SPECIAL ARTICLE

Sex, gender and gender identity: a re-evaluation of

the evidence
Lucy Griffin,1 Katie Clyde,2 Richard Byng,3 Susan Bewley4

BJPsych Bulletin (2021) 45, 291–299, doi:10.1192/bjb.2020.73

1
Priory Hospital Bristol, Bristol, UK; Summary In the past decade there has been a rapid increase in gender diversity,
2
Southern Health NHS Foundation Trust,
particularly in children and young people, with referrals to specialist gender clinics
Hampshire, UK; 3Faculty of Health,
University of Plymouth, UK; rising. In this article, the evolving terminology around transgender health is
4
Department of Women & Children’s considered and the role of psychiatry is explored now that this condition is no longer
Health, King’s College London, UK classified as a mental illness. The concept of conversion therapy with reference to
Correspondence to Lucy Griffin alternative gender identities is examined critically and with reference to psychiatry’s
(drlucygriffin@[Link]) historical relationship with conversion therapy for homosexuality. The authors
First received 23 Dec 2019, final revision consider the uncertainties that clinicians face when dealing with something that is no
28 May 2020, accepted 5 Jun 2020 longer a disorder nor a mental condition and yet for which medical interventions are
© The Authors 2020. This is an Open frequently sought and in which mental health comorbidities are common.
Access article, distributed under the
terms of the Creative Commons Keywords Sexual and gender identity disorders; ethics; comorbidity;
Attribution licence ([Link] phenomenology; consent and capacity.
[Link]/licenses/by/4.0/),
which permits unrestricted re-use,
distribution, and reproduction in any
medium, provided the original work is
properly cited.

In 2018 the Royal College of Psychiatrists (RCPsych) issued tolerant social attitudes. Homosexuality was removed from
a position statement to promote good care when dealing the World Health Organization (WHO) ICD-10 classification
with transgender and gender-diverse people that relates to in 1992. In 2014, the RCPsych published a position state-
‘conversion therapy’.1 In this article we reappraise the phe- ment explicitly rejecting conversion therapy and supporting
nomenology of gender identity, contrast ‘treatments’ for a ban.6 Same-sex orientation is regarded as a normal, accept-
homosexuality with those for gender non-conformity, ana- able variation of human sexuality.
lyse the relationship between gender dysphoria and mental Enshrined in the Equality Act 2010, lesbians and gay
disorders with particular reference to the younger cohort men in the UK now enjoy the same civil rights as heterosex-
of transgender patients, and ask how psychiatrists can uals in terms of healthcare, marriage and raising of children,
address distress related to gender while upholding the cen- and equal employment. Although they enjoy equal status and
tral tenet of ‘first do no harm’. increased visibility in most Western societies, there remain
countries and cultures where same-sex practice is taboo or
criminal, and where people still seek treatment.
Homosexuality and conversion therapy
Male homosexuality was outlawed in the UK in 1865 until
the Sexual Offences Act 1967 decriminalised sexual acts
Beyond sexual orientation
between men. During that time, homosexuality was shame- In recent years, increasing links have been forged between
ful, stigmatised and conceptualised as a mental disorder. lesbian and gay communities and those representing other
Psychiatry was instrumental in its treatment, which contin- gender identities. Stonewall describes ‘any person whose
ued even after the legal change.2 gender expression does not conform to conventional ideas
Attempts to ‘cure’ same-sex desire included psychother- of male or female’ as falling under the umbrella term ‘trans’.7
apy, hormone treatment and various behavioural interventions. Definitions have evolved beyond those included in the
These interventions are now considered ‘conversion’ or ‘rep- 1992 ICD-10 under ‘gender identity disorders’, with which
arative’ therapy.3 One high-profile failure for such ‘treatments’ psychiatrists might be familiar.8 Transsexualism was widely
was Alan Turing. After being found guilty of gross indecency in understood to mean ‘a desire to live and be accepted as a
1951, he was prescribed oestrogen, which rendered him impo- member of the opposite sex, and an accompanied discomfort
tent and caused gynaecomastia. He died by suicide in 1954.4 of one’s anatomic sex’.8 Underlying mechanisms are poorly
Conversion therapies lost popularity as evidence understood, although there are similarities and overlaps
emerged of their ineffectiveness,5 coupled with more with both body dysmorphia and body integrity identity

