by Susan Matthews, UK Academic
The Charing Cross Gender Identity Clinic is the ‘oldest and largest adult clinic’ in the UK. It was founded in 1966, the year that the first sexual reassignment surgery was carried out at Johns Hopkins Gender Identity Clinic, the world’s first GIC founded the previous year by psychiatrist and sexologist John Money (1921-2006). The founding clinician at Charing Cross, Richard Green (1936 -), came with an impressive academic pedigree, having worked with Money, collaborating on research on boys who demonstrated cross-gender behaviour. Money liked to claim (with some justification) that he had invented the modern sense of the word ‘gender’ – andit was Money who named the clinic (specialising in the treatment of intersex and transsexual patients) a ‘Gender Identity Clinic’. (Up until the second half of the twentieth century, the word ‘gender’ referred to grammatical gender, a feature of language not human identity). Money was a psychiatrist by training but working with the new specialism of endocrinology his clinic was able to achieve unprecedentedly convincing results in gender transition.
1966 was the golden age of gender specialists, a period in which Money and Green felt an exhilarating confidence not only in their ability to improve the lives of intersex and transsexual patients through surgery, but also in their ability to understand the mystery of human gender (a concept that they themselves had defined). This was also the year that Money acquired what seemed a perfect test case and one that came with an inbuilt control when Bruce Reimer, one of a pair of identical twins, suffered a medical mistake that destroyed his penis in the course of a routine circumcision. Drawing on his expertise with intersex, Money recommended that the baby should undergo orchidectomy and be raised as a girl. Bruce became Brenda and was subject to yearly consultations with Dr Money. But when Brenda decided to revert to a male identity at 14, took the name David and refused to attend any more annual inspections, Money failed to correct the many publications that he had drawn from this case. In the end it was not so much the ‘failure’ of the gender reassignment, but the fact that Money lied about his findings, continuing to reissue earlier accounts and claiming that Brenda was ‘lost to follow up’ that threatened his reputation. Some remained loyal, not least Richard Green who described Money in a 2010 BBC documentary as a ‘brilliant man, one of the most brilliant men I have ever met’. According to Green, Money did the best he could – given what was then known about gender.
Back in 1966, surgical solutions for psychological problems seemed to offer a breakthrough in patient care and sex reassignment was not the unique procedure it now seems. At the time, there was no hesitation about naming transgender as a ‘disorder’, indeed the term ‘gender identity disorder’ was taken from Green’s work. This was the time when lobotomy was still widely practised: Antonio Egaz Moniz had won a Nobel prize for the procedure in 1949, and although the operation was banned in the US in 1967, lobotomy continued in the UK in reducing numbers until the 1980s. As a child I met a woman who had been my mother’s best friend, who had undergone a lobotomy after a breakdown following an affair by her husband – who as next of kin had authorized the operation on his wife. Seeing her capable of no more than flat small talk left me with a lasting horror of psycho-surgery. What I didn’t realise then was that demand for lobotomy came from patients, enthused by claims made for the procedure.
‘The Death Star’
Back in 1966, the science of gender identity was in its infancy and both Money and Green were highly respected. Money’s professional standing was based on his expertise in the treatment of intersex for which he devised a widely accepted protocol. But intersex was particularly important to Money because he believed that by studying intersex he could gain an unprecedented understanding of human gender identity. In a 1996 introduction to the reissue of his classic 1972 Man & Woman, Boy & Girl: Gender Identity from Conception to Maturity, Money explicitly thanks his intersex patients: ‘The majority of people who contributed to this new meaning of gender were hermaphrodites or intersexes. To them social science and social history overall owe a debt of gratitude.’ What Money did not acknowledge in this introduction was that by 1996 the consensus amongst clinicians about how to treat intersex had been challenged by the patients themselves – many of whom viewed Money’s protocol as invasive. Many felt that their bodies had been subject to unnecessary surgery and believed that they had been lied to: some called Money’s intersex clinic at Johns Hopkins the ‘Death Star’.
The difficulty is to know which elements of the science of gender spawned by the Johns Hopkins Gender Identity Clinic need to be revised and which rejected. For the Reimer case is open to many different readings. Zoe Playdon attributes the failings of UK gender identity clinics to this history, associating them with the ‘falsified research’ of the Reimer case and arguing that they ‘still generally coerce patients into extended psychiatric treatment, often lasting for years, in the absence of any identifiable mental health problems and without informed consent.’ But she is wrong to claim that Money and the Johns Hopkins clinic were ‘conversion therapists’. In the field of transsexualism, they saw themselves as sexual radicals, at the forefront of supporting gender reassignment. If their model of gender roles was conservative that is unsurprising for a rigid model of gender underpins the whole field of gender reassignment with its insistence on matching bodies to socially defined roles. Certainly the psychiatric assessments described by the Reimer twins (both of whom subsequently committed suicide) appear to have been unprofessional and probably traumatic. But for intersex patients, so were the surgical therapies imposed on their bodies. Playdon cannot conceive that the medical and surgical procedures evolved in Money’s clinic might require challenge as much as the particular model of psychiatric assessment that Money used.
