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Working with gender difficulties in adolescenceClinical Psychologist GID Service – Dr Aidan Kelly.Transcript.. Dr Aidan Kelly is a Clinical Psychologist who works at the GIDs Clinic based at the Tavistock. Based in London and Leeds with a relationship with a Dublin Clinic. Transcript. It’s really really great to see so many people here to talk about this. I think things have come on a lot and it’s a good sign there’s so many interested people. I am a clinical psychologist at the Gender Identity Development Service in London. (explains he is Irish). I am one of the small numbers of the team that come over monthly to (unclear) to run a clinic here. I was a little bit disingenuous I realized with the original title of this presentation because I think I wrote down about adolescence but in hindsight I maybe should talk about the whole of childhood really because they relate to each other quite well.So the idea is, today, to do a brief introduction, talk about the service I work in. consider identity but also gender identity in a wider context. It is really, really, complicated its really, really, yeah, complicated and there’s lots of things to think about. We won’t get to think about them all today but maybe I can plant some seeds, get you kind of thinking and I’ll be round after and during the break and after if people want to think a bit more about what’s mentioned and then obviously, particularly how we support the young people that I see and I am sure you guys see as well. And who are exploring their gender identity as well.So, what do we do? We support young people and their families and who are experiencing gender difficulties in the development of their …or difficulties in the development of their gender identity. They don’t necessarily …it’s not an outcome specific service so you don’t have to say I know what I want when I come to the service if you know it’s just something you need to explore and think about that is what we are really kind of about.. it’s not outcome specific. So, when I talk about the service I am talking about the Tavistock in London. It was first established in 1989. The main bases it has are in London and Leeds its funded through the NHS and we see young people up to the age of 18 erm and we work closely with local services such as you know yourselves or CAMHS or these sorts of local services You’ll see that the service from 1989 to now looks very very differently and also part of the service in includes the Dublin outreach and we see much much more mainly kind of older teens but then the primary school aged kids we do see primary school aged kids. Probably the youngest kids I have on my case load are probably six or seven and there’s a range of .at the moment we see a lot more assigned. so, I use the term assigned female at birth to refer to I guess refer to what people think of as people born with an anatomically female body. So we are seeing a lot more of them now proportionately it’s about three to one so over 75% of our referrals are assigned female at birth so whereas maybe five, six or seven years ago it would have almost been a flip on that, an almost reverse. We can think about and have ideas about why that might be, but the answer is I actually don’t know. There might be theories and ideas about what might be going on and there’s a range of identities and we can think more about what do I mean when I say identity .For example we are seeing a lot more of what we call non-binary individuals, at the moment, and not everyone will identify as trans or non-binary for the rest of their lives. Identities are such that they are critical complex and can evolve and develop especially for young people. We also see a small number of young people who are children of trans parents. And so, if a parent comes out as transgender, we will help support the child around understanding that, and thinking about that and the implications for the family. 99% of what we do is with young people who identify as transgender but it’s not just that. I will think about the Dublin service in a minute but <Shows graph illustrating a dramatic rise in referrals to the Tavistock.>We want your ideas about what this is all about I don’t know how clear it is but basically ..first year of referrals in 1989/90 I think there was 3 referrals and you are coming up to 2015/16 and we are coming up to ..then corrects himself and refers to 2016/17 to say we broke 2000 referrals, in a year that’s across all of the UK and Ireland….you can see there in about 2010 the referral rate started doubling its been going up and up and up and that’s around the same sort of time as when the gender or the sex assigned flipped on its head and it went from predominantly assigned males to predominantly assigned females being referred. This is reflected, these are UK figures, but this is pretty much reflected in Ireland as well and the same proportion wise.In Dublin it’s pretty similar to the UK but obviously much smaller numbers. At the moment we’ve got 51 active cases that are open and I just put 17/33 there and that basically refers to assigned gender or natal sex as some people call it... so 17 of those are assigned male and 33 are assigned females on the caseload at the moment. As I said the monthly clinics at Our Lady’s Children’s Hospital, Crumlin and we’re starting. I’m trying. So I am the first person