Epistemic Injustice

Iworked​  for eleven years as a consultant clinical psychologist at the Gender Identity Development Service (GIDS), the sole NHS service for gender-diverse young people, based at the Tavistock Clinic in London. It’s a job history I no longer disclose when I meet people. The work of the GIDS team has been the subject of unceasing media – and social media – attack in recent years. We weren’t hammered just in the right-wing press. On Newsnight in June last year, a critique of our work was illustrated with gloomy shots of the unlovable 1960s Tavistock building, and of discarded toys in a derelict attic – childhood lost, innocence destroyed. The producer invited a gender-critical commentator to repeat the claim he’d made on Twitter that the provision of puberty-suspending medication echoed Nazi experimentation on children. Elsewhere, GIDS has been portrayed as offering what an Observer journalist called ‘ideology-driven medicine on steroids’, as being a place where ‘dissenters [are] silenced/moved out.’ As the only provider of specialist care for these young people, GIDS became the locus of all adverse comment.

In 2015 I gave evidence to the Women and Equalities Committee on behalf of GIDS (the transcripts are available online). The committee, which was established after the 2015 election, had chosen transgender equality as the subject of its first investigation. I was asked about the experiences, diagnosis and portrayal of gender-diverse young people, including children under the age of ten. I explained that, in the view of GIDS, affirming a young person’s account of their gender experience was not the same as taking it at face value, and that medical intervention would not alleviate the distress of all these young people. My exchange with Angela Crawley, the SNP MP for Lanark and Hamilton East, was illustrative. She noted that she had heard a lot from me about ‘ethics’ and ‘protocols’ and ‘bureaucracy’, and said she worried that ‘there is an element of placing the assessor’s view on the individual rather than taking into account the individual’s views.’ Like most of the committee, she seemed persuaded by the testimony of Mermaids (a support and advocacy group for young gender-diverse people and their families), which was critical of GIDS. In its written submission, Mermaids condemned us for ‘not provid[ing] any streamlined route to fast-track puberty blockers’, for taking the ‘outdated and harmful’ approach of ‘watchful waiting’, for having staff ‘who are openly unsupportive’ of trans and non-binary young people, and for ‘emphasis[ing] uncertainty and complexity’ in our public statements. The committee chair, the Conservative MP Maria Miller, intervened after I mentioned the lower age limit of sixteen set by GIDS for the prescription of cross-sex hormones: ‘Is that something that you are looking at and considering?’ she asked. I said that it was a subject of discussion and review, not only at GIDS but at clinics around the world, and that we felt caution must be used when considering fast-tracking hormones for under-sixteens. 

The representation of GIDS has shifted a great deal since that morning of gentle questioning by trans-friendly MPs. Within eighteen months the service was being portrayed as operating in a clandestine fashion. If our protocol was a surprise to anyone, it was because they had failed to take an interest in it, not because our practices were covert. Our specification, drawn up by the commissioners (NHS England) after extensive consultation between 2014 and 2016, was a lengthy and detailed public document and our activity was reported in detailed metrics. An exacting Care Quality Commission inspection in 2016 interviewed clients and staff, scrutinised our processes, trawled through masses of files and data and gave us a rating of ‘good’. We presented our work regularly at conferences. But in those years GIDS came under immense pressure, from without and within, and in August 2018 a damning internal report, based on conversations with an anonymous group of anxious, unhappy and overwhelmed GIDS staff, was sent to the board of the Tavistock and Portman NHS Trust. The author used the language of ‘whistle-blowing’: GIDS appeared suspect and unaccountable, although it had always operated in plain view.

