Freedom of expression around diversity guidelines

Numerous psychologists call for review of the BPS Guidelines for Psychologists Working with Gender, Sexuality and Relationship Diversity; plus response.

Following the response to J.K. Rowling’s essay ‘Reasons for Speaking Out on Sex and Gender Issues’ and the 18 June Newsnight report of safeguarding concerns at the NHS Gender Identity Development Service, we call for an immediate review of the recent BPS Guidelines for Psychologists Working with Gender, Sexuality and Relationship Diversity (BPS, 2019).

These guidelines state that a ‘gender-affirmative’ stance should be the default position adopted by psychologists. We are concerned that the instruction to ‘integrat[e] an affirmative stance into their model of practice’ restricts the use of many core models (systemic, trauma-informed, developmental) in formulating the factors resulting in the clients’ presentation. This places limitations on researchers and practitioners exploring the wider context of ‘gender’ and seeking to establish ‘best-evidence’ for the support of individuals with gender dysphoria.

For those unfamiliar with the guidance or discussion in this field, ‘gender affirming’ practice calls for psychologists to work on the basis that an individual’s belief in self-ascribed gender is ‘valid and legitimate’. We hope all psychologists value and respect the varied understandings that people hold of the world around them and of their personal experience. We suggest it is possible to value and respect a client’s experience, without taking a position of affirmation. Indeed we often do this within our work with various client groups. The BPS guidance stipulates that practitioners validate a belief in gender (both in general and in particular to the individual’s sense of self) without considering the evidence base in relation to the practice of belief validation.

Individuals who are questioning their identity with respect to their sex and gender clearly report significant levels of psychological distress. The long-term implications for this population resulting from the provision or denial of access to treatment are substantial. We recognise that appropriate, evidence-based guidelines are imperative to support the skilled psychological practice which our profession seeks to uphold. However, such guidelines can only be effective when these are the result of comprehensive research, conducted in an environment that supports free and independent enquiry.

In particular, we think it is imperative that psychologists are not prevented from using our core professional skill of formulation, exploring the origins and nature of distress rather than ascribing to one pre-determined ‘diagnosis’ or explanation. With other presentations we are in agreement that there are multiple contributory factors to psychological distress. It is only from this exploration that we can develop individualised formulations to guide our attempts to alleviate that distress. We think the current guidelines effectively prohibit psychologists from taking a questioning approach and applying ethical practice in these situations. The absence of a robust evidence base supporting psychological and medical intervention is a concern in this rapidly growing population, leaving significant gaps in our understanding of many relevant issues. The disproportionate increase in presentations of females to services, the phenomenon of so-called Rapid-Onset Gender Dysphoria, the voices of individuals who have desisted or detransitioned, and the experiences of those for whom existing treatments have been of value must all be addressed in the search for quality research informing best-evidence practice. Such research can only be conducted in an environment that is open to discussion in a respectful and professionally inquisitive manner.

We would like to see the current guidance withdrawn and the topic reviewed afresh in accordance with the rules of proper intellectual inquiry: the weighing up of evidence; the ethical considerations of psychological practice; and the avoidance at all times of ad hominem forms of argument. Some of the signatories below, with others, have submitted a formal request for the withdrawal of the guidance to the Society. We hope that readers will support our expectation that the freedom of expression of all psychologists will be defended, unambiguously and at all times, in relation to both research and practice.

Dr Katie Alcock (Senior Lecturer in Psychology)

Rachel Corry (Occupational Psychologist)

Ms Nina Gadsdon (Psychology Masters Student)

Dr Louise Fernandes (Clinical Psychologist)

Ms Pat Harvey (Guinan) (Former Chair of the Division of Clinical Psychology)

Dr Peter Harvey (Former Chair of the Division of Clinical Psychology)

Mr Ian Hancock (Retired Consultant Clinical Psychologist, Director of Psychological Services, NHS Dumfries and Galloway).

