CAMHS and gender identity

I work in Child and Adolescent Mental Health Services (CAMHS). One of the roles of CAMHS is to act as a gateway to the Gender Identity Development Service (GIDS) at the Tavistock and Portman in London. GIDS is the only service in the NHS that can prescribe hormone treatments to young people under 18 with gender identity issues. I’m something of a CAMHS jack-of-all-trades, and gender identity issues aren’t a large part of my role, but they’re a part of my role nonetheless.

The purpose of this blog post is to assemble some of my thoughts on the role of CAMHS with regard to gender identity. It’s a bit different to my usual blogging content in that it isn’t so much giving my own views as inviting others to give feedback. I think I should give the usual preface that any opinions I state here are personal ones and not necessarily those of my employer.

If somebody under 18 wants to reassign their gender, then the usual route to do so is for their GP to refer them to the local CAMHS team. CAMHS then carry out an initial assessment before referring them to the GIDS. In Wales, where I work, the local CAMHS also have to apply for funding from the Welsh Health Specialised Services Committee. I’m happy to say I’ve never heard of the funding being turned down. CAMHS then remain involved to act as a local point of contact for GIDS.

I’ve heard the view expressed that access to a gender service shouldn’t be via CAMHS, because being transgender is an identity, not a mental illness. These objections are reflected in the new DSM5 retitling “gender identity disorder” to “gender dysphoria”. I have some sympathy for this view. After all, we’re agreeing that it’s not the young person’s mind that is necessarily “wrong” and might need to be changed, but their body. On the other hand, I know that GIDS feel it is very important for the local CAMHS to be involved, not least because the big changes a young person may be going through (not to mention the huge levels of stigma, harassment and discrimination still sadly faced by transgender people) can trigger a mental health crisis. Either way, CAMHS remains the route of access for a gender identity service in the NHS whether one agrees with this or not.

I’m not an expert on the process that a young person goes through, but my understanding is that it generally starts with psychological therapies, before proceeding to hormone treatment if the young person and the GIDS agree that this is the right option. They start with the more reversible treatments. Surgical procedures can only happen after the young person turns 18. It’s a long and arduous process, and some young people find the length of time extremely distressing, especially if they already feel certain who they are and what they want. Though I also know that the GIDS would say that these are huge changes, and by no means everybody will eventually go on to gender reassignment. They would argue that this makes it right and proper to take it slowly.

The main question I find myself pondering is this. Given that the local CAMHS teams are not specialists in gender identity, but nevertheless act as the gateway to a service, do we do a good job of treating young transgender people with respect and dignity? I would hope that we do. However, the stigma transgender people face in society is enormous, and the people who work in CAMHS are just as much products of society as anyone else. I wouldn’t be at all surprised if comments left in response to this post wind up not being flattering at all to CAMHS.

As I said before, this post is more of a request for feedback than me standing here as the “expert”. Is CAMHS doing a good or bad job when working with transgender young people? If it’s a bad job, what do we need to do better?

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5 Responses to “CAMHS and gender identity”

  1. I think you’re doing a good job, Phil. Why? Because you’re asking questions and reflecting, not judging. It’s not rocket science, but I think opening up discussions to explore and debate is sadly lacking in the system these days.

  2. One of the challenges of working with trans people is to try to look beyond the way that the professionals tend to view them and to focus on their own subjective experience. Given that most of us experience our physical and mental sexes as being aligned (“cisgender”), it can be hard to understand how someone could have the opposite experience. As a result, the scientific and therapeutic profession has often focused on the pathologies said to drive trans identity or the clash with sociocultural norms around gender and sexual identity. In the past therapists refused to work with trans clients because they believed they were not facing up to the existential reality of their physical sex, and much of the research work has concentrated on how trans experience fits in with categories of sexual behaviour (homosexual, bisexual and heterosexual) that these days look increasingly narrow.

    However, there’s been some interesting research lately in Sweden and the Netherlands that focuses on trans people’s own experience and this is starting to throw up results that demonstrate that trans experience is very wide, and that much of the work done to date is superficial. I think this is really helpful in working with trans clients, as their sexual experience is as unique to them as it is to anyone else.

    One of the areas that came up in the Dutch research (Trans People’s Experience of Sexuality in the Netherlands: A Pilot Study, Journal of Homosexuality, Volume 61, Issue 5, 2014) is that trans people often report skipping essential
    stages in sexual development, because growing up with transgender feelings makes it difficult to discover sexuality the way many of their cisgender peers do. Trans gender teens often struggle with gaining sexual skills and often feel pressured by social norms into trying to be someone they are not.

    This makes the initial work that CAMHS can do with trans gender teens really important, even if CAMHS staff may not be in possession of specialist training in this area. Trans teens are likely to feel very pressured as they explore their sexuality in an often hostile environment, so listening to them and enabling them to understand their unique experience is key. Frankly, not having specialist training in the area of trans sexual work may be a real advantage given the historic prejudices of the profession towards people with this experience.

    I have a copy of the Dutch paper that I am happy to share.

    Graham

    • Hi Graham

      I’d definitely be very interesting in having a peek at the paper. Can you e-mail it to thus_spake_z at hushmail dot com please?

    • I have not had a problem working with transgender issues although I am cis. I do not see it as a disadvantage, and like you say is possibly an advantage. The biggest challenges for me as a counsellor are working with clients who are very close to me demographically, life experience-wise and attitude-wise as there is more of a danger of transposing my experience onto the clients. This is a risk I take very seriously and work on in clinical supervision.

      When I was about 10 there was a flood of documentaries about transsexuals (as referred to back then). I clearly remember developing deep empathy and a basic belief that if somebody feels that they are in the wrong gendered body then they are.

      No matter what a client’s issues, the exploration is always of their subjective experience. Anything else is assumption, judgmentalism or projection.

      I have not worked with teen transgender issues. It seems that there should be two types of intervention required pre and post reassignment op; fact-based, informative consultations where they can learn about the how/when surgery/hormone treatment, and a separate therapeutic relationship where they can fully express their lived experience, hopes and fears without the judgment, opinion or agenda of the professional.

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