It wasn’t surprising that staff were distressed and divided. A huge social change was underway, and we were on the frontline. Today a set of authoritative bodies are attempting to tackle some of the intricate and multi-faceted issues concerning gender identity in young people. In October 2020, the High Court conducted a judicial review, Bell v. Tavistock, to determine whether the practice of prescribing puberty blocking treatment to children had been lawful, and also considered whether the information provided to children was sufficient for them to give meaningful consent to treatment. The court rejected the proposition that under-eighteens are incapable in law of giving valid consent. But instead of dismissing the judicial review it gave extensive guidance on practice and procedure. Notably, it drew up a kind of checklist for clinicians to use in evaluating a child’s ability to consent. And it suggested that clinicians should seek a court order before starting any child under sixteen on puberty blockers (and recommended the same legal procedure for those aged sixteen and seventeen). In October this year the Court of Appeal overturned this judgment. Its arguments focused on the cornerstone Gillick ruling of 1985, according to which clinicians have the responsibility to decide, on a case by case basis, whether a child has the competence to consent to treatment. The appeal judges made clear that Gillick remains the correct legal approach, without the need for any additional criteria, given that all clinicians are subject to professional regulation, with established review mechanisms. Second, they ruled against the guidance that applications to court were required, holding that there was no legal obligation to do this. Third, they criticised the High Court for relying on expert evidence that was ‘contested and untested’, and for making declarations which wrongly implied that evidential questions about puberty blockers were resolved.

Meanwhile, in the fallout from Bell v. Tavistock, the Family Court ruled (in AB v. CD and Ors) that whether or not a child is competent to consent, court authorisation isn’t necessary if the child, their parents and the clinician all agree that treatment with puberty blockers is the best course of action. This case implicitly confirms that prescribing puberty blockers to under-sixteens does not constitute harm or risk of harm to the child. This court, too, declined to rule on the benefits or detriments of treatment. Justice Lieven concluded: ‘I am wary of the court becoming too involved in highly complex moral and ethical issues on a generalised, rather than case specific basis, [especially where] division of clinical and ethical views has become highly polarised … These are precisely the type of matters which are best assessed in a regulatory and academic setting and not through litigation.’

One such assessment is the report by NICE (the National Institute for Health and Care Excellence), published in March, on the evidence for the clinical effectiveness, safety and cost-effectiveness of puberty blockers for under-eighteens (and, separately, of cross-sex hormones). It found it hard to draw any conclusions, and soon afterwards the Cass Review was set up by NHS England to investigate the implications of NICE’s evaluation. Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, is leading this ambitious and wide-ranging independent inquiry into the way gender identity services for young people in England and Wales should be organised. Finally, as a footnote, the Medical Practitioners Tribunal Service has been hearing charges against the UK’s main private provider of puberty blockers: it’s alleged that Helen Webberley inappropriately prescribed puberty blockers to young patients, sidestepping the GIDS/NHS England regulatory framework. She was suspended by the General Medical Council in 2018, but continued to practise from outside the UK.

GIDS did not originate at the Tavistock Clinic, which is internationally known for psychodynamic training and therapy. In the late 1980s, the child and adolescent psychiatrist Domenico Di Ceglie became interested in the small number of gender-diverse children who appeared at the Child and Adolescent Mental Health Service (CAMHS) in South London. Most had been born male and were still living as feminine boys. He developed a minor clinical speciality in their treatment and, in 1994, moved his nascent team of three clinicians to the Tavistock Clinic. As well as his psychiatric specialism, Di Ceglie had trained as a psychoanalytic psychotherapist and was therefore a Tavistock insider. His clinic slowly forged links with similar specialist services in other countries, chiefly with Ken Zucker’s small clinic in Toronto and a team in Utrecht, which pioneered puberty suspension. But its base at the heart of British psychoanalytic training and treatment set GIDS apart from equivalent services from the beginning. 

In his much revisited Therapeutic Aims for GIDS, first codified in 1998, Di Ceglie set out an eclectic mix of objectives for the clinical team. The name ‘GIDS’ was chosen to reflect a view of gender diversity as first and foremost a ‘developmental’ process, not a disorder or a form of (psycho)pathology. GIDS was to take a stance of ‘non-judgmental acceptance’. Rather than trying to reverse or cure atypical gender feelings, our primary objective was to tackle the negative effects of gender dysphoria on a child’s social and emotional development. Clinicians would challenge ‘the cycle of secrecy’ and try to reduce the feelings of shame and unworthiness in young people who felt at odds with their body. At the same time, GIDS would respect a set of psychoanalytically inflected aspirations: ‘to allow mourning processes to occur’, ‘to enable symbol formation and symbolic thinking’, and ‘to promote separation and differentiation’. The complex, often multiple, motivations for seeking social and medical transition were acknowledged. So, too, were the high levels of adversity the young people faced and the intricacy of disentangling difficulties that were specifically gender-related from those associated with other developmental issues. Central to the GIDS model was an attempt to create a trusting therapeutic dialogue with the child and family, while not losing sight of notions of fluidity, contradiction and change.