Dr John Higgon (Consultant Clinical Neuropsychologist)

Dr Anna Hutchinson (Clinical Psychologist)

Dr Gill I’Anson (Consultant Clinical Psychologist)

Mr Eric Karas (Retired Consultant Clinical Psychologist)

Dr Jeanie McIntee (Consultant Clinical & Forensic Psychologist & Psychotherapist)

Dr David Pilgrim (Former Chair of the History and Philosophy Section) 

Julia Richards (Educational Psychologist)

Cas Schneider (Consultant Chartered Clinical Psychologist)

Karen Scott (Retired Educational Psychologist)

Dr Sarah Verity (Chartered Clinical Psychologist) 

Dr Robert Watts (Clinical Psychologist) 

Anne Woodhouse (Clinical Psychologist)

 

Colleagues who felt they needed to remain anonymous:

Consultant Clinical Psychologist NE England

Clinical Psychologist NE England

Consultant Forensic Psychologist S England

Clinical Psychologist NW England

 

Society response: We acknowledge that the BPS is a broad church, and there will always be differing views among our members on some issues. We are confident that our guidelines are based on the best current evidence and research in this important area, having been developed by experts working in the field. Clearly we share your concern about the safeguarding of children and young people, but our guidance is specifically for the care and treatment of adults, not children.

The draft guidance was sent out for Society-wide consultation on 19 March 2019. It was also sent to the Royal College of Psychiatrists, APA, BACP, BABCP, UKCP, Stonewall, LGBT foundation and COSRT for comment. At the close of the consultation on 12 April 2019 34 responses had been received. Just one of these responses mentions the issue of dissenting voices that is raised in your letter. This respondent also stated that the document was ‘well intentioned and positive’.

All our guidance is periodically reviewed. This particular guidance is the second version, having been revised in 2019. If there is a change in practice or evidence, then the need to revise the guidance would be established. In this instance, we will review the guidance if there are implications for the care and treatment of adults following the outcomes of:

  • the judicial review regarding the use of hormone blockers in child services on grounds of capacity to consent
  • NHS’s Independent review of puberty suppressants and cross sex hormones
  • NICE review of the latest clinical evidence.

As a Society we are committed to our members having a view and welcome different perspectives. As such any revised guidance will be sent out for Society-wide consultation and we would welcome your input into the revised consultation process.

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Comments

I was surprised to see Alcock et al argue for the withdrawal of guidance for psychologists working with gender, sexual and relationship diversity. I was surprised because I simply do not recognise the version of the document  described. Contrary to what is claimed, no where in the actual document do I see a rejection of useful models, not unless they refer to the statement that ‘modalities which do not accept GSRD identities and practices as being entirely as valid and legitimate as other identities and practices must not be used’ p7 - but that doesn’t stop us using helpful models of practice, and on what grounds would psychologists want to use any approach that pathologises sexuality and gender? Similarly no where do I see a definition of affirmative, let alone one that suggests a rigid, static understanding of gender that is not open to evolution, updating and development in light of deepening  understanding. Nor do I read a a call to eschew research - either the use of existing work nor work that would further strengthen the field. To the contrary the guidelines explain that ‘psychological practice should be evidence- based and include established best practice’ p7.  It is for this reason that I have used these guidelines in my teaching for many years and students have never voiced the concerns outlined by these colleagues. To the contrary, what has happened on several occasions is trainees have fedback that these guidelines are unusually clear and useful and help them think their way through the complexities of practice. Of course this doesn’t mean that these guidelines cannot be further developed but no where does the document claim to be the final word. It is clearly open to ongoing development as evidenced by this being the second iteration and I was  pleased that the Society noted some potentially useful areas of development already on the horizon.