within the service that’s Irish…I don’t know if that’s a good or a bad thing but I am I guess, because it’s a HSE bought in service, and it kind of happens to be honest after I guess I focussed on the NHS service. We need to focus on the NHS work and I guess until now it’s been difficult to give Dublin and Ireland all the energy and resource it needs so I guess I’ve kind of taken the lead on the Irish Service at the moment. I’m trying to do a lot more working alongside other agencies and I’ll just put down for example I was down in Tralee running a clinic down there or the first time. Down in Kerry doing a clinic with the local CAMHS service there to try to help train them up so that they are at least not just referring then on to us and wondering what kind of magical or crazy stuff kind of happens there what you do so kind of actually doing joint assessments with some of the well ..I’ve got one of the psychologist and the social workers so I’ve got a different case going with each of them and I’m kind of supervising them as they kind of do a bit of work and I come back over to Tralee a few months later and check in. It’s trying to pass on expertise and move it around the country to skill people up so it’s not such a …It can feel like a scary thing to start talking about and people can feel quite de-skilled and when someone says something about gender issues and they don’t really know what do I do, where do I even ask, what’s the first thing to think about and I guess it’s just demystifying it because I guess essentially these are just young people you know, you know you work with them you know how to do that anyway and it’s just they’re given a little bit more information and thinking about how we start to take about gender, I suppose. Erm yeah so, I mean there are about 30 people on the waiting list, and we are getting two to three new referrals each month and how do we get those referrals. they come. it’s a funny system because it’s not an HSE service and is covered by the treatment abroad scheme. So, you have to usually go to CAMHS or a paediatrician to get the referral to get funding to come to our service…it’s a bit of a minefield compared to the UK where a GP can refer straight to our service. Which causes problems when there’s long waiting lists there, I know that. There are in terms of Ireland in terms of a service here which we were trying to help support the local HSE to do and there’s rumblings that there’s one kind of coming quite soon. They’ve been trying to get funding for the last 4 or 5 years. I am hopeful that something is going to happen which I am really excited about. I know they have funding for the psycho-social arm on the adult side so to a move to a more formalised adult service and the child service might be a year behind that. So that’s the service level stuff but what is it we even do…I’m a psychologist. We are predominantly psychologists, but we have social workers, family therapists we’ve got psychotherapists. that’s most of them. A multi-disciplinary team typical of what you would find at a CAMHS. We are very much family focused. The first stage when a young person comes to us is an assessment phase which usually lasts between four to , well I’ll say three to six but four to six sort of sessions where we meet with the family, the young person. We work in pairs, me and another colleague. We will try to get to know the family, development history, education and social side, well-being, health and, of course, obviously gender and how that develops and evolves over time. Basically, at the end of the assessment we will come up with some recommendations which might mean more talking, thinking about family stuff. It might mean medical, physical interventions, age dependent and or it might be that actually the process itself has been helpful and they might just go on their way and get back on normal lives. We do lots of group and family days, usually in London but we are trying to get something going in Dublin soon. We really want to try to link with local services to support young people to think about gender. As I said we do what we call a stepped care approach. These are young people in developing bodies and minds and maturity and so we do things in a very kind of cautious ..people get annoyed with us because we move too slowly but give its young people we think it’s appropriate that we move slowly and it’s not just a physical intervention service, although that’s part of what we offer with an endocrine team and actually Irish people we do have the endocrinologist and hormone doctors are based I Crumlin…so now need to travel to London now they can get it locally in Ireland. We also do psych-social support but it’s a bit more difficult in Ireland as we come less regularly. Slide on Physical Interventions Just in terms of what we offer in terms of the world agreed kind of criteria/protocol for child services. I should have pointed out that the Gender Identity Services I work on is the largest service in the world, probably because we are national so these are the largest numbers you will get in terms of service size. In term of physical services which young people are really keen to know about it. in terms of what can I get and how soon can I get it. We start off with something that is physically reversible, okay so which is something called a hypothalamic blocker which basically pauses puberty. It stops