The Charing Cross GIC, then, was founded in a very different world from that we now inhabit, a world to which we would not want to return. The science of gender emerged from a tiny group centred on John Money and its findings were ethically compromised. It was a world in which the authority of the clinician was unchallenged, and in which transsexualism was believed to be rare but universal and unchanging. Although Money’s students and followers have gone on to found a series of treatment centres, the numbers of ‘gender’ specialists are relatively few. Echoes of the founding beliefs are still apparent in a 2011 paper by James Barrett, currently lead clinician at Charing Cross GIC. ‘Disorders of gender identity have probably always existed, inside and outside Europe’, Barrett writes, citing a 1975 study (Heiman). Citing a 1996 study, he presents the condition as vanishingly uncommon: ‘It seems that the incidence of transsexualism is very roughly 1 in 60000 males and 1 in 100000 females, and it seems to have remained constant’ Given that ‘Treatment is drastic and irreversible’, Barrett insists that diagnosis must be entrusted to the experts of the gender identity clinic:
The least certain diagnosis is that made by the patient, made as it is without any training or objectivity. This uncertainty is not lessened by the patient’s frequently high degree of conviction. Neither does the support of others with gender dysphoria help, since conviction leads people to associate with the likeminded and to discount or fail to seek out disharmonious views.
For Barrett in 2011, the aim is to ‘pass’ and he reports that ‘At least one patient has been undetected by her general practitioner and by her boyfriend of 9 years. Another was undetected in the course of several lesbian relationships.’
These assumptions do not fit the world that Barrett and his colleagues encounter now when rates of transsexualism are rising sharply – not remaining constant. The incidence of transsexualism in women exceeds that in men. The whole notion of diagnosis is seen as inappropriate: patients self-identify, drawing often on online guidance, and the role of the clinic is simply to accept a diagnosis formed by the patient. For many of those who claim a trans or non-binary identity, passing is no longer the aim. Above all, transsexualism, now redefined as transgenderism, is no longer a disorder. In this changed world, the function and the funding of the Gender Identity Clinic is thrown into doubt. Clinicians do not understand the world they now encounter, nor are their theoretical models adequate to understand their patients.
A mighty taxonomological struggle
It is not surprising, then, that Trans is now a thing like no other, a condition without a theoretical model. Barrett compares it, in a 2016 blog post for the BMJ, to ‘the Australasian Platypus’:
The first specimens were dismissed as a joke of some sort.
But then more came, and alive and kicking at that. There followed a mighty taxonomological struggle. They were reptiles or perhaps some sort of bird, surely, as they were warm blooded, laid eggs and were venomous. On the other hand, the fur argued for mammals, but they didn’t have proper breasts, the defining feature of the mammals, and that business of being venomous is more of a reptile-like thing, is it not? And they do lay eggs…but warm blooded…perhaps a bird of some sort…?
In the end, it was all solved by everyone admitting that the Platypus was real, important, couldn’t be dismissed and didn’t fit any existing category very well. It got its own, special category where it has paddled, very happily, ever since, albeit joined by echidnas and some long-extinct fossilised forebears.
The difference from the Money/Green generation is striking. When Brenda Reimer insisted – despite an upbringing and a family that told her she was a girl – that inside she had never felt female, this high profile (and unique) case seemed to demand a new model of gender identity. For David Reimer as for many now, gender was a strongly felt internal sense of self. Richard Green’s 2010 comment that Money’s model of gender identity was the best that was known at the time was an attempt to overcome the threat to his professional identity as a gender specialist created by the fallout from the Reimer case. Yet there was no model to take its place. Trans clinicians are now unwilling to offer a theoretical model of gender. Doctors are asked to prescribe hormones on the basis that medication reduces distress and leads to an improved quality of life (claims that are hard to support from evidence).