 

These colleagues feel ‘the current guidelines effectively prohibit psychologists from taking a questioning approach and applying ethical practice in these situations’. How on earth does one come to this understanding? I am perturbed as there is a ‘deja vu’ quality to this argument. In years gone by, multiple discussions/ arguments occurred to the effect that we should not offer lesbian and gay clients an affirmative therapy. Amongst the range of concerns (some scarily problematic) seemed to be a concern that ‘affirmative’ might have to mean the privileging of a static identity marker over and above an attuned understanding of lived experience. I hear echoes of that here. Yet, it seems to me that, as in the past, these concerns can be ameliorated with the recognition that ‘affirmation’ does not imply anything static. To affirm as valid, the experience being described, means that one has to  recognise what a client tells us is valid. We should still  be aware that that may become more alive and nuanced as time goes on - experience is dynamic and in flux. Affirmation does not require a premature assumption of one singular experience, not if one is truly aiming to be attuned to the client’s experience. Initial understandings are always open to evolve, contrary to what seems to be floated in this letter this document supports formulation. Although I would be concerned if a psychologist was found waiting to pounce and somehow doubt an expression of sexual or gendered identity. 

 

Contrary to the authors claim, these guidelines do not imply that GSRD folk should be understood as not having ‘multiple contributory factors to psychological distress’. In fact, the guidelines explicitly remind us that ‘many of the principles and guidelines discussed below apply equally well to heterosexual, monogamous and cisgender people, as well as people with forms of diversity other than sexuality, gender or relationships’ - p4.  This is an explicit suggestion that we should bring our most contextualised understanding to all clients. If it were the case that a client’s experience lead a clinician to have to somehow doubt the gendered or sexual identity aspect of a client’s experience, this can still be assisted by these guidelines, they simply remind us that good practice requires that ‘robust clinical reasoning should be presented on those occasions when an identity or practice is not supported’ p6. How is that not best practice?

 

So rather than see a need to withdraw these guidelines, I would think there is a need for them to take greater prominence in psychological training and policy in order to ensure that a richer, more nuanced understanding of them is available to more psychologists, and that in turn, we as a Society would be more able to respond usefully when the time comes to update them. That is where the real value of freedom of expression would come to the fore, potentially resulting in a vital and enriching engagement rather than simply more of the ‘cancel culture’ that is so prevalent today.

The response from 'the BPS' (unknown authorship) misrepresent this guidance. It does refer to young people and children in several of its sections and paragraphs. Those of us who have actually read the document can confirm this point and so could the editor of The Psychologist please verify the veracity of responses from 'the BPS' in the future? Also I want to make a particular point about the long response from Martin Milton at the end of his defence of the Guidance. The 'cancel culture' he refers to is directed today in practic at gender critical commentators on social media, not the ideology of gender affirmation and its advocates. This then is a strange inversion by him about the reality of today's puerile social media norm of the baying mob. The letter I signed that he objects to is in that very context. Why did some colleagues agreeing with it feel unable to sign it or wanted to appear in anonymous form? The answer is today's culture of identiy politics which intimidates those unwilling to conform to a current orthodoxy of thought. Our letter was in part a plea for freedom of expression unconstrained by intimidation and ad hominem logic (legitmised now by the norms of identity politics more generally). Do readers of The Psychologist who have all benefited from the advantages of higher education shaped by the values of The Enlighement (reason, evidence and freedom of expression) want those values to be protected or not? The slur of TERF or the meme of 'Kill A TERF' are from those who are committed to a 'gender affirmation' at all costs position. If they drop these mindless slogans and start to actually openly debate sex and gender in a respectful manner then some progress might be made. Claiming as Milton does that the cancel culture comes from critics of the gender affirmative orthodoxy is a complete misrepresentation of what is happening today in practice. Our letter was an attempt to end the 'no debate' approach not promote it.

 

Modesty no doubt prevents Professor Milton from mentioning that he was a member of the advisory group that worked on the diversity guidelines that I and other psychologists have critiqued in this edition of The Psychologist.  His role as an advisor certainly qualifies him to elaborate on the intention of the guidelines, which we appear to have misunderstood.