your body producing naturally occurring sex hormones so for Assigned males it would be testosterone for assigned females that would be oestrogen. It doesn’t further masculinise or feminise your body it just stops things progressing any further. That won’t be offered until at you are at least half way through your puberty, which occurs at different ages. This is because for lots of young people beginning puberty is a really important thing and how you integrate your idea about yourself in terms of not just gender but also sexuality it is really important that a certain amount of puberty is allowed to occur. You are allowed to develop an idea of who you might be attracted to… And also, the limited evidence we do have in this area which this is a massively under-researched and quite an experimental area especially in terms of young people. The limited evidence that we do have is that people, young people, before coming into puberty who express gender related difficulties and it’s not clear whether that will sustain throughout puberty. People argue over the numbers, but it is definitely a 50/50 sort of split in terms of what we expect. There are some people who go through puberty who continue on to express a wish and identify with the gender they were not assigned at birth but there are also the young children who experiment and play and for them, once they hit puberty. So experiment and play with things that may be things that are stereotypically associated with the other gender and once they come to puberty they find a way of incorporating and that identity within the body which they inhabit,. So, puberty is pivotal, it’s really, really important, it’s a scary thing but it is also a really important thing too. So once we have gotten to a point where we think this is the right thing to do and with the family and really often we are often putting responsibility back on the family because we don’t have the evidence base to say its these kids and not these kids or how we can pick out which kids should go forward and which ones shouldn’t Its really a holistic piece of work to make sure that the young person as much as they can, but really the family that we are thinking about everything they need to be thinking about engaging in open and honest conversations about things that have gone on in the past..just so that we know that if they come back to us in 10 or 15 years, not to come back to us but just they think back themselves in 10 or 15 years and go “you know what I made the right decision for me , at that time”. And that’s really what our holistic assessment is really about So in terms of the medical signs it’s the hypothalamic blocker which if you stop taking it your body will just kick back in and continue and reproduce the naturally occurring sex hormones and your puberty will basically finish off, it will kick back in if it’s not already naturally finished. People often young people will just be “give me the blocker, really quickly, it’s totally reversible and just give it to me quickly because my body is changing and is distressing me. The blocker is not a benign thing it’s not a …it comes with, I don’t mean a financial cost, but it comes with a downside. Especially around energy , especially if the person has mood difficulties the blocker can sometimes make that worse and it also takes away those sex hormones so that whole thing about, in terms of being attracted to people, developing crushes ..when all your teen peers are getting in to relationships and developing social connections.. In that sense it will be gone. I mean not totally gone but that drive, that kind of interest in whether it’s the opposite or the same sex or whatever its kind of greatly reduced. And we don’t worry because we don’t have long term outcomes for this. We do worry what impact that might have on their identity because sexuality is such an important part of your identity, who you are attracted to /So, the hypothalamic blocker is available dependent on puberty. So, the youngest, depending on hour far into puberty you are, you could, in theory get the blocker as young as ..I’ve never given it to someone whose ten but it’s probably 11 or 12…so it’s really , really quite young. It’s very much the exception. It’s very much the exception. It’s not quite precocious puberty but it’s an early puberty but often we are thinking about 13, 14, 15. Then once you are on the blocker for a minimum of a year we would continue meeting, thinking, it’s not quite therapy but it’s a therapeutic piece of work then cross sex hormones which are definitely not fully reversible. They are available from 16 okay…Once you start taking them, it’s not an instant thing overnight, changes will start to happen and even if you stop taking the medication it won’t ..it won’t undo itself, I suppose so it’s quite a serious thing. And that’s as far as we go I the child and adolescent service and any surgeries or things like that are only available in the over 18 okay. So that’s kind of the physical side of things. There’s a lot of information to take in there. .