Has the Tavi Lost its Way?

Has the Tavi Lost its Way?
The Gender Identity Debate

The Gender Identity Development Service (GIDS), which was founded in 1989, now finds itself at the centre of a political battleground. It was commissioned by the NHS to provide a specialised service for children and adolescents and is currently managed by the Tavistock and Portman NHS Foundation Trust. In recent years there has been a significant increase in the number of referrals to GIDS and this has occurred at a time when the service has moved from a therapeutic model to one that also prescribes medical interventions. The treatment provided by GIDS has raised serious ethical concerns about life-changing decisions that young people may later come to regret.

The challenges presented by young people diagnosed with 'gender dysphoria' and conflicting ideas about the nature of the service they need have triggered a huge amount of public debate. The concept of 'gender identity' seems difficult for many people to grasp. They assume that at birth we are recognised as either male or female and should accept this reality. I believe that the expression of uncertainty about one's gender identity should be seen as 'a cry for help' and the professional response requires a sound grasp of the responsibilities of services dealing with the child in distress. The Tavi has been caught off-guard by the complexity of the challenges presented by children with gender identity problems.

The failure of the Tavistock and Portman Trust to provide the necessary oversight of the work of GIDS was noted in a recent report by inspectors from the Care Quality Commission [See link below]. It is ironic that the Tavistock Institute offers training and consultation to other organisations and prides itself on its application of psychodynamic theory to organisational systems but has not apparently come to the help of this dysfunctional organisation. Leadership from the Tavi is urgently needed so that GIDS does not collapse under the weight of unrealistic expectations.

The Tavi is a globally renowned institution with a vast heritage of therapeutic knowledge and experience. The work of the Tavi, and the ideas emanating from it, have always underpinned my own thinking about personal growth and development. Recent concerns about GIDS raised by some people at the Tavi were mainly focused on the risks posed by medical interventions. However, there is now more interest in examining the quality of clinical practice.

The social worker, Sonia Appleby, the safeguarding children lead for the Tavistock Centre and an adult psychoanalytic psychotherapist, has recently won an industrial tribunal on the grounds that she had been prevented from carrying out her safeguarding work and her professional reputation had been harmed by the actions of staff. I am pleased that the tribunal resolved the conflict between parties in favour of the social worker. Its decision recognised the necessity of safeguarding a child's well-being and the statutory duty on all social workers with safeguarding responsibilities. It is important to remember that when a child's physical well-being is in jeopardy the law makes a child's interests paramount over all other claims to be heard, such as those from parents demanding fast-track gender transition.

On the surface it appears that the approach at GIDS is essentially caring and supportive. It seems to accept the family's perception at face value and works from a theoretical base that has little to do with Freud's notion of psychotherapy. Its non-judgemental approach to 'gender dysphoria' is meant to be liberating. It is possible that a child's negative feelings about his or her body may have come to some extent from experiences outside the family or from social media. However, while it is now much easier for children to access information about sex and sexuality their immaturity can make it difficult for them to process this information emotionally. Some children with a vivid imagination may adopt an unrealistic fantasy that they can be whatever they want to be. The possibilities can now seem limitless with the use of medication.

The work at GIDS is based on the diagnosis and treatment of 'gender dysphoria'. Its thinking about treatment appears to come from a theoretical base of valuing diversity and recognising the complexities of gender differentiation and fluidity in gender identity. Its approach seems very different from Freud's approach to diagnosis and treatment. While psychoanalytic theory has undergone fundamental change in recent years, particularly from the influence of feminists, I am concerned that the focus of work at GIDS has shifted too far away from an interest in exploring the impact of the family dynamics on the child's psyche. A paradigm shift has been used to normalise gender identity problems and to provide a service that is family centred. There seems to be a reluctance to consider the possibility that the child may benefit from individual therapy from an appropriately trained therapist.

The intense focus on gender identity appears to mean that other aspects of the child's identity and functioning may be given less attention. This raises questions about the referral pathway. In some cases a referral to the local Child and Adolescent Mental Health Service (CAMS) might be more appropriate for some children because this would offer a broader focus to diagnosis and treatment. Furthermore, if the child presents with more complex problems it is possible that this will require input from the local education authority.

The adolescent stage of development certainly requires a different approach from that provided for younger children. A young person may benefit from seeing a psychotherapist who is good at relating to young people and offers a deeper understanding of the developmental task of dealing with puberty, separating emotionally from parents and moving into adulthood. If the young person can accept the idea of therapy, instead of medication, this would be an opportunity to explore any unmet dependency needs and fantasies with the help of the therapist. It would certainly be appropriate to let the adolescent choose whether to have a male or female therapist. The young person's relationship with the therapist would also be an opportunity for learning to understand the nature of relationships in practical ways. The support from someone who has the capacity not only to care and worry but also to think about and clarify feelings and normalise ambivalence might be very helpful.

I had always assumed that Freud's views of the psyche were at the core of any therapy offered by the Tavi and his belief in the value of the 'talking therapy' taken for granted. Psychotherapy is about getting to know the Self better. Few of us know ourselves completely and we may all have some unresolved issues and need defence mechanisms to avoid pain. The development of new insights may help young people understand how the physical changes associated with puberty require them to make a mental adjustment and accept the challenges of growing up and moving towards adulthood. The focus of work at GIDS should therefore be more on helping young people struggling with this stage of development.

Hilary Searing