Panorama.2019.02.25.Trans.Kids.Why.Medicine.Matters

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Panorama.2019.02.25.Trans.Kids.Why.Medicine.Matters
Transcript
00:00More and more young people are questioning their gender.
00:07Being trans isn't a choice.
00:09When people see me on the street, I want to be perceived as a woman.
00:13The numbers of under-18s seeking help from the NHS
00:17has risen sharply in the last five years.
00:20This isn't some frivolous choice that kids are making without thinking about it.
00:25Health professionals are feeling under pressure.
00:29I've become increasingly concerned about the large number of patients
00:32who want physical treatment as quickly as possible.
00:35For others, there's no time to waste.
00:38We get lots of children who are already in puberty,
00:41who are very distressed, who are saying,
00:43please stop me developing any further, I cannot bear this.
00:47There are calls for better regulation of this new area of medicine.
00:51The quality of the evidence is terrible,
00:53and we urgently need a new regulator.
00:56Tonight, we ask, do we know enough about the care offered to transgender children?
01:02Is there an impact on brain development that has longer-term implications?
01:08We don't have the answer to that.
01:12I'm Faye Kirkland.
01:14I'm a journalist and I'm also a family doctor.
01:17For young people questioning their gender,
01:20GPs can be the first port of call.
01:23It's a relatively new area of medicine,
01:26and I want to find out how much we understand about the care available.
01:31I want to find out how much we understand about the care available.
01:36I'm in Leicester to meet Jade.
01:39Being trans, it's not something you choose, it's something you choose to act on.
01:44When people see me on the street, I want to be perceived as a woman.
01:48Jade, who's 18, is biologically male.
01:51During rehearsals for a school nativity play,
01:54she realised she didn't feel like a boy.
01:57She's a bit of an introvert.
01:59She's a bit of an introvert.
02:01She's a bit of an introvert.
02:03She realised she didn't feel like a boy.
02:06I wanted to be cast as an angel, and the teacher said,
02:09no, only girls can be angels, and I had sort of flipped out about it.
02:14So that was sort of my first, like, inkling.
02:17When teachers ask what you want to be when you grow up,
02:20they're like, what career do you want to go down?
02:23And I'd jokingly say, like, oh, I want to grow up to be a girl.
02:27As she grew up, she became more and more unhappy.
02:31When puberty, like, started, and I just felt this huge disconnect.
02:35I was, like, growing taller and broader, and I just...
02:39I wasn't having any of that, but I never talked about it.
02:42I just... I knew that it wasn't right.
02:45I sort of knew that it wasn't, like, normal.
02:49Similar stories are shared online by transgender bloggers.
02:53From as early as I can remember, I have always felt incorrect.
02:58It basically made me feel like there was something really wrong with me.
03:01I would scream at the thought of not being able
03:05to be wearing the clothes that I wanted to wear.
03:10Gender dysphoria is a feeling of intense distress
03:14around a physical body that doesn't fit in
03:18with one's sense of one's gender identification.
03:22It's a profound experience for many young people
03:26and is exceedingly distressing.
03:29Holly Carl-Michael runs the only NHS service offering child gender medicine
03:34to under-18s in England and Wales.
03:37Based at the Tavistock Centre in London,
03:40she sees many young people with gender dysphoria.
03:45Often, young people will wish to be rid of the secondary sex characteristics
03:50or are afraid of them developing, if you like,
03:53which don't match the sense of themselves.
03:57With the onset of puberty, children experiencing gender dysphoria
04:01may fear the beginning of periods, the growth of facial hair or breast development.
04:08For the first stage of medical intervention,
04:12it would be in the early stages of puberty,
04:15so we would start with a puberty blocker.
04:23The use of medication to block puberty, to put it on pause,
04:27was pioneered 18 years ago by this clinic in Amsterdam.
04:34We started for the first time treating transgender adolescents
04:38with puberty suppression
04:40to actually create time and rest for transgender adolescents.
04:47It was considered fully reversible treatment,
04:50so they had the time to make decisions about more irreversible parts of treatment.
04:58It was another ten years before the Tavistock Centre
05:01began prescribing blockers to children in the early stages of puberty.
