Only one in England and Wales

Getting out of the culture wars

The court decision against the Tavistock clinic has reignited the battle over trans rights. Paul Demarty looks at the confusion

The vexed question of transgender rights has once again flared up, with a high court judgment against the only NHS clinic dedicated to helping young adults and children with gender dysphoria.

The Gender Identity Development Service (GIDS), run from London’s Tavistock and Portman NHS trust, has long been subject to controversy - hardly surprising, given that it is sitting at the centre of a decreasingly reasonable culture-war issue. Its work has faced a serious setback with this ruling, which considerably restricts the terms under which young people can consent to particular treatments. Foremost among those treatments is ‘puberty blockers’, which seek to delay the development of secondary sexual characteristics, to make future gender transitioning easier for patients.

The consequences of these therapies are serious, permanent and to a large extent poorly understood. The case is suitably exemplified by Kiera Bell, the young woman who brought the case to court along with others. Bell first investigated transitioning to male at the age of 14, and by 16 - having been referred to the GIDS - was taking puberty blockers. After years of further hormone treatments and surgery, she came to believe that she had made a mistake, and is now ‘de-transitioning’. She evidently feels that the GIDS failed in its duties towards her.

The Tavistock clinic itself has been widely criticised for its failure to produce important information in court: its administrators apparently had no records of the age profile of people referred for puberty-blocker treatment; nor had it taken steps to evaluate the effectiveness of what is, at the end of the day, an off-label use of drugs designed to fight particular cancers (and in some cases also used for the voluntary chemical castration of serial sex offenders). In the light of all this, the high court ruled that it was unlikely that under-16s could give meaningful consent, and even for those older it may be appropriate to require a court order. The implementation of this order is delayed until December 22 to allow for an appeal, which will hopefully find the clinic’s lawyers better prepared than the shambles so far.

Of course, the treatment of adolescent gender dysphoria is not merely a medical matter: it is, now that gay marriage is in the rear-view mirror, the premier battleground for culture wars, politics so far as they impinge on gender and sexuality. For better or worse, the judgment is interpreted as favouring one side against the other. The first side consists primarily of conservatives - and secondarily of those people who call themselves gender-critical feminists, but are better known pejoratively as ‘trans-exclusionary radical feminists’ or ‘Terfs’; the second is primarily made up of left liberals with a bias towards identity politics - and secondarily most of the socialist left (which, however, has a small ‘Terf’ minority).

The Tavistock clinic is therefore no stranger to controversy. It faces consistent accusations of ‘fast-tracking’ teenagers for transition procedures, which may not be in their best interests (as turned out to be the case for Bell). In 2018, a highly-critical review of the clinic’s work was produced, leading to the resignation of one of the governors - psychoanalyst Marcus Evans, who complained (as is routine in these discussions) that “the debate and discussion required” to understand this “complex area” is “continually being closed down or effectively described as ‘transphobic’ or in some way prejudicial”. The clinic’s defenders point to the extreme difficulty transgender and gender-dysphoric teenagers have in getting any kind of treatment at all (the Tavistock GIDS is the only centre of its kind in England and Wales), and cite the negative psychological consequences of failing to deal with these problems.

Serious approach

One aspect of the neuralgia that attends the transgender rights issue is the habit each side has of accusing the other of ‘politicising’ the issue. The right wing declares that the best interests of children (in this case) are overridden by ideological fanaticism, while the pro-trans liberals scold the right and the Terfs for their callous indifference to the misery of gender dysphoria. The problem, in reality, is that it is not politicised enough. In each case politics is regarded as a matter of moral failure: dogmatism on the one site, bigotry on the other; and we must subordinate ourselves to ‘the facts’ of biological sex and/or gender identity.

The trouble is that we are dealing not with ‘the facts’, but with abstract models, and these models are already thrown into politics. The missing dimension in the argument in fact forms part of the Terf critique, which is entirely drowned out by the primary contending forces of liberal identity politics and social conservatism. Once we strip away the crocodile tears about people being mean to them on the internet, their core idea is that gender identities, unlike biological sex, are not fundamental, first-order phenomena, but emerge from historical and social reality. The result is fetishised bundles of ideas, virtues and so on, which are identified as ‘masculine’ and ‘feminine’, and are imposed on men and women, regardless of whether they actually fit, with the result that male supremacy is both psychologically internalised and projected onto biology. Thus, in Simone de Beauvoir’s famous phrase, ‘one is not born, but rather made, a woman’.