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Griffin et al Sex, gender and gender identity

Fig. 1 A page from The Gender

Book12 (reproduced with
permission of www.
[Link]).

disorder.9,10 Sufferers might embark on social and medical There is a lack of consensus demonstrated as to the
intervention to help them ‘pass’ as the opposite sex. exact nature of the condition. Questions remain for psychia-
Historically, a diagnosis of gender dysphoria would have trists regarding whether gender dysphoria is a normal vari-
been required for doctors to intervene in this group.11 ation of gender expression, a social construct, a medical
Transgender, however, has become a much broader disease or a mental illness. If merely a natural variation, it
category (Fig. 1). New terminology reflects a conceptual becomes difficult to identify the purpose of or justification
shift from clinical disorder to personal identity.12 Crucially, for medical intervention.
gender dysphoria is no longer integral to the condition.
The World Health Organization has renamed ‘gender identity
disorder’ as ‘gender incongruence’ and reclassified it as a
‘condition related to sexual health’ rather than retaining it in Conversion therapy relating to gender
the chapter pertaining to ‘mental and behavioural disorders’,13
The RCPsych gives a description within the position state-
a somewhat discrepant placement, reflecting a political rather
ment of ‘treatments for transgender people that aim to sup-
than scientific decision-making process.
press or divert their gender identity – i.e. to make them
By contrast, DSM-5 has removed ‘gender identity disorder’,
exclusively identify with the sex assigned to them at
renaming it ‘gender dysphoria’. It is possible to meet the criteria
birth’.1 Conversion therapy is described as ‘any approach
for a diagnosis of gender dysphoria within DSM-5 without
that aims to persuade trans people to accept their sex
experiencing body dysphoria relating to primary or secondary
assigned at birth’. It goes on to include ‘placing barriers
sexual characteristics,14 and the American Psychiatric
[to] medical transition’. Unfortunately, the statement does
Association emphasises that ‘not all transgender people
not define ‘approach’ beyond alluding to psychoanalytic or
suffer from gender dysphoria’.15
behavioural talking therapies. Thus, conversion therapy for
The following is from the 2018 ICD-11:16
transgender people appears conflated with that for homo-
‘Gender incongruence of childhood is characterized by a sexuality. Furthermore, there is little evidence that it is tak-
marked incongruence between an individual’s experienced/ ing place in the UK.17 Historically, a diagnosis of gender
expressed gender and the assigned sex in prepubertal chil-
dren. It includes a strong desire to be a different gender dysphoria was required before medical intervention;10 this
than the assigned sex; a strong dislike on the child’s part of is a part of standard gatekeeping that is now being criticised
his or her sexual anatomy or anticipated secondary sex char- as a ‘barrier’ instead of regular safe medical practice.2 Now, a
acteristics and/or a strong desire for the primary and/or self-declaration of being ‘trans’ appears to be indication
anticipated secondary sex characteristics that match the
experienced gender; and make-believe or fantasy play, toys, enough for a patient to expect their doctor provide a range
games or activities and playmates that are typical of the of complex medical treatments, with no evidence of dys-
experienced gender rather than the assigned sex.’ phoria being required.18
The position statement1 could also be read as suggesting
Definitions are inadequate in explaining how anyone experi- that full medical transition is an ultimate goal in gender-
ences the gender of the opposite sex. Without further explan- diverse patients, rather than considering a range of possible
ation of ‘toys, games or activities’ that are typical of each sex, goals, which might include limited interventions or
this is left to parents, teachers and doctors to determine. The reconciliation with one’s own (sexed) body. With regard to
inference might be that gender-congruent behaviours have conversion therapy in children, the statement does not
some objective existence and not fulfilling them might indi- refer to desistance; evidence suggests that the majority of
cate a ‘trans’ identity. Children who do not conform to social children left alone reconcile their identity with their bio-
norms and expectations come to dislike their sexual charac- logical sex; the feelings of 60–80% of children with a formal
teristics: that embodiment of their gender dissonance. diagnosis of gender dysphoria remit during adolescence.19–21