05:06Many of their patients are aged around 15.
05:10How do you, on the one hand, accept and support a young person's self-identification,
05:16whilst at the same time leaving things open?
05:21For us as a clinic, what it means is working on a case-by-case basis.
05:27Jade was a patient at the Tavistock Centre two years ago, when she was 16.
05:32She hasn't taken puberty blockers.
05:35There's just so much thinking that needs to be done
05:37before making life-changing decisions further down the line about hormone blockers,
05:41when there are so many changes happening in your body and life.
05:45The drugs are said to be reversible,
05:47but there's emerging evidence they may have more long-lasting effects in other parts of the body.
05:54They are fully reversible in the sense that
05:57if you stop taking the puberty blocker,
06:01then your pre-programmed sex hormones will resume and you will continue to develop.
06:08Is there an impact on brain development in some way
06:13that has longer-term implications?
06:16And we don't have the answer to that.
06:24Doctors do their best to advise patients,
06:27making important choices about their care based on the best available evidence.
06:35You know, gender dysphoria is a distressing condition.
06:38One of the key issues is to be able to say to parents and children,
06:43here's an informed decision based on the evidence.
06:50I'm in Oxford to visit the University's Centre for Evidence-Based Medicine.
06:54Panorama asked the centre's director to review the most up-to-date research
06:58from across the world into outcomes for children and adolescents.
07:03What does the medical evidence actually show?
07:05He began by posing some basic questions.
07:09What does it say about the benefits? What does it say about the harms?
07:12Have I got sufficient sample size? Well, the answer's no.
07:15Have I got sufficient evidence with quality? Well, the answer's no.
07:18And based on all that, can I make an informed decision? Well, the answer's no.
07:22Three different areas where you look at the evidence and just say it's not fit for purpose.
07:28Puberty blockers have long been used to treat children
07:31with a condition that means they start puberty way too early.
07:35Less is known about the long-term safety of their use in transgender medicine.
07:41If you ask me about puberty blockers, what can you tell from the evidence?
07:44You can tell very little, apart from they give you the intended effects
07:49in terms of blocking and suppressing puberty.
08:01Ten years ago, doctors concerned about this lack of evidence
08:04asked Professor Neil Evans to study the effects of puberty blockers in sheep.
08:10We could see differences in the size of different areas within the brains
08:14associated with whether they had gone through puberty or not gone through puberty.
08:18So having the blockers changed the anatomy, if you like, of the brain?
08:22Absolutely, yes.
08:23So we're now increasingly realising that at the time of puberty,
08:26our brain changes quite a lot.
08:28If we change the hormone environment that the brain is in then,
08:31that we're bringing about long-term changes in how the brain is able to work.
08:37Puberty resumes if the drugs are stopped,
08:39but Professor Evans can't be sure how significant the changes he observed in sheep brains are.
08:47So fully reversible. We're not sure where we are with that.
08:51We don't know.
08:52There are a variety of different reasons why it's acceptable for these treatments
08:55to be given to these patients at this point in time,
08:57but no, we don't know what's going to happen.
08:59So it is in some ways a live experiment.
09:03The Tavistock Centre agrees there should be more research,
09:06but say they also have to manage risks.
09:11There are questions around risk,
09:13but there's a reason why people have even begun to think
09:17about using something like the puberty blocker in young children.
09:21And so what you have is a real phenomenon,
09:24and that phenomenon is young people who are hugely distressed around their gender identity.
09:31And so some of the evidence I think that is important
09:35is that young people and families who have gone forward for this treatment
09:40are exceedingly positive about it.
09:44Over the past five years,
09:46the number of children referred to the Tavistock Centre
09:49has risen from 468 to 2,519,
09:55an increase of more than 400%.
10:00Most of the children seeking help are biologically female,
10:03but identify as male.
10:06No-one knows why this is.
10:11Perhaps there's something about the role of women in our society,
10:16and in some ways, is it preferential to have a male role rather than a female role?
10:26There have also been arguments around sexuality
10:30and whether for some of these young people in the future,
10:33the outcome will be around sexuality rather than gender.
