Entry 6 – Following the interim report (March 2022)

Posted in: Journal

We are far more united and have far more in common than that which divides us”

Jo Cox

Thank you to all those that have taken the time to read the interim report which was published on 10 March.  It is good to see that the response has been largely positive. I think this reflects the fact that everyone with an interest in this area shares the same really important objective – to do the right thing for children and young people who are questioning their gender or are in distress, and to get them the support they need as soon as possible.

The interim report needs to speak for itself and the Review doesn’t intend to comment on the various interpretations that have emerged in response to its publication.  However, I think there may be some misunderstandings about the standard clinical requirements which we have talked about in the report, particularly with regard to the process of assessment and diagnosis.

I have been clear that there needs to be better agreement and guidance about the appropriate clinical assessment processes that should take place. Current debates around gender can create an artificial binary opposition between explorative and affirmative stand points. This is an oversimplification of a complex issue and can sometimes create misunderstandings of the kind I have referred to. In practice clinicians have a spectrum of approaches and do not necessarily see these models as mutually exclusive.

I have also noticed some debate around the inclusion of the need for a diagnosis and differential diagnosis, and whether that means we are pathologising gender identity or seeing it as a mental health problem. I think it is worth clarifying what is meant by these terms.

Applying medical thinking to gender identity isn’t required until and unless a young person needs treatment. The regulations are particularly tightly defined when a doctor is considering prescribing medication, and especially medication that may have some life-long effects. Doctors then have a professional obligation to go through a process of ensuring that it is appropriate for the health needs of the individual, which means making a positive diagnosis (what the condition is) and a differential diagnosis (what the condition isn’t). This applies in all areas of medicine.

The process of differential diagnosis is neutral in terms of outcome – it’s not about preferring one diagnosis over another; it’s just about getting it right. It isn’t about trying to rule out every conceivable explanation before confirming any particular diagnosis – only about ruling out other diagnoses that might be likely for that individual, or where getting it wrong and missing another diagnosis could have serious consequences. Achieving this involves taking a holistic, considered approach to each individual about the possible causes of their distress and identifying the most appropriate pathway for them. This must always be done with sensitivity and in partnership with the young person and their family.

This same requirement is reflected in the internationally developed Endocrine Society gender dysphoria/gender incongruence guidance which recommends that health professionals responsible for diagnosing gender dysphoria should meet a range of criteria including “the ability to make a distinction between GD [gender dysphoria] /gender incongruence and conditions that have similar features”.

Clearly there is still a lot of work to do and there remain differences of opinion, but I feel all have recognised that we must come together if we are to improve services and provide help to the children and young people who are at the heart of this work. I am particularly grateful to the service users, clinicians, charities, support and advocacy groups who have engaged so positively with the Review. As we move into the next stage of the Review we will continue to need your support to build the evidence base and reach consensus on the way forward.

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