(Slide with lots of colours…I include only because…Why? What is the point. My point)I always separate out erm the physical side and the identity and sometimes they get kind of merged together in to one. So people think if I identify as male of female I need to do X, Y or Z and that’s almost a fixed pathway and well-meaning adults can fall into the same trap. And the more and more work we do we realise this is not the case. Whether they identify as male, female, non-binary or gender queer or all these terms you might become familiar with… How they become comfortable in their body might be different for each person. Someone who tells me they identify as MTF, or FTM or non-binary does not necessarily mean that medial physical changes are the right thing for them.… Diagnosis is a part but a small part of what we do. Diagnosis is called Gender Dysphoria. I could probably diagnose people in one session, but we meet for one to six sessions. Actually there are many people who meet that criteria but there will experience Gender Dysphoria in their teenage years who will, with time, no longer experience that and, with time, will be able to integrate how they feel about their body , within their identity and come to terms and come to accept the themselves. Some won’t and that’s the tricky part. The diagnosis is not necessarily the hard part actually It’s the assessment of whether this is the right thing of whether this is the right thing for this person at this time…So when we are doing that we are also thinking about identity as a whole of which Gender is a part. I am often thinking about this Venn Diagram he tells us…Slide The Biological sex is your anatomy is a really important part of sexuality and sexual identity is there. Gender Identity is I guess quite a personal and individual thing and young people may take time to come to think about it. Some will tell you straight away from a very young age and will stick to that .say this is my identity and that’s fine but some will take some time to explore that and form that, I suppose,. Gender Expression is a thing that can confuse people sometimes. Say I identify as a male, or whatever, and my idea of masculinity might be different to someone else’s and how I express myself as a man might be different to how someone else…people often talk about traditional, you know the tradition of sort of man and or these kind of metrosexual sort of guy. So, I guess even within the idea of masculinity or femininity and just in terms of theirs different ways that I would let you know, not let you know but I would maybe dress and even my manners, my hands or how I sit, if I cross my legs in a particular way or I can in an S shape is normally seen as a more feminine way of sitting. I don’t know. How you express your gender is a complicated thing and it takes young people…and it’s kind of hard to think about it, I supposeThen there’s gender roles. So, what do men do, what do women do. What does it mean to pick up the dustpan and brush or hoover? What does it mean to be really big into football or all these things that often we will talk about gender stereotypes. Say that’s a boy thing or that’s a girl thing well actually why, why is it? So, a lot of it is deconstructing and yeah I suppose critiquing with the family or the young person. How do you come to this Gender Identity? How do you incorporate it into your world? Because the last thing we want is a young person changing their body to fit in with they think societies rules are. There is a level of that, and we can’t change society. I would love to be able to change society and take gender out of it all together because then what does it matter? You just express and be what you want to be or how you identify. But there’s a reality to some of society. And then we also want to just help young people feel that they can carve out a space for themselves to be and express themselves however they identify really. Now he brings up this slide. It should be very familiar to anyone engaged in this topic. To do this sort of work we often use things like the Gender Unicorn, if you type this in online you might have seen it before. It just kind of introduces the idea of continuum’s for these different parts of identity or gender identity I suppose. It just helps and just how especially with children, not so much for themselves but for their parents, or friends of school or where does Uncle John fit in terms of his Gender identity. Is he more or less manly than so and so and so it’s just kind of shaking it up a bit? It’s a nice tool that I use to talk to young people. So, I guess I’m trying to get through in terms of time.I guess in terms of what often come out when I did this sort of talk the common worries that I get (see slide below). Are we intervening too young, these young people in their bodies they’re young they haven’t fully formed and its mentally as well as physically and what about sexuality? How do we know that a young person it’s not more about sexuality rather their gender identity. What happens when there’s a traumatic history, particularly relevant to this audience to you guys (I presume the professionals in the room would work with trauma)…and how does that influence. Does it not? How would we know if it did? And I guess I always go back to its really important that we know about history and trauma and thinking about that. At the same time, we need to think well we are here, because we are here. I’m not saying it doesn’t matter how we got here, it does but it also not everything as well.How can they know? Especially for young children? What does gender mean to an 8 year old to a 38 year old is probably quite a different thing and if especially if it’s an adult asking them and they are