10:46She ran like a boy and walked like a boy from the earliest possible age.
10:52She wouldn't entertain anything feminine or pink,
10:56and she actually said that she wanted to be a boy,
10:59that she was a boy.
11:02Fiona, not her real name,
11:04says her son experienced gender dysphoria from an early age.
11:08At 11, he was living as a boy
11:11and being treated with puberty blockers at the Tavistock Centre,
11:14but he was still distressed.
11:16My son noticed that his friends at school were progressing through puberty naturally,
11:22with bodily changes and voice changes,
11:26and he wasn't.
11:29Comments would be made,
11:31and he felt incredibly uncomfortable and sank into a deep depression.
11:36Aged only 12, he wanted to begin treatment with a male hormone, testosterone.
11:42The start of a journey towards irreversible changes to his body.
11:47He wanted more than anything in this world
11:50to be prescribed hormones in order to progress through puberty with his peers.
11:58Hi, guys. Today I thought I would do a whole video on how I got onto testosterone.
12:02I'm officially six years on testosterone.
12:05Not all trans people go on hormones, but I always knew I wanted to,
12:09and I fought very, very hard to get it.
12:12The NHS advises that only young people
12:15who've been taking blockers for a year and are aged around 16
12:19can progress to hormone treatment with testosterone or oestrogen.
12:24The Tavistock Centre told Fiona her son was too young,
12:28so she looked elsewhere.
12:30I managed to find a private doctor,
12:33Helen Webley, who was prepared to hear us out.
12:39Dr Webley runs Gender GP,
12:41the only private clinic in the UK offering care and treatment to children and young people.
12:46To many in the NHS, she's a controversial figure.
12:51The NHS say that you have to be around the age of 16
12:55to have gender-affirming hormones,
12:58and I think our UK children, some of them, find that very difficult.
13:03I think children should be allowed the second stage of treatment,
13:06which is gender-affirming hormones,
13:08when it's right for them and the family and their situation,
13:13and that might be before 16.
13:17Following consultations, counselling and tests,
13:20Dr Webley prescribed testosterone to Fiona's 12-year-old son.
13:26He would come home from school and he'd be on cloud nine
13:29and say, Mum, Mum, my friends have said my voice has dropped.
13:33But not everyone was so pleased.
13:36Complaints from other doctors about cases like this
13:39have in part led to Dr Webley's suspension from the medical register.
13:44At the moment, she can't practice as a doctor, but others in her clinic can.
13:50What would you say to your critics who would say, you know,
13:53you're assessing people too quickly,
13:55you're giving medication in a way that the NHS doesn't?
13:58What makes you think you're right?
14:00I know I'm right because of all the patients that we've treated
14:03telling us that what we're doing is right.
14:05The outcomes are good. This isn't brand new.
14:08But what's developing is a much more gender-affirmative approach,
14:12and that's what Australia and America are using very successfully.
14:19I would feel concerned about introducing a less reversible treatment
14:26that has long-term implications at a much younger age.
14:30For us, it's about ensuring that there is time and space
14:35for proper exploration before taking any irreversible steps.
14:45With more and more young people seeking referrals to the Tavistock Centre,
14:49waiting times can now be anything up to 18 months.
14:53It creates pressure for families and their children.
15:00A lot of people assume that once you come out, that's the hard part's over.
15:07Ruben transitioned when he was 24.
15:10Jade's been going to his support group in Leicester for years.
15:14It still can be incredibly frustrating for young people, can't it?
15:18And I think particularly if you've waited a long time already to come out,
15:23because if your family aren't going to be supportive
15:26or it's taken you a long time to find the courage to come to this decision,
15:30to move forward, and you're kind of like,
15:33OK, yeah, I'm ready to start my life now,
15:36and then you find out that there's this potentially two-year wait,
15:40it can be quite crushing.
15:45There are many transgender children who come to us already in puberty
15:50because they've been waiting a long time on the NHS
15:53or they've just been referred to the NHS,
15:55but the waiting time is going to be up to two years,
15:57who are very distressed, who are saying,
15:59please stop me developing any further, I cannot bear this.
16:02But what would you say to people who are waiting on the waiting list now?