With no theoretical model, analogy is often the next best thing. Those arguing for access to medical intervention frequently invoke – and discard – parallels with gay abandon. But in every case, the differences are as significant as the similarities. A key claim is that the fight for transgender equality mirrors that for homosexual equality in decades gone by. It should not need pointing out that you don’t need to alter your body to be gay. Homosexuality does not depend on medical or surgical intervention – except in countries such as Iran where homosexuality is currently illegal. Attempts to change the bodies of homosexuals are considered some of the most flagrant crimes of the last century. When Alan Turing, the early computer scientist and code breaker, was forced in 1952 to take androgen blockers to control homosexual urges or face imprisonment, we rightly blame doctors for complicity in denying his human rights. But Turing’s treatment was later mimicked in Money’s clinic: in the key year 1966, John Money became the first US doctor to prescribe androgen blockers to a patient dealing with paedophilic urges. The parallels are at the least problematic. Responding to James Barrett’s 2016 piece, a GP writes: ‘I personally and professionally object to Dr Barrett linking the transgender status of a patient to that of being Gay or Black. My Gay and Black patients do not need me to prescribe medication to maintain their status.’
Equally problematic is the comparison with intersex which formed the basis for Money’s theories on gender. Trans activists borrow terms like ‘assigned male (or female) at birth’ from the language of intersex: ‘When a person is born, a doctor assigns a gender by only looking for one thing: the presence or absence of what they consider to be a penis. […] As they grow up, the doctor’s guess can turn out to be wrong, either because the person had an undiagnosed intersex condition, or they are transgender and don’t identify with their assigned gender.’ Yet trans people by definition belong to the 99% of human beings for whom genital, gonadal and gene sex is congruent. For this group sex is not assigned at birth but is a biological fact. To suggest otherwise is to co-opt intersex narratives. 
Trans treatment protocols were established within the academic fields of sexology and psychiatry. Yet trans (it is now claimed) has nothing to do with sexuality or with mental health: Barrett writes in 2016 that ‘My patient interviews are not ‘psychiatric’ just because I come from an originally psychiatric background. They relate specifically to gender dysphoria.’  The body of professional knowledge that Barrett mobilises is the knowledge of gender, a discipline defined and originated in the clinic run by Money and a discipline whose methodology is unique.
Given the lack of any parallel, it is not surprising that the treatment protocol established over the last fifty years has been described as ‘a unique intervention not only in psychiatry but in all of medicine.’ It is also not surprising that it is increasingly difficult to know where gender specialists should be accommodated and who should fund them.
Over a period of fifty years, the Charing Cross Gender Identity Clinic has catered for a large number of patients. But it has also been somewhat accident prone. Perhaps clinicians become blasé as they become accustomed to prescribing irreversible treatments. James Barrett started his career as a sceptic and gatekeeper, joining in 2006 with colleagues Richard Green, Stuart Lorimer and Don Montgomery, to report the leading gender clinician at Charing Cross, Russell Reid to the GMC (General Medical Council) for professional misconduct, a charge of which Reid was found guilty. Colleagues, including Barrett, accused Reid of blurring ‘professional boundaries by calling patients his nephews and nieces’. Past patients claimed that Reid ignored a series of traumatic events in supporting gender transition which they came to regret, and failed to acknowledge co-morbidities such as psychosis. In subsequent years, gender surgeon James Bellringer was eased out of the clinic for undisclosed reasons. And the clinic has found it hard to recruit sufficient psychiatric and surgical staff.
But only a decade since the Russell Reid inquiry, Barrett now presents a very different account of the clinic and of the role of the gender expert. A Freedom of Information request in 2016 by the Guardian newspaper revealed that the ‘number of referrals has almost quadrupled in 10 years, from 498 in 2006-07 to 1,892 in 2015-16.’ James Barrett told the Guardian: “It obviously can’t continue like that forever because we’d be treating everyone in the country, but there isn’t any sign of that levelling off”. (So much for Barrett’s 2011 claim that the incidence of transsexualism is constant and unchanging.) The clinic is currently funded by the West London Mental Health Trust. But funding this new demand places an intolerable strain on underfunded mental health services: the Kings Fund showed in 2015 that ‘Mental health problems account for 23 per cent of the burden of disease in the United Kingdom, but spending on mental health services consumes only 11 per cent of the NHS budget.’ For the mental health trust which funds the Charing Cross GIC, the only answer is to end their contract with NHS England, a solution that paradoxically matches the demands of trans activists who call for the depathologization of trans and the removal of medical gatekeepers. James Barrett is clear that “clinicians have long felt that West London Mental Health Trust is not a good fit for the unique and specific service we provide (the vast majority of those we see are not mentally ill).”