 

It is interesting that he sees the guidelines as flexible, non-prescriptive, and so forth, whereas we interpret them in the opposite way.  This alone suggests a need for clarification, at the very least, of the content of the guidelines.  I would urge readers to read the twelve page document for themselves and come to their own conclusions as to whether the document is prescriptive, but for those who prefer not to, they may be interested to know that the words ‘should’ or ‘must’ appear 86 times in the document, and therefore on average seven times per page.  ‘Established practice’ is elevated over ‘personal opinion’, even though it is acknowledged that all of this is taking place in a ‘changing socio-political context’. 

 

It is indeed changing.  Since the publication of the guidelines, a major review of gender identity services has got underway and a detransitioner is seeking legal redress for medical and psychological treatment that in her view did not meet the appropriate standards.  It will be interesting to see how the next version of the guidelines incorporates this changing socio-political context.

 

The document skates over significant debates in the research.  For example, it asserts that:

 

It has been consistently found that stigmatising, stressful experiences for GSRD individuals can lead to increased risk of emotional problems, suicide attempts and substance abuse. This should not be treated as de facto evidence that GSRD is psychopathological, as it is the marginalisation and repression which causes the difficulties, rather than the identities and practices themselves.”

 

No doubt the ‘minority stress’ hypothesis articulated here explains some proportion of the increase in psychopathology seen in the gender dysphoric population, but the document completely fails to discuss other data which suggests that gender dysphoria may, for some individuals at least, be part  of a wider disorder.  For example, de Vries et al. (2010) note that nearly 8% of their sample of gender dysphoric children met criteria for autistic spectrum disorder, compared to a population base rate of 1%.  It is easy to see how bullying and discrimination might lead to depression and self-harm, less easy to see how the same maltreatment might cause autism.  I leave it to the reader to consider why the minority stress hypothesis is cited in the guidelines whilst the ‘autism’ hypothesis is ignored.

 

On the autism.org.uk website Dr Sally Powys, a consultant clinical psychologist, describes the difficulty of working with young people expressing gender dysphoria:

“In my clinical practice I have worked with autistic people with GD, both with and without a learning disability and I am aware that gender transition can be particularly difficult for an autistic person. Outcomes have ranged widely: (some are) wanting to transition fully to the opposite gender with hormone treatment.  (For others) the desire to transition has turned out to be more of a confusion, fetish or distress at growing up.

It can be difficult to help autistic people with reduced cognitive ability understand what they think and feel, and to support them to communicate this and decide what course of action to take.”  (network.autism.org.uk)

 

Her words neatly summarize the complex territory of gender dysphoria.  Such a nuanced approach is sadly lacking in the BPS guidelines.

 

The guidelines also fail to comment on the dramatic increase in the numbers of young people coming forward to gender identity clinics.  Figures for England, quoted on the BBC News website, indicate a total of 97 referrals in 2009/10 as against 1,398 in 2015/16.  This may reflect a more liberal and tolerant society, in which young people feel able to question their gender identity.  On the other hand, it may reflect the combination of social influence via social media and friendship groups, and a somewhat over-zealous attitude on the part of gender identity health professionals.  Again, the competing hypotheses are not discussed in the document.  How could they be, when the surely alarming increase in referrals over the past decade doesn’t get a mention?  In the same BBC news article, Sasha, who has transitioned, has this to say:

"The decisions I made were absolutely right for what I needed then. I believe now, on looking back, that there may have been more options to be a bit more flexible in thinking about my gender identity that I didn't quite pick up on at the time," they said.

While Sasha is happy with the physical changes to their body, they said sometimes they wished they had "taken things a little bit slower or waited until I was a little bit older".

 

One wonders how she experienced the ‘gender affirmative’ approach that seems to be the norm in gender identity clinics, and whether, in the long term, this was in her best interests.

 

 

 

Refs:

 

https://network.autism.org.uk/knowledge/insight-opinion/gender-dysphoria-and-autism-challenges-and-support retrieved 25th September 2020

 

de Vries et al. (2010) Autism spectrum disorders in gender dysphoric children and adults  Journal of Autism and Developmental Disorders  40(8)

 

https://www.bbc.co.uk/news/uk-36010664 retrieved 25th September 2020