saying mum I am a boy or mum I m a girl. What do they mean…I mean what do they actually mean by that…?Yes, there’s often worries about difficult life ahead, what this might mean in terms of physical intervention. It can often mean you are signing up to be a patient for the rest of your life, you know in a way you’re taking what’s essentially a physically a healthy body…you might say in terms of Gender it’s not but medically it’s a healthy body and you’re introducing medication and making it depend on medications and so it’s really quite an ethically quite a complicated area.. and again, especially for children. Yes, physical intervention. Some people say get in there, help them, puberty is distressing, get in there before it gets too far down the line. Some people say give them more time. How can they know until they are over 18 and these sort of things. And a big concern is fertility because once you block puberty you are not producing. and once you go on oestrogen or testosterone .its different and everyone’s an individual but certainly not going to be producing your naturally occurring hormones and after a period of time this .. there will be fertility issues if you ever did decide to come off. and we are talking about starting a child down this path and what 14-year-old can think about whether I want to have kids. Most say they don’t but when they get to, I don’t know, 28 or 30 that might change.. in fact it often does. So in a way we’ve only started talking about fertility in the last 4 or 5 years before that we are putting people down this pathway and actually them coming back to us in 14 or 15 years later going you never really said.. and that’s what I mean about this being such a new area. We weren’t even doing the hypothalamic blockers under the age of 16 until 5 years ago. We don’t have people who are 40 or 50 to see how’s your life been? Were we right to intervene so early? We don’t know. Think about what your worries are. It’s a big group so I’m not going to field questions. Next slide: So How do we support children and young people presenting with Gender Identity Difficulties. I guess it’s a developmental approach and that means …how they can grasp and hold on to concepts. obviously a 6 year old is different to a 16 year old.. it totally varies across age. I will go into the development stuff a bit more after this slide….This is what we call associated difficulties, other things that go along side, often, not always but often. So, this is taken from our clinic and its self-report not diagnostic… So about 42% will report low mood or a lack of concentration . its not a formal depression diagnosis but they will report that. We have a very hight rate of ASD traits. again, not diagnostic but we do a screener, a self-report and around 30% report autistic traits in the clinical range so would be highly indicative of a diagnosis. What’s that about? Why is there such a high number with autism presentation coming to our service? Got some ideas about it. Quickly I can share that people with this condition will find social interactions difficult and will often feel a gap and engaging with peer groups can be quite difficult and is ..because genuinely it is not just a physical thing but a social thing and does it relate in some way. Doesn’t mean they are less able to go forward just means we need to think about the whys and how they have gotten to this point. I mean self-harm is unfortunately becoming increasingly common. We do have thoughts of suicide. We are fortunate, at least in the teenage group, its rare. we do get some, but I don’t think it’s more than the CAMHS population. Obviously, there are people who feel down and attempt to end their lives at the same time it’s not usually higher than the CAMHS population, which is still quite high so I don’t know if this is a win. We do try to support all aspects not just g ender Bullying is quite common. We get a lot more of the internalising behaviour rather than getting angry getting anxious. I am aware I am flying through this I hope it’s not too much. In terms of development… slide …We kind of break into three groups. The pre-puberty, the peri-puberty and the Pubertal children. You are born you have no idea of the boy or girl thing; you just explore the world and don’t know about the binary. That awareness comes from the social world over time. At age 2 able to label themselves as boy or girl but based on external things, such as hair or a dress. To a 2-year-old if you’ve got long hair and a dress you are a girl…Later on At least he is not keen on interfering with young children.If a young person is feeling confused we try to demonstrate a kind of varied gendered expression but we are completely neutral on outcome…we will often encourage Dad to do this with them to show them its Ok. Sometimes we get referrals for 5-year olds and we think we are not going to interfere yet. Sometimes we get parents who are really anxious that they son is playing with dresses and high heels. 