This claim is important, for if trans were a disorder (as in 1966), the work of the clinic would belong in a worrying tradition, one that harks back at the worst to lobotomy and calls up disturbing memories of the treatment of David Reimer. If trans has any links to body dysmorphia, to anorexia, or to self-harm, then it could not be appropriate to medicate or to offer surgery, however acceptable to the patient, however fiercely demanded. Colin Ross identifies the underlying ethical problem:
Gender identity disorder is unique among all DSM-IV-TR diagnoses. It is the only disorder in which treatment is designed to confirm, reinforce, and validate the belief that is the basis of the mental disorder. In all other diagnoses, the symptoms in the diagnostic criteria are viewed as pathological and the goal of treatment is to remove the symptoms. In gender identity disorder, however, the body is altered to match the belief that is said to be a symptom of mental disorder. This is self-contradictory. Either gender identity disorder should be dropped from DSM-V, just as homosexuality was dropped from the diagnostic system, or gender reassignment should be discontinued. The core contradiction in the current approach to gender identity is an ethical problem in the mental health field.
For James Barrett and the Charing Cross GIC, the only way out of the quandary is to separate the GIC from the Mental Health trust. But to do so is to admit that this form of necessary body modification is without parallel. It is unique and specific. Gender is not like anything else.
‘Unique and specific’
In a recent discussion with Jay Stewart, founder of the Gendered Intelligence community support group for trans and non-binary young people, I was struck by the insistence that the young people he works with are not mentally ill. Any distress they might experience comes from people saying ‘unkind things’. Their problems are caused by a society which is slow to accommodate diverse gender identities. Yet Stewart’s claim did not match the picture I saw at a recent visit to the GI parents’ support group where a parent claimed that all the young people have co-morbidities. Stewart dismissed the distress , the self-harm and depression that parents described as ‘an account I do not recognise’. He does not use the term ‘gender dysphoria’ with its acknowledgement of unhappiness. Trans is a movement for health and happiness.
James Barrett by contrast admits that trans people can suffer from mental illness. But mental illness, where it exists, has nothing to do with a trans identity. Writing in 2016 to the London Review of Books, Barrett is proud that co-existing mental illnesses are no bar to accessing the unmitigated good of gender transition services:
Patients have already advanced perfectly satisfactorily through all stages of treatment with coincidental diagnoses of schizophrenia, chronic renal failure, paraplegia, emotionally unstable personality disorder, learning disability and autism. Patients currently being treated in the UK include those unwell enough to be detained under the Mental Health Act in a secure hospital.
The contrast with Barrett’s position in his 2011 paper (or his 2006 action against Russell Reid) is striking and reveals what we already know: that scientific ‘objectivity’ reflects the demands and assumptions of the society it serves. The beliefs of the gender specialist have a history – a starting point and perhaps an end. Barrett’s position now means that gender dysphoria cannot be caused by mental illness (as Reid’s patient accusers believed). If trans is never a pathology, then existing mental illness is nothing to do with trans. Barrett does not offer a psychiatric assessment but a gender assessment to patients at the Charing Cross GIC. A clean bill of mental health from Barrett can coexist with a disability diagnosis from a local mental health trust which has led to Personal Independence Payments (PIP). Yet to qualify for PIP you must have ‘a long-term health condition or disability and face difficulties with ‘daily living’ or getting around.’ It is curious that the onset of the diagnosed disability in the case known to me, coincided with the onset of gender dysphoria. But gender specialists work to a different model of mental health than Mental Health trusts. In the US, blogger, psychologist and detransitioner ‘Third Way’ says that ‘a lot of the treatment now for gender dysphoria just throws out the basic principles of psychology’.  He comments that ‘people who detransition often talk about issues of trauma’ and that ‘these are things that can be worked on psychologically’.
Voices that matter
A belief that trans is never a pathology makes it impossible to recognize evidence of psychological vulnerability and trauma in this population. A 2011 Swedish study into long terms outcomes of transgender patients concludes that this group is liable to suffer from a range of psychological difficulties: ‘Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.’ In this study, sex reassigned patients fared markedly less well than a comparable group matched ‘for premorbid differences regarding psychiatric morbidity’.