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Definitions of sex, gender and gender identity ‘essence’. As a pure subjective experience, it may be over-
whelming and powerful but is also unverifiable and unfalsifi-
Gender theorists propose that all people must have a gender able. If this identity is held to be a person’s innermost core
identity; it is not waivable. For those people whose internal concept of self, then questioning the very existence of gender
identity aligns with their sex, the word cisgender and ‘cis’ identity becomes equated with questioning that person’s
terminology are used. Those whose identity is wholly that entire sense of being, and consequently risks being consid-
of the opposite sex are described as transgender or ‘trans’. ered a threat to the right to exist, or even as a threat to
However, there are other identities for those whose internal kill. Behaviours such as ‘misgendering’ or ‘dead-naming’
sense lies somewhere between or outside a neat fit into either are understood by proponents of gender theory to be
gender-binary category. Fluidity and fluctuation in gender destructive, debasing and dehumanising.28 This might
identity is also recognised, with categories such as ‘non- explain why the prevailing discourse has become as sensitive
binary’, ‘gender-fluid’, ‘genderqueer’, ‘pangender’ and ‘gender- and at times inflammatory as it has.
fuck’ all recorded by clinicians at the UK’s Gender Identity Nonetheless, notions of gender identity are still con-
Development Service (GIDS) for under-18-year-olds.22 The tested and raise some ethical questions for professionals
social networking site Tumblr presently describes over 100 working at the interface of physical and mental disorder.
different genders.23 Without a strong male or female identifi- Most psychiatrists reject Cartesian dualism, whereby
cation, ‘agender’ becomes itself another gender identity. the mind is something imprisoned inside the body, or the
Some consider gender identity to be fixed and absolute, ‘ghost in the machine’.29 How should doctors consider the
with some neuroscientists asserting that it develops in utero body? We are born as, and die as, a body; we are our bodies.
in the second-trimester brain.24,25 However, there is little to How can someone be born in the wrong body? Many
no convincing evidence to support fundamental differences patients bring a ‘wrong’ or ‘wronged’ body to their doctor;
between the brains of females and males.26 If one’s ‘internal these may be traumatised, wounded, diseased or disliked
sense of being a man or a woman’ no longer refers to a ‘man’ bodies. How should doctors react when someone informs
or ‘woman’ as defined by biological sex27 then the definition them that, although they inhabit the body of a man, they
of gender identity risks becoming circular. are in all other respects female? We must deal with all our
Within current debates, if gender identity becomes patients with compassion but also make safe medical deci-
uncoupled from both biological sex and gendered socialisa- sions when demonstrable material reality is at odds with a
tion (Box 1), it develops an intangible soul-like quality or patient’s subjectivity.

