Shortly after publishing the piece which flagged the Welsh Gender Service as a potential Service of Concern (now a fully fledged Actual Concern) I received an email from a former gender clinician I had briefly met in London earlier this year. Let’s call her Anna.
Anna worked at an adult gender clinic between 2016 and 2019 and still works in the NHS. When I met her, I asked if she would consider doing an interview. At the time she politely declined, but took my card.
Anna told me she had been prompted to get in touch after reading reports about the Welsh Gender Service. Her email said: “Nothing has changed. It’s a scandal. I’m happy to speak with you.”
I have verified Anna’s identity and her role at her former place of work, which I am not naming to protect her anonymity. This is her first interview. I start by asking Anna how she ended up working in a gender clinic.
“I trained as a therapist”, she tells me “and I’ve always worked in mental health services and psychiatry. I suppose I was just looking for something different, really. So this job came up, and the job title was Clinical Team Leader and Senior Practitioner at the [gender clinic].”
Diagnostically Focused
Anna got the job, half of which involved working on the managerial and operational side of the service, whilst the other half involved taking on the role of “doing the baseline assessments… assessing for gender dysphoria.” Each patient was referred to the service by their GP or by the Tavistock children’s gender identity service (now closed). The patient would be assessed over a minimum of two ninety-minute one-to-one sessions with different clinicians. One clinician would be a medical doctor – usually a consultant psychiatrist. The other could be a psychologist or mental health practitioner, like Anna. “What we were doing”, she told me, “was seeing if they met the diagnostic criteria for gender dysphoria and transsexualism and whether they were ready to progress to cross-sex hormones and surgery.”
At the time, Anna’s clinic used the criteria for gender dysphoria in DSM-5 (the standard American psychological manual) and gender incongruence in ICD-11 (the World Health Organisation’s International Classification of Diseases). The relevant definitions are helpfully laid out in Appendix 10 (pp375-376) of the Cass Review.
Perhaps naïvely, Anna thought the clinic “would work like all the other NHS services I’ve ever worked for. I thought the job would be about psychological formulation – that is, understanding why people want to transition and working with them to think about that, and then decide what is best.” When Anna started work, she found the clinic “wasn’t like that at all. It was very diagnostically focussed.”
The system was based on traffic lights. If a patient met the criteria for a gender dysphoria diagnosis, the assessor would tick a green box. Another green box would be ticked if they were considered “stable” and suitable for and social transitioning (though Anna remembers the expectations involved in social transitioning falling away somewhat whilst she was there). Stable meant no acute mental illness or recent suicide attempts, rather than historical risk. Four green boxes ticked after both assessments meant a diagnosis of gender dysphoria and a potential testosterone/oestrogen prescription. If either assessor ticked amber or red, the patient’s case would be brought up at a wider weekly “clinical team discussion”.
Blue in the Face
Anna describes this system as “crazy”. I ask how NHS mental health patients outside a gender environment would normally be assessed. “In terms of psychiatry,” she replies “you wouldn’t be really fixed on diagnosis. Maybe in the 1970s or whatever, but nowadays… you’re working with people presenting problems. Someone might have schizophrenia, but it’s about what difficulties that is causing in someone’s life. Why have they got schizophrenia? Let’s think about this person.”
For the first six months or so, despite thinking it was “a bit odd”, Anna went along with it. Eventually she started raising questions. “My concerns were that somebody could meet the diagnostic criteria for gender dysphoria or transsexualism, but it wasn’t about gender. Somebody I remember very, very clearly, was a young woman, who was identifying as a man. She had very large breasts, and she wanted cross-sex hormones. She wanted testosterone and she wanted her breasts to be removed. Okay. But her history was that she had been sexually abused for many years by her father, and the sexual abuse was around her breasts. It’s so bloody obvious. I could stand next to somebody at a bus stop and say “What do you think of that?” And they’d say, “Of course you’d need to think about the sexual abuse.” Of course you would. But at the gender clinic, she met the diagnostic criteria for gender dysphoria. So she went through.”
Anna also quickly became aware that “about 50%” of the clinic’s referrals had a diagnosis of autism. “But I would guess a further 20%, maybe more, had undiagnosed autism or something very similar. They had very fixed beliefs, eg if I feel uncomfortable in my body, then I need to be somebody else. Things were expressed in a very concrete way: If I become a man, if I become a woman, if I get this such-and-such removed, that’s going to solve my problems.“
Anna thought her job was “exploration”, but this was “hardly done at all. It was done a bit, but hardly at all. The overriding thing was, do they meet the diagnostic criteria? And I suppose I kept saying, till I was blue in the face, you can meet the diagnostic criteria, but it’s not about gender. It’s about other things.”
Man In A Dress
Remember this was 2016, a period Anna describes as “peak trans”. The clinic practised gender-affirming care and giving patients the diagnosis they were asking for was what gender-affirming care looked like. Anna was forced to examine her position.