Perhaps the most important voices are those of transitioners and detransitioners who are now beginning to explore what they see as a relationship between trans and trauma, challenging the constricting logic which demands that the complexity of human experience must fit the constructs of the gender narrative. Carey Callahan describes how depersonalization both drove her to identify as trans and intensified while taking testosterone. Not only is there a huge rise in teenage girls identifying as trans or gender non-binary but there seems to be a marked overlap with those suffering from eating disorders and self-harm. One blogger writes: ‘I am a female to male transgender with an eating disorder, and this kind of thing is very common among trans men. Gender dysphoria can cause us to have body dysmorphia because our minds and our bodies are not congruent and we hate the bodies that we were born with!’ Jack Monroe, the food writer who now identifies as transgender has described how ‘all through high school’ she ‘struggled with a severe eating disorder.’  In studies, the overlap between trauma and gender dysphoria is striking. How else could we explain the overrepresentation of trans people within US army veterans? A 2013 study shows that Gender Identity Disorder in the Veterans Health Administration is roughly five times higher than in the general US population (22.9 per 100 000 amongst veterans rather than 4.3 in 100 000 persons). Suicide-related events among veterans with gender identity disorder occur 20 times more frequently than in the general US VHA population. Gender identity disorder is increasing amongst US veterans, nearly doubling over ten years.
According to Barrett, the interventions offered at the Charing Cross GIC make for ‘happier and healthier lives’. But if the rise in transsexualism is an expression of the multiple forms of trauma in modern life, then the attempt to de-pathologize trans and to separate trans provision from mental health services may have devastating consequences. It is an understandable response to the dark early history of gender identity study, yet gender clinicians remain fixed within a closed set of assumptions that blind them to the evidence.
 Terry Goldie, The Man who invented Gender: engaging the ideas of John Money (Vancouver: UBC Press, 2014); Lisa Downing, Iain Morland, and Nikki Sullivan, Fuckology: critical essays on John Money’s diagnostic concepts. (Chicago: University of Chicago Press, 2015); John Colapinto, As Nature Made Him: The Boy Who Was Raised as a Girl, p25.
 ‘Money continued to insist to his scientific, academic, and medical colleagues that the case was “lost to follow up”’, John Colapinto, As Nature Made Him, 202.
 BBC Horizon, 2010, ‘Dr Money and the Boy with No Penis’. Currently available at https://vimeo.com/55409956. The BBC team began following the Reimer case and recording interviews in 1979. (Colapinto, 168).
 John Money, Anke A. Ehrhardt, Man & Woman, Boy & Girl: Gender Identity from Conception to Maturity, Northvale N.J.: Jason Aronson Inc, 1973, 1996), xii.
 Alice Dreger, Galileo’s Middle Finger: Heretics, Activists, and one Scholar’s Search for Justice New York, Penguin, 2015, 40.
 A letter to the BMJ from Zoe Playdon claims
 Zoe Playdon, ‘Unequal treatment of transgender people’
BMJ 2016;353:i2329doi: http://dx.doi.org/10.1136/bmj.i2329 (Published 26 April 2016)
 James Barrett, Advances in psychiatric treatment (2011), vol. 17, 381–388 doi: 10.1192/apt.bp.109.007484
 James Barrett, http://www.bmj.com/content/352/bmj.i1694/rapid-responses
 Jeremy Luke, ‘Gender dysphoria: shared care is the answer’
BMJ 2016;353:i2326http://dx.doi.org/10.1136/bmj.i2326 (Published 26 April 2016)
 Daphna Joel, ‘Genetic-gonadal-genitals sex (3G-sex) and the misconception of brain and gender, or, why 3G-males and 3G-females have intersex brain and intersex gender’,
Biology of Sex Differences 2012, 3:27 http://www.bsd-journal.com/content/3/1/27Daphna Joel
 New Narratives 2014 rejects ‘COINing’, or co-opting intersex narratives: ‘we have a strict no-COINing policy (co-opting intersex narratives). That means, if you are a trans woman who “suspects” or wishes you were intersex, but have not been diagnosed, please either see a doctor or cut it with the appropriation.’
 James Barrett, http://www.bmj.com/content/352/bmj.i1694/rapid-responses
 ‘Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden’
Cecilia Dhejne, Paul Lichtenstein, Marcus Boman, Anna L. V. Johansson, Niklas Långström, Mikael Landén
Published: February 22, 2011http://dx.doi.org/10.1371/journal.pone.0016885
 Colin A. Ross, Ethics of Gender Identity Disorder, Ethical Human Psychology and Psychiatry, 11.3, 2009. https://www.questia.com/library/journal/1P3-1923231181/ethics-of-gender-identity-disorder
 19 May 2016. http://www.lrb.co.uk/v38/n10/letters#letter1
 ‘TWT Another detransitioner speaks’. https://youtu.be/zZKDWpIggPQ.
 Blosnich, John R. et al. “Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care.” American Journal of Public Health 103.10 (2013): e27–e32. PMC. Web. 10 Aug. 2015.