Box 1. Sex, gender and gender identity Children and adolescents

Sex The Gender Identity Development Service (GIDS), Britain’s
Humans are sexually dimorphic: there are only two viable gametes only specialised gender service for children and adolescents
and two sexes, whose primary and secondary sexual character- and based at the Tavistock Centre, London, has recorded a
istics determine what role they play in human reproduction. Sex is 25-fold rise in referrals since 2009, most marked in bio-
determined at fertilisation and revealed at birth or, increasingly, in logical girls (‘assigned female at birth’), who make up the
utero. The existence of rare and well-described ‘disorders (differ- majority of referrals presently (Fig. 2).30
ences) of sexual differentiation’ does not negate the fact that sex Despite gender dysphoria no longer falling within the
is binary. The term ‘assigned at birth’ suggests a possibly arbitrary
remit of mental illness in ICD-11, there is a substantial
allocation by a health professional, rather than the observed
body of evidence of increased levels of mental illness
product of sexual reproduction.
Gender among adults, usually attributed to societal responses to
Gender describes a social system that varies over time and loca- gender non-conformity or ‘minority stress’.31 De Vries et al
tion and involves shaping of a set of behaviours deemed appro-
priate for one’s sex. It operates at an unconscious level via strong
social norms, yet is also rigidly enforced by coercive controls and 2000
sometimes violence.18 The ‘rules’ exist regardless of how indivi-
duals feel about them. Gender can thus be perceived as oppres- 1500
Yearly referrals

sive and potentially painful to all people of both sexes within

patriarchal societies, the dominant form of social structure across
most, although not all, of the globe. Feminist theory holds that 1000
gender operates as a hierarchy, with men occupying the superior
position and women the subordinate. As long as this hierarchy 500
exists, all women are harmed to some extent, whether or not they
conform to their sex stereotypes.19
0
Gender identity
2009/2010 2012/2013 2015/2016 2018/2019
If sex refers to biology, and gender to socialisation and role, then
gender identity may be viewed as the psychological aspect. The Year
American Psychological Association defines it as ‘someone’s 0 Natal males 0 Natal females
internal sense of being a man or a woman’.20 Gender identity is
thus distinguished from biological sex and gendered Fig. 2 Referral rates to the Gender Identity Development Service at the
socialisations.21 Tavistock Centre (Tavistock and Portman NHS Trust) in London
between 2009 and 2019.30

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Griffin et al Sex, gender and gender identity

Severe eating disorder 2%

ADHD 11%
Psychotic symtpoms 13%
In foster placements 13%
ASD 26%
Self harm 53%
Anxiety 55%
Bullying 57%
Depression 64%
Total Severe MH probs 75%
Natal females 87%

0 10 20 30 40 50 60 70 80 90
33
Fig. 3 Referrals to an adolescent gender identity clinic in Finland over a 2-year period (from 2011–2013).

measured psychiatric comorbidity among those referred to a as primarily attracted to boys. This raises important ques-
child and adolescent gender clinic in The Netherlands and tions about current societal acceptance of young lesbians
also found increased rates of depression, anxiety and suicidal even within youth LGBTQ+ culture. It is possible that at
ideation in this younger group.32 However, a potentially least some gender-non-conforming girls come to believe
worrying picture regarding causes and consequences themselves boys or ‘trans masculine non-binary’ as more
emerges from more recent research in this young, increas- acceptable or comfortable explanations for same-sex sexual
ingly natal-female population. attraction,35 a kind of ‘internalised homophobia’. Autism
Kaltiala-Heino et al examined referrals to an adolescent spectrum disorders are consistently overrepresented in
gender identity clinic in Finland over a 2-year period, finding referred children and adolescents.36
high rates of mental health problems, social isolation and The RCPsych’s position statement acknowledges these
bullying (Fig. 3).33 Most bullying pre-dated the onset of gen- elevated rates of mental illness within the transgender popu-
der dysphoria and was unrelated to gender incongruence. lation,1 but appears to attribute them primarily to hostile
Similarly, in the UK, Holt et al34 found that associated external responses to those not adhering to gender norms
difficulties were common in children and adolescents (or sex-specific stereotypes).37,38 A deeper analysis of mental
referred to the GIDS in London (Fig. 4). Same-sex attraction illness and alternative gender identities is not undertaken,
was particularly common among natal females, with only and common causal factors and confounders are not
8.5% of those referred to the GIDS describing themselves explored. This is worrying, as attempts to explore, formulate

Psychosis
Eating difficulties
Associated difficulties

Abuse
Bullying
Anxiety
ASD
Low mood
Suicidal ideation
Self-harm
Opposite sex attracted
orientation
Sexual

Bisexual
Same sex attracted

0% 10% 20% 30% 40% 50% 60% 70% 80%

Natal males Natal females

Fig. 4 Referrals to the Gender Identity Development Service at the Tavistock Centre (Tavistock and Portman NHS Trust) in London between 1
January 2012 and 31 December 2012.34 ASD, autism spectrum disorder.

