-to place to doctors and counsellors and therapists and nurses to learn how to provide care or how to assess somebody. Even they don’t stipulate how much assessment is required. And yet I see myself as a doctor is under investigation for not enough assessment when actually what I’d love to do is follow your idea with the word question assessment. Are you trans? How can I help you best with your trans journey? But I feel even in the Gender GP model that we’ve created, it is under scrutiny for not enough assessment. And so, therefore, the patient’s going through identity systems have to have a certain amount of assessment in order to please others, not because we feel that it makes anything safer for the patient. But to please others and to tick other people’s boxes.

Florence Ashley:

Yes. I’ve actually heard about the process again to you, and I’m just completely baffled to be because it brings up the whole question of like whether standards of care are global or national which is a big question of bioethics. But one thing that I find particularly baffling as well is that the WPath standards of care actually state that informed consent model protocols are consistent with the guidelines presented in WPath’s standards of care 7, which are flexible clinical guidelines that allow for tethering of different protocols. And you know, it’s written like black letters in the standards of care. So it’s completely baffling to me that people are going like, “Oh, this is a lack of competence or something.” and it’s like it’s literally in the international standard of care. Also, are you saying that practices which are common in the United States, which is arguably you know—maybe not we all have our opinions of the United States—but their medical sources are still like serious organizations and institutions they’re certainly not poorly thought, at least not more poorly thought than many other countries including the UK—and so the idea that like this is incompetent and like what, so you’re saying that the practice which is really like the gold standard in the United States is somehow dangerous in the UK? Like what is that? So this is terribly weird to me. And also had some parts when you mentioned cosmetic surgeries, I don’t think that cosmetic surgery is are too easy to access. I think that the informed consent process is horrendous for them. So this is a very different thing, right? And I don’t think that they should do more assessments. That’s not what I think the problem is. I think that surgeons just don’t give all the information that people need to make an informed decision, and that’s something I have also criticized in the context of trans health care. And that has been criticized at the (unclear 51:58) level in terms of surgeons. And I also have an article that’s forthcoming on the matter regarding the fact that I don’t think that surgeons give all the information people need. But that’s not a matter of whether the informed consent model is is wrong or not. It’s saying well, you know, just because we’re in favour of the informed consent model doesn’t mean anything goes. You still have to gain informed consent, and informed consent is not a rubber stamp. Informed consent is a meaningful decision-making process that you know should be done in the correct manner. And I think there are huge issues with how it’s being done right now, with 20 page long forms that people just like sign and don’t understand what is even in the information. You do need doctors and surgeons to give them a true understanding of what’s going on. One of the things we see is with breast augmentation and specific implants that have you know severe risks associated with them in terms, and those risks are not necessarily always well explained to the patients. And I think it’s like people have taken that approach of like we’re just through all the information to the patient and help them make sense of it. But you know you need to actually do your job as a clinician or as a surgeon in many of those cases and actually sort information for the people that are seeking care with you. I think that’s very important I think that’s not something that’s done properly in a lot of cosmetic surgeries, and I think that it’s also an issue in some of trans health, especially when it relates to surgeries and surgical options. What are the benefits of different techniques? What do you need to know before your surgery? Well, one thing that people often don’t know is don’t think about this the impact it’s going to have on our mental health and on their everyday well-being when they have to go off hormones for three weeks before surgery. You know, that has been a huge problem for me when I went the first time for facial feminization surgery. And when I had bottom surgery, later on, I was much more prepared and actually took measures to manage my mental health during those weeks. And you know that is something that’s really important, and people have to know but is often not done by a surgeon. Because they’re like, “Well, that’s not part of you know the kind of risks that they understand to be part of the informed consent process.”

Dr. Helen Webberley:

Personally, I think too much time is spent assessing whether that person is truly trans, and not enough time discussing and negotiating the right way forward for that person’s medical or surgical intervention. Florence, I’ve met someone else, Johanna Olsen Kennedy, who could talk all day on the subject, but unfortunately, we don’t have all day. We are time-limited. Thank you so much for your passion and sharing your knowledge with us today. You’ve made me feel even braver if that was possible. You referred to some articles that you’ve written and published. It would be great to have some let some of those links so that we could just put them at the bottom of the podcast so that people can explore your ideas a bit further.

Florence Ashley:

Absolutely. And if anyone wants to read my work, I put all of my publications on my website, florenceashley.com, and there are free versions that are not behind a paywall on my website. Brilliant.

Dr. Helen Webberley:

That’s great. Thank you very much. And I’m sure, Marianne, you join me in thanking Florence for her wisdom today.

Marianne Oakes:

I really enjoyed it. It’s been lovely and empowering to listen. Brilliant. Thanks ever so much.

Florence Ashley:

Thank you.

Marianne Oakes:

Bye.

 

Thank you. We hope you enjoyed our program. Do go ahead and subscribe if you haven’t done so already. If you or anyone else is affected by any of the topics discussed on our podcast and would like to contact us, please drop us a line at [email protected]. We’re very happy to accept ideas for future episodes and guests, or if there is something specific you would like us to cover. You can also visit our website, www.gendergp.co.uk. You can follow us on social media @gendergp, and you can sign up to our monthly newsletter. Full details can be found on our show notes on the podcast page. Thanks for listening.