I am worried that the social work profession has been silent on the impact of gender identity issues on our work, in particular concerns about the affirmation approach to working with people who identify as transgender. I have worked with children in care for over 20 years and this is a fairly recent phenomenon; late 2020 was the first time I worked with a teen who identified as transgender and there have been more since then.
Are social workers afraid to talk about the issues? Anyone who raises concerns is labelled ‘transphobic’ and a ‘bigot’ and some social workers - such as Sonia Appleby, Rachel Meade and Lizzie Pitt - have faced disciplinary processes for raising their concerns about the impact on safeguarding children, women’s rights and the rights of lesbians. They were all successful in challenging their treatment, and “gender critical” beliefs are protected under the Equality Act 2010.
Gender Critical beliefs are classed as believing biological sex is real, unchangeable, and that there are situations when sex should take precedence over gender identity in how we organise society (eg single sex services, sports, crime statistics). Alternatively there are those who believe that everyone has a gender identity, that this is innate and should take precedence over biological sex with regards to how we organise society. Along with this belief is the view that transgender people should have access to hormones and surgeries to change their bodies to fit their gender identity, this is known as ‘gender affirmation.’
In spite of gender critical beliefs being protected in law, the conversation in social work is still stifled; the predominant narrative is still that gender critical beliefs are bigoted. Workplace cultures for many people are dominated by policies and training which are gender affirmative, including our own regulator Social Work England; this leads to a fear of speaking out, of demonstrating our professional curiosity, and questioning the narrative.
It is positive that Social Work News is starting to post on this topic with Vince’s latest Supervision article, however he presents a pro-affirmation approach as the accepted approach, demonstrating how this narrative continues to dominate.
This runs contrary to the evidence; in April this year Dr Hilary Cass published her independent review of the evidence for care of gender distressed under 18s following a 4 year investigation. This review was prompted by a judicial review into puberty blockers initiated by Keira Bell, a young woman who transitioned medically but regretted it. In her own words she was “a girl insecure in my body who had experienced parental abandonment, felt alienated from my peers, suffered from anxiety and depression, and struggled with my sexual orientation.” She says she got caught up in the idea that transitioning would solve all her problems.
The Cass review found the majority of children presenting with gender issues have comoborbities which could be causing their distress and which should be treated; autism, ocd, trauma, depression and anxiety and she recommended a holistic approach to help these children. Studies into the Tavistock Gender Identity Service found that 35- 48% of children referred displayed traits of autism, a study into referrals from 2009-2011 found 4.8% were children in care (compared to 0.58% of all 0-18s). The Cass Review is thorough; it covers child development and social context and should be read by anyone working with gender distressed young people.
There was a 4,000% rise in referrals for teenage girls to the Tavistock GIDS from 2009-2017, a similar rise in referrals for teen girls is seen across the world. This is partly explained by social contagion; the rise coincides with the development of smart phones (2008) and social media (Tumblr started in 2007 and some detransioned girls say they first learned about being transgender on Tumblr). Teenage girls are known to be susceptible to social contagion, including anorexia and self-harm, puberty is a difficult time and can cause distress; this distress is genuine but how young people experience and understand their distress can be culturally influenced. Symptoms of mental distress vary according to the ‘symptom pool’ a culture and time specific collection of symptoms which develop unconsciously at the population level and manifest at the individual level. There is a rising number of detransitioners; people who regret their medical transition and identify as their biological sex again, many of them were affirmed and medically transitioned as young teenagers. Their stories tell us that they wish professionals had explored more deeply into what was going on for them and supported them with their other mental health issues.
BASW has recently published articles in their Professional Social Work magazine but is yet to follow up with practice guidance; Julia Ross, chair of BASW wrote: “We have a professional responsibility and a duty of care to children and young people caught up in what is a distressing and confusing time.”
Social workers are in a unique position to be able to give advice and support to parents along with other professionals. An article on the NHS ending the use of puberty blockers for children who identify as transgender acknowledges that there are differing views among social workers - those who believe that the evidence points to affirmation being the best treatment and think the Cass Review was biased, and those who are concerned and wary of the affirmation approach.
There is a misconception that therapists in the UK who don’t take an ‘affirmation’ approach will be damaging to a transgender person and will be seeking to change their identity: this isn’t the case. Therapy is about exploring this and has no agenda but to help the person understand themselves better. For children and young people we need to take a developmental perspective; we know that identity formation is a process and ongoing throughout adolescence, Gender affirmative therapy can be a tick box exercise to put a child on a medical pathway, often with only a couple of appointments children have been recommended for puberty blockers ; a concern raised by many whistleblowers from the Tavistock and other gender clinics in USA.
Social workers working with gender-questioning children and teens need to question the affirmative narrative and look at more sources of information; the systematic evidence reviews carried out in England (The Cass Review), Sweden and Finland all found no evidence that the benefits of ‘gender affirming care’ which prioritises access to medical treatment (puberty blockers, cross sex hormones and surgeries) outweigh the harms. They all recommend psychotherapy as the primary approach to help children and young people with gender related distress and to also treat any comorbid conditions rather than hope that gender affirmation will cure all their distress.
Social workers need to be professionally curious about this subject and wary of trusting the information we find or are given in training without critically analysing it and being aware of potential biases: Both Stonewall and Mermaids are ideologically driven in one direction; they are pro-affirmation and critical of the Cass Review.
It is important that we take lived experience into account, but this cannot be our only source of information; the evidence base is clear and we need to be wary of the affirmative approach as it can lead to medical harm. For information about taking a more cautious approach to working with transgender people social workers and other professionals can look at the evidence base on SEGM (society for evidence based gender medicine) and guidance on Genspect or on Therapy First to find therapists who will take an exploratory approach. Genspect also offer support for parents who show caution against affirming their children and there is also The Bayswater Support Group for parents.
We need to have open conversations as professionals so we can do the best for the people we work with; these conversations need to go beyond talking about children and teenagers with gender distress: There are other implications for social work practice relating to the gender critical/gender affirmative divide: single sex refuges, prison, rape crisis centres, children whose parents transition, the impact on law and policy and the impact on safeguarding.
These are all conversations we need to be able to have openly as they all involve a balance of rights, we can have these conversations respectfully while upholding our values but we must have them.
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