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and treat coexisting mental illness, including that relating to and gatekeeping or to a less palatable interpretation that
childhood trauma, might then be considered tantamount to preventing physical and sexual maturation crystallises gen-
‘conversion therapy’. Although mental illness is overrepre- der dysphoria as a first step on a cascade of interventions.43
sented in the trans population it is important to note that gen- The GIDS remains under intense scrutiny regarding research
der non-conformity itself is not a mental illness or disorder. criticisms.44 Although in the early 2000s it was criticised for
As there is evidence that many psychiatric disorders persist being too conservative and not offering puberty blockers,
despite positive affirmation and medical transition, it is puz- there appears to have been a volte-face made in response to
zling why transition would come to be seen as a key goal external pressure,45 without the publishing of robust data
rather than other outcomes, such as improved quality of life showing that this intervention is effective and safe.
and reduced morbidity. When the phenomena related to iden- Puberty blockers are known to affect bone and, possibly,
tity disorders and the evidence base are uncertain, it might be brain development. They put users at risk of developing
wiser for the profession to admit the uncertainties. Taking a osteoporosis46 and are associated with reductions in
supportive, exploratory approach with gender-questioning expected IQ.47 They are described as ‘buying time’ for ado-
patients should not be considered conversion therapy. lescents to make up their mind about whether to proceed
with transition. Long-term effects are not known, but infer-
tility appears inevitable when cross-sex hormones are intro-
Suicide, self-harm and current controversies duced shortly after puberty blockers.48 Loss of sexual
Transgender support groups have emphasised the risk of sui- maturation will also be associated with lack of adult sexual
cide. After controlling for coexisting mental health problems, function, although it is unlikely that a pre-pubertal child
studies show an increased risk of suicidal behaviour and self- can truly understand this side-effect at the time of consent.
harm in the transgender population, although underlying Those seeking transition are a vulnerable population
causality has not been convincingly demonstrated.39 Then, who suffer from high levels of suicidality, psychiatric mor-
expressed in the maxim ‘better a live daughter than a dead bidity and associated difficulties. Medical and surgical tran-
son’, parents, teachers and doctors are encouraged to affirm sition is sought to relieve these psychiatric symptoms.
unquestioningly the alternative gender for fear of the Plausibly, there is an initial reduction in distress following
implied consequences. There is a danger that poor-quality transition, although no controlled trials exist. Therefore,
data are being used to support gender affirmation and tran- the long-term outcome of medical and surgical transition
sition without the strength of evidence that would normally in terms of mortality and quality of life remains unknown.
determine pathways of care. One 20-year Swedish longitu- No long-term comparative studies exist that satisfactorily
dinal cohort study showed persisting high levels of psychiatric demonstrate that hormonal and surgical interventions are
morbidity, suicidal acts and completed suicide many years superior to a biopsychosocial formulation with evidence-
after medical transition.40 These results are not reassuring based therapy in reducing psychological distress, body dys-
and might suggest that more complex intrapsychic conflicts phoria and underlying mental illness.
remain, unresolved by living as the opposite sex.
Established risk factors for self-harm and suicidal
behaviour appear to be age related (younger trans patients
Clinical implications
are at higher risk) and include comorbid mental health pro- It is unclear what the role of psychiatry is in the assessment
blems, particularly depression, and a history of sexual and treatment of gender dysphoria, now that it is no longer
abuse.39 Thus, all new patients of any age warrant thorough considered a diagnosable mental illness, and whether there
assessment and formulation using a biopsychosocial model; is still a place for a routine psychosocial assessment. It
the best evidence-informed interventions should be pro- could be argued that patients should be deterred from gen-
vided. If this is followed by an individual desisting it should der intervention pathways while comorbid mental illness is
not be considered conversion therapy. That term should treated (Fig. 5). Without long-term follow-up data, it is not
perhaps be reserved for coercive treatments. possible to identify those who might reconcile with their
Best psychiatric practice avoids oversimplification of the sex and those who might come to deeply regret their medical
causes and treatment of suicidal behaviour and self-harm. and/or surgical transition. Moreover, it is not transparent
Preliminary data from a small ‘before and after’ pilot study where ultimate and legal responsibility for decision-making
of the use of puberty blockers at the Tavistock Centre in lies – with the patient, parents (if the patient is a child),
selected children found a reduction in body image problems psychologist, endocrinologist, surgeon or psychiatrist.
in adolescents following a year of puberty suppression. Psychiatrists understand that human development is
However, positive effects were offset by increases in self- necessary, but not always comfortable. Puberty, although a
harm and suicidal thoughts.41 Surprisingly, this unpublished normal physiological process, is associated with particularly
study was deemed a success such that prescribing of puberty high levels of psychological and bodily discomfort.
blockers was introduced as standard practice and commis- Psychiatrists’ role is to journey with patients as change is
sioned with scaling up of services. There was no develop- navigated and to provide support through sharing uncertainty
ment of alternative psychological approaches, nor were and difficult decision-making. But in the current climate, psy-
randomised controlled comparisons made. chiatrists may be unsure whether addressing psychological
Evidence suggests that almost 100% of children com- and social antecedents will lead to accusations of conversion
mencing puberty blockade go on to receive cross-sex hor- therapy. Attempts to reconcile a sufferer’s discomfort with
mones.42 This requires further interrogation to ascertain their actual body would be good practice in other conditions
whether the high figures are due to robust, effective selection involving body image disturbance, such as anorexia nervosa.