“I turned myself inside out, thinking, am I transphobic? I was accused of being transphobic on a number of occasions. One of the consultants said to me once, “the thing is, we’re giving people what they want”. And I said, “if you were faced with someone who was anorexic, would you help that person to starve themselves?” Because it’s the same thing. Just because somebody wants it… if they want their leg chopped off, are we going to do that?”
I ask Anna to tell me more about the people referred to the clinic. On occasion she says she would find herself “in a room with a bearded man, in a dress. Not always. Sometimes it would just be like sitting in a room with any bloke, really, but they were telling me that they’re a woman. And I would say, “why do you think that?” Generally there would be really stereotypical reasons – “I like cooking. I’m really empathetic.” A 1950s housewife view of a woman. It would feel like a very regressive and quite aggressive view of womanhood. And that was disturbing.”
For some men it was a sexual fetish. “There was a group there where I thought it was autogynophilia… men attracted to the idea of themselves as a woman, and wanting to fashion themselves into one. Clearly nobody would say that outright in an assessment, but as a team, occasionally we’d say, we think this is autogynophilia. My view was it applied to a lot more people than the team acknowledged.”
As for the women… “I would sit and almost want to weep because a young woman would come in and say “Oh, well, I’m not into dresses, I’m not feminine, I’m attracted to other women. So I’m wondering whether actually I am a man?” And I would think you’re a lesbian. You’re a gay woman. But again, they’d meet the diagnostic criteria. So.…”
Blocker Brain
Another chilling example Anna gave was her experience of dealing with 18 year olds who had been put on puberty blockers whilst at the Tavistock children’s gender clinic. “Because they’d been on puberty blockers, it felt like being in the room with a 13 or 14 year old. Cognitively and emotionally, it felt like somebody much younger to the point where, as a team, it felt like we were working in an adolescent service. But we were an adult service. I’d never worked with adolescents. It’s a different field. So I suppose we were… I wouldn’t say out of our depth, but it was uncomfortable.”
I pick Anna up on the point about cognition. Was she saying that these teenagers’ mental development had slowed?
“Totally, yeah. Totally. And I can remember we had a training session with some of the endocrinologists from the Tavistock children’s gender identity service. And I put that to them and they went, “No, no, no. There’s no evidence for that.” I said, “well, that’s what I’m seeing”, but they were just: “No, no, no. That’s not a thing”.”
The lack of curiosity which we saw at the Tavistock, WellBN surgery and almost certainly at the Welsh Gender Service was alive and well at Anna’s clinic. “Quite soon after I started working there”, she tells me, “I said, “how do we follow people up?” And I was told “Oh, we don’t follow people up.” I said, “what do you mean?” They said “we don’t follow people up because we’re not commissioned to work with people post-surgery”. So people would go through all the system, have the surgery and then that would be it. Occasionally you get people wanting post-surgery appointments and we just told them we were not commissioned to work with people post-surgery.”
I Don’t Think
That lack of care also meant a lack of information. Anna references the York study, carried out for the Cass Review, during which several gender clinics refused to hand over their data to Cass’s researchers (see Cass Review p20). This would have given the NHS an insight into how patients were faring after their gender treatment. Anna’s theory is that they couldn’t have handed over any follow-up data, even if they wanted to. “They bloody don’t have it because they didn’t do it. And again, in what other area of medicine would you not be having follow-up?” Anna found herself watching people put on a conveyor-belt to life-changing surgery “and then they would just disappear.”
Despite the apparent red flags, Anna describes a sense of purpose at the clinic. “There was an ease to the work in the sense of: desperate people come. They know exactly what they want. As a clinician or as a service, you give them what they want. Everybody’s happy. You can feel quite righteous, I suppose, we’re being really trans-affirming. We’re doing the right thing for these people.”
I suggest this is confusing political decision-making with clinical decision-making.
“Absolutely”, replies Anna. “When I started working at the gender clinic, it was 50/50 men and women coming through with a reasonable spread of ages. And then when I left, it was 80%, young women under the age of 25 wanting to transition to be male. And I would say in meetings, “in any other field in any other field of medicine, if your demographics changed that significantly over that short of a period of time, wouldn’t you be asking questions? Why are we not stopping what we’re doing and asking these questions?””
Anna sounds quite forceful at this point and apologises for getting upset. The whole period has clearly affected her, with certain episodes sticking in her mind. “There was a consultant psychiatrist who was also a psychotherapist. He worked part-time with us and part-time at the psychotherapy service, and he’d say: “when I work in the psychotherapy service, that’s where I think. And when I come to the gender clinic, that’s where I don’t think. I just do do what’s asked of me.” And I remember thinking, but you’re a consultant. You can stop it. We need you to think. We need you to think.”