The problem with the conservatives, from this point of view, is obvious: they are the ones explicitly promoting these ‘traditional’ gender identities and tormenting those who do not fit in. On the other hand, the trouble with the trans-rights activists is that they simply take these identities as given, and assert that a mismatch of biological sex and gender identity is in reality a mismatch of two ontologically equivalent predicates of an individual person, which occludes the historical dimension. Instead, we should fight for a world where boys can play with baby-dolls and wear dresses, and girls can cut their hair short and play rugby, without being characterised immediately as ‘effeminate’ or ‘mannish’ (or the rather less polite ways of saying the same thing). The point, according to a common slogan, is to ‘abolish gender’.

It seems to me that the Marxist left - excepting that part of it that openly sides with the Terfs - needs to take this approach far more seriously than it does. We too must take account of the complicated interactions between natural and human history, and our tendency to outsource thought on these questions to intersectionalite types has introduced severe theoretical inconsistencies, due to the dependence of the latter on anti-realist theoretical models - quite apart from enlisting us on one side of an Alien vs predator-style conflict (“Whoever wins, we all lose”).

That said, it does not give us terribly much tactical help when we talk about the GIDS clinic controversy. The lazy, identitarian critique of Marxism - that we supposedly demand oppressed groups “wait for the revolution” before their demands are met - would certainly apply if all we have to offer to gender-dysphoric teenagers is the abolition of gender at some distant future point. Of the thousands of youngsters on the GIDS waiting list, some number will develop a stable transgender identity, and some others (like Bell) will not, and their negative feelings about their biological sex will turn out to have been a symptom more like an eating disorder than an enduring sense of self.

Here is another way - besides the curious afterlife of ‘traditional’ gender roles - that historical forces bear upon the GIDS controversy. Ours is, after all, a very sick society, psychologically speaking; depression and anxiety are at epidemic levels (no doubt exacerbated by that other epidemic that is currently going on) and adolescents suffer especially badly in this regard. We would advance the hypothesis that a large part of that additional burden consists in the relentless incursions of adult society on teens’ autonomy (as exemplified by the insistence, in all the media coverage of the GIDS, on talking about 14- or 15-year-olds as children). This is, of course, excellent preparation for adult life itself (in Heathers - that great satire of adult America’s incomprehension of its kids - Veronica’s mother tells her that “when teenagers demand to be treated like adults, it’s normally because they are being treated like adults”).

Just as capitalist society causes much of this misery, so it is atrocious at even ameliorating the symptoms. The GIDS clinic is not the only mental-health service with a completely impossible caseload to handle in this country: the same forces that pared down the national health service to the point that it was very nearly overwhelmed by a rare but basically well-understood pandemic scenario - the insistence on running with no slack - has quietly relegated the nation’s psychology to a very minor consideration. (A friend of mine, a mental health nurse, is exasperated by the fact that the NHS can offer you a desultory course of cognitive behavioural therapy and basically nothing else until you deteriorate to the point that you need to be sectioned.)

The clinical criticisms of the GIDS must be taken seriously, then, but if we are to take them seriously, we must understand that any clinical response by an organisation like it is hobbled from the get-go; we have a society that infantilises its adolescents, demands they conform to fetishised gender ideals, and denies them humane and worthwhile treatment for the psychological difficulties they will very likely encounter.

On balance, the high court judgment is a poor one - whatever the GIDS’s failings, we cannot seriously believe that taking these decisions out of a clinical setting into a courtroom will be an improvement. But nor can we take liberal trans-affirmation at face value, for it mischaracterises the wider frame in which people come to question their identities, gender and otherwise, and thus increases the chance that people will make serious errors, as did Kiera Bell.

The Terfs, of course, have fatal defects of their own. Much of the ‘gender-critical’ argument we laid out above could no doubt be accepted by the typical pro-trans liberal feminist. But the intense polarisation stems rather from low-political aims than high theory. Radical feminism became NGO-ified in the 1980s, and the advance of the transgender cause among progressive-minded people - particularly the now-dead Gender Recognition Bill - seemed to threaten the remaining municipal institutions (refuges, rape crisis centres and so on) administered by that wing of the feminist movement.

The resulting antipathy turns this zero-sum contest over dwindling state largesse into mutual hostility, with Terf criticism of the GIDS clinic and trans protests at the cis-women-only spaces of the Terfs denounced in each case as violence. The result is that the Terfs have become a meat-shield for Tory reactionaries, and the transgender movement has become hostage to its most deranged Twitter keyboard warriors.

Fighting these battles as identity politics is precious little use to anyone who might want the help of the GIDS. But for the left it has been a total disaster.