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A psychiatric trainee is working in psychotherapy. The patient, in the course of the

therapy says, “I am a woman trapped in a man’s body”.

Should the trainee explore this within the psychotherapy, or affirm their new gender and
avoid further discussion of the topic?

A female patient with anorexia is referred to a private psychiatrist as she is distressed

by her breasts and is requesting a bilateral mastectomy. She wants “A boy’s chest”.

Should the psychiatrist explore the gender dysphoria in the context of low body weight,
or should the patient’s stated gender identity be affirmed and the patient referred for
surgery?

A
A CAMHS psychiatrist has been asked to assess a nine-year-old girl for ADHD. In the
course of the assessment, the child says, “I think I’m a boy!”

Should the psychiatrist ask, “Why do you think you are a boy?” or accept the child’s
Fig. 5 Are these scenarios examples of assertion without question?
good clinical practice or conversion
therapy?

The magnitude of any benefits of medical and surgical tran- the use of gender-affirming hormones for children and adoles-
sition is not clear. Follow-up studies are sparse, and with the cents states that these drugs ‘can cause substantial harms,
new cohort of adolescents, clinicians step even further into including death’ and concludes ‘the current evidence base
the unknown.49 These young people are not comparable to does not support informed decision making and safe practice’.51
adult, mainly male-to-female, research participants on whom Among a plethora of online videos by teenagers proudly
existing empirical clinical guidelines were based. Doctors are displaying their mastectomy scars a worrying increase in
now questioning the wisdom of gender-affirmation treatment detransitioner testimonies can now be found52 (Fig. 6).
of children and young people, citing poor diagnostic certainty These are mainly young women who have rejected their
and low-quality evidence.50 A recent review of evidence for trans identities and are reconciling with their birth sex.