Castration as a Treatment Option
I ask what kind of response Anna got for raising her concerns. “It wasn’t really responded to very well. I think I was humoured, really. It was quite a fairly small team. It was the most difficult experience of my professional life. I was treading a line between having to manage a team, having to do a job, but also thinking, what we’re doing is wrong. It’s unsafe, and I suppose I moved… over time. I started the job thinking, well okay, this is a new field for me. This is how it’s done. I’ll just fit in. And then I suppose towards the end of my time there, I wasn’t putting anybody through [for a gender dysphoria diagnosis] at all. That got me in a lot of hot water. But yeah, I was I was raising my concerns. The consultant wasn’t interested, but then I raised them with my manager and his manager.”
Anna describes a fairly bleak meeting she had outside the clinic with a senior person at her NHS Trust. “I was in tears. I was saying, “look, there’s all these vulnerable people. We’re castrating them as a treatment option. We’re not thinking about it properly. It’s so wrong.” And he said, “I agree with every word you’re saying, but what you don’t understand is that the gender clinic bankrolls the mental health services in this Trust*. It brings in a lot of money for the Trust.” I said, “In that case, I’m out of here. I’ve been trying and trying. Really legitimately, and with a lot of integrity to raise this, and you’re not fucking interested, are you? That’s all you care about.” I felt like the little boy looking at the emperor’s new clothes.”
Towards the end of her time at the clinic, Anna’s unwillingness to put people on a treatment pathway led to her becoming “very ostracised… I was shouted at. I was bullied. And so sometimes there were days where I’d think, you know what, I’m just going to put people through because I can’t…. It’s too much. And I think it’s that bit I have to live with”.
Unsurprisingly, Anna’s mental health began to suffer. She wasn’t sleeping well. “I was being tearful at work. I can remember having to build up my strength every day just to go to work, just to withstand it.”
By the end, Anna says she was on her knees. “My husband was very concerned and it was him that said, “you’ve just got to leave”. I’d asked for a transfer to another part of the trust but that wasn’t forthcoming, and obviously I was trying to get another job. But my husband said, “you just need to leave. We’ll manage financially. Somehow we will manage. But you can’t go on like this.”
Anna went off sick. She left the clinic, retrained, and continues to practice within the NHS. She is still haunted by the people she put on a path to life-changing treatments. “I have to live with that. I was part of that system until I refused.”
Gender Liability Insurance
Anna now believes that all adult gender clinics need to be shut down with patients treated by integrated mental health units.
“I don’t think gender clinics should exist. I think the supply creates its own demand. Let’s look at it: the NHS is castrating people as a treatment option. Is that right? I don’t think so. The NHS is removing healthy breasts and doing surgery on healthy vaginas, for things that have such low evidence base, including cross-sex hormones”.
When she resigned, Anna sent a letter to the chief executive of her Trust and all the managers in between. “They took three weeks to respond, and they said, “do you want a do you want an appointment with HR?” That was the response.”
Anna’s attempts to blow the whistle ultimately failed, but it did put her in contact with the Trust’s Speak Up champion, a person trained to deal independently and confidentially with staff concerns. The two became friendly and stayed in touch after Anna left the clinic. Although nothing changed as a result of Anna’s concerns the Speak Up champion later told her “what the Trust did do almost immediately after I left is take out liability insurance on the gender clinic. That says it all, frankly.”
I ask about the Levy Review, commissioned to look at adult gender clinics in the light of the Cass Review into children’s services. It was published in December and its findings can be read here. Although she says she spoke to Levy, Anna calls his review “a waste of time”, because it didn’t consider the NHS non-surgical specification for gender services – just whether or not the gender clinics were adhering to them. Anna calls the specifications “not fit for purpose”. Whilst she was working at her gender clinic, they were using the non-surgical specifications and patients were being set on the approved treatment pathway without other factors being considered.
Today, Anna is firmly of the view that when it comes to dealing with people presenting with gender incongruence, the current approved treatment pathway is little more than “pseudo-medicine.” She says “We haven’t got an evidence base for hormones. Hormones are prescribed off licence. We haven’t got proper evidence base for the surgery. There are no long-term follow-ups. I just think the whole thing is wrong.”
I am grateful to Anna for her time and her willingness to come forward. I hope it makes a difference, and that other clinicians with qualms about the current NHS treatment pathway might also be willing to get in touch.
* When I queried how the gender service could generate cash to fund mental health services. Anna explained that gender clinics attracted decent settlements from the central NHS funding pot, but the money was not ring-fenced. It was given to each Trust as part of a general settlement which the Trust could spend as it saw fit. Clearly Anna’s trust was diverting some of the money given for gender services into its mental health provision. Anna says this happens across the NHS, and is an accepted part of the system. “I’ve never understood it”, she says.
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