16:05I think, you know, of course we can always support people better,
16:09and ideally there wouldn't be the waiting lists.
16:12It's not a simple question of more funding,
16:16but unfortunately, with the best will in the world,
16:19you can't magic up specialists in a highly specialist area.
16:23Local services need to be skilled up to be supporting young people.
16:31Make some noise for Jade!
16:40It's distressing to hear that you'll have to wait a year,
16:43more than a year, to be seen,
16:47but I understand the wait because it gave me a lot of time
16:50to think about what I wanted from Tavistock.
16:57Jade waited a year to be seen by the Tavistock when she was 15.
17:01She'd had a traumatic childhood
17:03and thinks the time helped her process her feelings
17:06and prepare for counselling.
17:08Therapy helped me talk about not just gender stuff at Tavistock,
17:11but talk about everything.
17:13I took a lot of time playing with my identity,
17:16which I think is an important thing to do, especially for young people,
17:21because it gave me that time to realise that, like,
17:24I lived my life as a feminine guy, but that wasn't it.
17:27There was something more to it.
17:35But I've spoken to parents who fear waiting,
17:38worried about what might happen
17:40if their children go through puberty in the wrong gender.
17:45My son was prepared to take his own life
17:48because he wasn't living the life he was meant to be, or who he was.
17:57I think, for parents, there is this idea that,
18:00if my child comes out as trans,
18:02they're automatically going to start self-harming,
18:04their life is going to be doom and gloom,
18:06when, actually, that's not necessarily the case.
18:08And the more that we do to support them,
18:10the less likely we make it that they're going to have
18:13those horrible experiences.
18:18There's some research suggesting young transgender people
18:21are at an increased risk of suicide,
18:24but the Tavistock says current statistics should be treated with caution.
18:30I think the figures around self-harm, suicidal ideation,
18:35and, indeed, suicide, need to be interpreted with great caution.
18:40I think, for families who have a child experiencing gender dysphoria,
18:46often the way in which statistics can be presented
18:51can lead, perhaps, to an assumption
18:54that the panacea to this, if you like,
18:58is to start physical treatment as quickly as possible.
19:03And our experience would be that that just isn't the case.
19:09The relationship between gender identity and mental health issues
19:13can be a complex one.
19:15I had a parent come to me quite recently and say,
19:19my child's been self-harming and they told me they're trans
19:22and I don't really understand it, but I supported them.
19:25And then the self-harm hasn't stopped. Why hasn't it stopped?
19:29I'm still struggling with depression, anxiety and gender dysphoria.
19:33I'm still... I'm not... I'm coping.
19:36I'm sort of, like, I'm not self-harming as much.
19:39After the sessions, I was realising that,
19:41talk about everything that I've been through,
19:43it made me realise for myself, like, how strong of a person I am.
19:51But some clinicians worry about patients
19:53who want to go straight to medication without talking first.
19:57I've become increasingly concerned about the large number of patients
20:01who want to be referred on for physical treatment,
20:04medical or even surgery, as quickly as possible.
20:09John, not his real name, is a child psychotherapist.
20:12He doesn't want to be identified
20:15and says there's growing pressure not to question young patients.
20:21So they come with a variety of different presentations,
20:26very highly anxious, school refusing,
20:29real difficulties with peer relationships, depression.
20:33They don't want to explore that
20:35and they feel that once their gender is sorted out in their mind,
20:40that all of those problems will go away.
20:43I think what we see is a wider environment
20:48that's very negative about any exploration
20:51and often see it as a delay.
20:53Why are you asking that?
20:55I know exactly who I am and how dare you ask that?
21:01Over at the Tavistock Centre, some clinicians have resigned.
21:05They're worried about the impact of increased demand for the service
21:09and the reliability of research for the treatment and care on offer.
21:16Former insiders, who didn't want to go on camera,
21:20claim they felt rushed into green-lighting medical interventions.
21:24This is what they told me.
21:27For some, I was fairly certain transitioning was the right course of action,
21:31but in the majority of cases,
21:33I was simply unsure how well things would work out for them in the future.
21:37Research is being conducted, but we are many years away
21:40from fully understanding the long-term outcomes
21:43from the interventions taking place today.