Female detransition and re-identification survey

Reasons given for detransition

“Wanted to “Became more

“Concern about loss of be a lesbian comfortable with my
fertility” girl again” gender non-conformity,
grew more into my
femalehood”

“Went through trauma therapy

which helped me stop
dissociating” “Realised the dysphoria
was a result of abuse”

“I feel I was duped “No effort was made

Fig. 6 Reasons given for to explore if there
into believing I
detransitioning in a female were other mental
was something I’m “My trauma was not
detransition and health issues”
re-identification survey run not” examined at all”
between 16 and 30 August
2016 and shared through
online social networking
sites.52

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Feminist concerns intervention as standard practice, and recommend hormonal

intervention after two appointments.58 This will further
In theory, universal human rights should not pit disadvan- scale up hormonal and surgical interventions in young
taged groups against one another, but in practice, disputes patients, who will miss out on pubertal development and
occur. Women’s rights activists point to persistent global necessary mental health treatment in their quest for inter-
inequalities, sex discrimination and violence against ventions that may harm and that they may later regret.
women and girls. They are concerned that ignoring sex as In the rapidly moving and politicised debate, psychia-
a reality risks no longer being able to name, measure and trists look to the RCPsych for guidance. Those providing
ameliorate sex-based harms. Endorsing old sex and gender and interpreting the scanty evidence from published
stereotypes in an attempt to validate young patients may research need to be independent and impartial, using best-
inadvertently shore up outdated notions of how men and quality measures rather than ideology. It is confusing to
women should look and behave. There is no reason to liken open-minded working with young patients as they fig-
believe that women have an innate love of pink and wearing ure out who they are to conversion therapy. Holding an
high heels and find map-reading difficult, any more than empathic neutral middle ground, which might or might not
men have a natural leaning towards blue and playing football include medical transition, should not be equated with
and make excellent leaders. this. Psychiatrists need to feel empowered to explore the
Inherent in the notion of ‘gender identity’ is that there meaning of identity with their patients, treat coexisting
already exists a specific subjective experience of being a man mental illness and employ a trauma-informed model of
or a woman. However, there cannot be a significant intrinsic care when appropriate.
experiential difference between male and female human The General Medical Council’s Good Medical Practice
beings when we cannot know what those differences are. demands of clinicians compassion, shared decision-making
One cannot possibly know how it feels to be anything and safeguarding of young people’s open futures.59 The coun-
other than oneself. Medicine may be in danger of reinforcing terargument to unquestioning gender affirmation is that the
social norms and reifying a concept that is impossible to process of medical transition may itself prove to be another
define over and above material biological reality. At present, form of conversion therapy, creating a new cohort of life-long
many health, social, educational and legal policies are being patients dependent on medical services and turning at least
adapted to give gender primacy over sex.53–57 some lesbian and gay young people into simulacra of straight
members of the opposite sex. Psychiatry sits on this
knife-edge: running the risk of being accused of transphobia
Conclusions or, alternatively, remaining silent throughout this uncon-
Language that confuses or conflates sex and gender identity, trolled experiment. Respectful debate, careful research and
while appearing inclusive, might have the unintended conse- measurement of outcomes are always required.
quence of closing down the means to understand complexity
and respond appropriately to patients’ emotional and mater-
ial reality. The medical profession must be compassionate,
accept differences and fight for those who are marginalised
and discriminated against.
About the authors
However, viewing transgender as a fixed or stable entity, Lucy Griffin, MBBS, BSc, MRCPsych, is a consultant psychiatrist at The
rather than a state of mind with multiple causative factors, Priory Hospital Bristol, UK. Katie Clyde, MBChB, MRCPsych, DGM, is a con-
sultant psychiatrist with Southern Health NHS Foundation Trust, Hampshire,
closes down opportunities for doctors and patients to
UK. Richard Byng, MB BChir, MRCGP, MPH, PhD, is a general practitioner
explore the meaning of any discomfort. Being gender non- and Professor of Primary Care Research at the University of Plymouth, UK.
conforming, or wishing to opt out of gender altogether, is Susan Bewley, MD, FRCOG, MA, is Professor (Emeritus) of Obstetrics and
not only not indicative of mental disorder – it is, in many Women’s Health, Department of Women & Children’s Health, King’s College
ways, an entirely rational response to present capitalist reli- London, UK.
ance on rigid gender norms and roles. However, when mul-
tiple medical interventions are required on an otherwise
healthy body or doctors are expected to deny the concept
of sex or the sexed body, the situation becomes less coher- Acknowledgements
ent. The notion of conversion therapy for those seeing them- We consulted a trans woman and a detransitioner for this article. We thank
selves as transgender relies on another binary – that of them for their input.
‘cisgender’ and ‘transgender’ – being set, closed, biologically
anchored categories without overlap, rather than a more
plausible hypothesis that one’s gender identity is flexible,
informed by one’s culture, personality, personal preferences
Author contributions
and social milieu. L.G.: undertook a search and analysis of the literature, and conceived and
The push for early bodily modification and hormones by wrote the paper. K.C.: undertook a search and analysis of the literature,
and contributed to the drafting of the paper. R.B.: participated in the concep-
some transgender patients is a cause for concern. New ser- tion and evolution of the analysis, critically reviewing the paper and suggest-
vices, modelled on commissioning guidance from NHS ing amendments incorporated into the final paper. S.B.: participated in the
England for adults of 17 years and above, will allow for self- conception and evolution of the analysis, critically reviewing the paper and
referral, preclude psychological formulation or therapeutic suggesting amendments incorporated into the final paper.