37.35Moving away from pathologizing cross gender behaviour. Now 90% of the pre-pubertal conditions are socially transitioned. It used to be that they won’t publicly presenting but now we are seeing lots and lots of parents are transitioning their children, cutting their hair, even living in stealth.38.00. This is a bit of a social experiment that we are a bit worried about. We don’t know how this is going to impact pathways for these young people That never used to happen until a few years ago and part of the problem with the waiting time which can be round about a year’s wait. By the time they come in this has already happened. It’s not that it shouldn’t happen, but it can happen quite quickly and we want to be thoughtful about it. Next slide Peri-Pubertal young people. That’s when you are coming onto the cusp of puberty and it can be at different ages. That’s quite a critical time actually and is when your relationship to your body starts to change erm, coming into puberty is quite a traumatic thing anyway but you are still pretty much a binary. There are men and there’s women and that’s it. Okay. You are quite rigid, usually, you are about nine maybe. You are quite rigid of what a boy and a girl is and if your assigned female and you love playing football or playing with cars or doing stereotypically boy things it makes sense if you say “Well I love that all my friends are boys. I see myself as a boy”, I suppose, and given developmentally this makes sense but you might understand and process this differently as you get older. A lot of the work at this stage is around managing parent’s anxieties as they think Oh my god. I’ve got a transgender child. I want to support them as much as I can and do everything that’s right and often it’s not the child its often the parents running around wondering when can I get the blockers? When can I get the hormones? When can I do this or that and actually its more about helping manage the anxieties? We still don’t actually know they are not far enough into puberty for us to really know yet but it is also the time they are starting to develop crushes and things like that so it’s really important to think about especially if they are same sex or what we call the assigned gender er if they are attracted to ..assigned male attracted to male. Is there? Are there homophobic messages around are there things like that around? We want to make sure we knock that on the head as much as possible, if possible.Then puberty. This is the bulk of our work and this is the hard part. This is the hard part, I think, and because this is when identities, sexual, gender and other sorts are starting to crystallise and become a bit more constant. I would say that the brain doesn’t fully mature until you are about 24/25 but you are coming into16, 17 , 18 and things are starting to crystallise a bit there and that’s why we feel Ok about medical interventions that that point (From 40:46Continues: And the only exception to that is I guess where things are complicated. We might be thinking of traumas in the past, previous difficulties within the family , what does it mean to be male/female and then if they are coming to us at that point, say 16, we really want to spend a lot of time going back, thinking about family, experience they had. Sometimes around violence and what it might mean to be a man if there’s a violent father/man in the house ..or what it might mean to be a woman if there’s a woman who is maybe perceived as weak , vulnerable.. something like that. People can have quit toxic views, not deliberately, about what it means to be a man or a woman and that’s your assigned gender. I’m not saying that’s causing it, but we just want to make sure that we have thought about all of these things first of all.So this is the puberty stage and when medical intervention starts happening erm .And so that’s when we support social transitions much more as a way of testing out and doing it in a staged way.. and we work a lot with kind of local agencies to support that.Take Away messages…Puberty is a really challenging time for all young people irrespective of gender and it can be very distressing so all young people will question things around sexuality..they might not overtly question gender or give it that name. but they will be thinking about things. about how am I going from boy to young man or young girl to woman you are going through.. it’s quite a scary thing and I guess we were all through the other side and it can be hard to think back and actually society is different now. It can be really hard to think back to all those really challenging things actually. It’s really helpful when a local assessment happens, an exploration and we try to support that from the Tavi *Tavistock* and also coming across to Dublin. The system, you guys are really important in terms of keeping conversations or keeping outcomes open because often it can be “that’s what I am. That’s it. Either support me or leave”. You can be supportive but also question what that means for them and I guess some of the tensions that there might be external dominant affirmative discourse being present or there might be the other side, really doubting and questioning ..oh questioning as in an “anti” argument. We try to straddle ourselves in the middle and try to be quite neutral. Yeah, so I guess, I won’t get to answer this but I guess we have for you to think about where you sit cause everyone is going to have different positions with regarding gender non-confirming children and how you support them …but I’m more than happy to talk to you in the break or feel free to call me at the Tavistock even if they have not been referred. Thank you. Round of applause. So, it is worth regarding where you sit … ................
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