21:46Counter to child development theory and knowledge,
21:48this service changes children's bodies
21:50with the aim of improving their mental health,
21:53which mostly does not seem to work.
21:57So serious are the concerns
21:59that the Tavistock Centre ordered an internal review.
22:03Its findings hadn't been published when we interviewed Dr Carmichael.
22:09You've had an internal review.
22:11Are you able to share its findings with me?
22:13I think it's just about ensuring
22:16that the structures around the service
22:19are robust and supportive for staff working in the service,
22:24but also that we don't compromise on the care
22:28that we provide for the young people coming to the service.
22:33The review is due to be published next month,
22:36but some staff who've already seen it say it doesn't go far enough
22:40and they're demanding an external inquiry.
22:44Gender clinics around the world are realising
22:47they need to do much more to find out what happens long-term
22:51to the children and young people who come through their doors.
22:55What we don't know is how will they look back
22:59when they're in their adult years.
23:02Do these adolescents, do these parents realise
23:05what sort of treatment they are getting?
23:08And how far-reaching the effects might be lifelong?
23:13Are they able to have long-term relationships?
23:16But also, what about their wish for children?
23:19And that, I think, are really questions we don't have an answer yet.
23:24The Tavistock doesn't have all the answers either.
23:27Do you think Tavistock has done enough?
23:30They haven't produced systematic data on the outcomes based on all children.
23:36In the absence of evidence,
23:38I just do not understand how they can inform children,
23:41adolescents and parents and families
23:44in a way that helps them make an informed decision.
23:48The Tavistock Centre now plans a new research project
23:51to record what happens to all its patients as they grow up,
23:55whether they're prescribed medication or not.
23:58We've just received a very large research grant
24:03specifically to follow young people who come to the service
24:08through and forward whatever their outcomes,
24:11and that's going to be really important information.
24:15But is that enough?
24:17To make sure these life-changing decisions by children and their parents
24:21are based on the best possible evidence in the future,
24:24Professor Hennigan says this area of treatment and research
24:28needs regulating now.
24:30It's incredibly hard, though, when you're in these emotive situations
24:34for people to take on board evidence.
24:36We urgently need a new regulator that has oversight
24:40to provide a much more rigorous approach and robust approach
24:45to the evidence to help inform decision-making.
24:54The Department of Health says it has no plans
24:57to introduce an independent regulator.
24:59NHS England says its policies are due for review
25:03and it will consider the most recent evidence available.
25:10While I've been making this film, I've been surprised
25:13by how many people don't feel able to speak openly
25:17about this important area of medicine.
25:21A lot of the time people don't feel confident enough to speak up
25:25because they feel like if they say anything remotely negative
25:29they're going to be branded as a transphobic bigot
25:32and anything remotely positive they're going to be branded
25:35as a lefty liberal snowflake social justice warrior.
25:41We're seeing the extreme sides of things
25:43and it's meant that there's all this space in the middle,
25:46all this grey area, that's not being explored.
25:50It can have a chilling effect on doctors.
25:54Not every doctor that I know of really wants to be involved
25:59in this type of care.
26:00It's because there's so many opinions about it, it's delicate,
26:05people criticise the care we provide.
26:08So it's, yeah, you're sort of in politics as well.
26:13At the moment there is a febrile debate, I think it's fair to say,
26:17going on and I think it has become more polarised.
26:22It's a really difficult space then for families and young people
26:28to be part of and I really hope moving forward
26:33that we can find some way of debating some of these contentious issues.
26:47Jade's now back on the waiting list at the Tavistock,
26:50this time for the adult service.
26:52She says she feels ready for the next step in her transition.
27:01Doing stuff like this helps because it's like if I can do this big thing
27:04I can do a small thing like riding a bus or going to class every day.
27:09So it's doing big things to help conquer small things,
27:14I think that's what helps me.
27:21The future of care for young transgender people
27:25lies in the life stories of the young people themselves.
27:29It's only by following the journeys of Jade and others like her
27:33that we'll understand much more about the best ways to support them.
27:37I'll hold the heights
28:07I'll hold the heights