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Declaration of interest 23 Common nonbinary genders. Tumbler, 2020 ([Link]

[Link]/gender).
None.
24 Bao A-M, Swaab DF. Sexual differentiation of the human brain: relation
ICMJE forms are in the supplementary material, available online at https://
to gender identity, sexual orientation and neuropsychiatric disorders.
[Link]/10.1192/bjb.2020.73. Front Neuroendocrinol 2011; 32: 214–26.
25 Savic I, Garcia-Falgueras A, Swaab DF. Sexual differentiation of the
human brain in relation to gender identity and sexual orientation.
References Prog Brain Res 2010; 186; 41–62.

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PRAXIS

International medical graduates: how can UK

psychiatry do better?
Emmeline Lagunes-Cordoba,1 Raka Maitra,2 Subodh Dave,3 Shevonne Matheiken,4
Femi Oyebode,5 Jean O’Hara,6 Derek K. Tracy7

BJPsych Bulletin (2021) 45, 299–304, doi:10.1192/bjb.2020.118

1
Camden and Islington NHS Foundation Summary The National Health Service (NHS) was created 70 years ago to provide
Trust, UK; 2Tavistock and Portman NHS
universal healthcare to the UK, and over the years it has relied upon international
Foundation Trust, UK; 3Derbyshire
Healthcare NHS Foundation Trust, UK; medical graduates (IMGs) to be able to meet its needs. Despite the benefits these
4
East London NHS Foundation Trust, professionals bring to the NHS, they often face barriers that hinder their well-being
UK; 5National Centre for Mental Health, and performance. In this editorial, we discuss some of the most common challenges
UK; 6South London and Maudsley NHS and the adverse effects these have on IMGs’ lives and careers. However, we also
Foundation Trust, UK; 7Oxleas NHS
Foundation Trust, UK
propose practical measures to improve IMGs’ experiences of working in psychiatry.
Correspondence to: Dr Emmeline
Lagunes-Cordoba (emmeline. Keywords IMGs; NHS; BAME; career; stigma and discrimination.
lagunescordoba@[Link])
First received 4 May 2020, final revision
4 Oct 2020, accepted 23 Oct 2020
© The Author(s), 2020. Published by
Cambridge University Press on behalf of
the Royal College of Psychiatrists. This is
an Open Access article, distributed under
the terms of the Creative Commons
Attribution licence ([Link]
[Link]/licenses/by/4.0/), which
permits unrestricted re-use, distribution,
and reproduction in any medium, provided
the original work is properly cited.

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