By the mid 2000s, it was apparent to us that social attitudes towards sex and gender minorities, and the concomitant right to self-determination, were shifting. Nonetheless, at GIDS a diagnosis of gender dysphoria alone did not lead to a particular pathway of care. We knew that for some young people a period of transgender or non-binary identification, coupled with intense body dissatisfaction, would resolve and we could then support them through a process of reconciliation with their birth sex. For others, the sense of radical bodily un-belonging would intensify. The limited but growing evidence, and a professional consensus built up since the 1990s, pointed to the appropriateness, following adequate assessment, of medical intervention for this group. Initially this could be with puberty-suspending medication, and for some, after the age of sixteen, with cross-sex hormones.

The work of the clinic always involved difficult ethical questions. If treatment was only to be offered following a period of therapeutic exploration, how much exploration was ‘enough’? If puberty blockers were prescribed to hold open future gender options, might they also serve sometimes to narrow down these options? Which children were at risk if we withheld treatment? What features of an autistic presentation, and what degree, would hamper an ability to consent? How could we balance possible future suffering (if the person came to see the physical changes made as unwanted or unnecessary) over suffering in the here and now? A willingness even to raise such questions earned GIDS an international reputation as a cautious, even conservative team. Indeed, it is on record as taking a very moderate line on many of the policy issues that have divided professional and public opinion. On early social transition, we counselled families to keep all options open (‘watchful waiting’). On formally recognising young people’s preferred gender identity, we advised schools to take time for careful consultation. On the extension of gender self-certification to under-eighteens, we feared it would undermine the work of assessment we were commissioned to undertake.

This work was ethically thorny even in GIDS’s early years, but the challenges intensified as the number of referrals began to climb dramatically after 2015. The reasons for this increase are many: most important, perhaps, was the removal in 2016 of any filter for referrals to GIDS, combined with a sudden increase in discussions about gender identity on the internet, amplifying a fascination – and anxiety – around sex and gender identifications and their expression. The increased online openness encouraged gender non-conforming young people to speak out. There was also a growing awareness of the opportunities presented by new and improving medical interventions, and a greater social tolerance of body modification. Waiting times soon grew to an intolerable twelve months, then eighteen, then longer. Among the new referrals, we were seeing a higher proportion of young people assigned female at birth – a pattern observed internationally. Many had autistic features, and some had complex histories of separation, loss and trauma. We were well aware that a service for young people with a ‘gender identity’ sign over the door risked inviting adolescents to resolve their anguish into a narrative about gender, a dilemma familiar to any specialist service that singles out one category of distress for attention and care. We had to be thoughtful, wary and open with our young clients about the way gender might be ‘put to the service of crucial psychic work’, in the words of the psychoanalyst Adrienne Harris. For years, we had relied on local CAMHS teams to screen and support young people with psychosocial difficulties before referring them to GIDS, and to keep that support in place while we attended to gender concerns. But in 2016, NHS England commissioners ruled that GPs, schools and social workers could refer patients to the service directly. More problematic still, many local CAMHS teams, overstretched and understaffed, withdrew support for these children, reasoning that a well-funded highly specialist service like GIDS should be able to cope. With adult gender services also buckling as a consequence of increased referrals, it became harder to feel confident we were discharging older teenagers to safe and appropriate care.

The most significant shift of all, however, was the growing resistance from families towards GIDS’s relatively slow-paced model of care. Young people and their parents, arriving at the clinic many months after referral, were becoming more assertive in their demands for validation of their new gender identity and for faster, earlier and simpler access to puberty suspension and cross-sex hormones. Typically, children arrived for their first appointment already having made a full social transition. Many saw little value in the exploratory work that was GIDS’s stock in trade. Often they felt our protocol concentrated too much power in the hands of professionals, whose authority and claims to knowledge they didn’t hold in high regard. The professional values of the public sphere – reflection, ample assessment and a cautious response to evidence – were now pitted against online sources of anecdote, emotion and personal history. Private providers waited in the wings, willing to meet these requests with a minimal protocol.

In response to these challenges we developed more careful processes and policies (for example, around consent), as well as fuller and clearer information about medical intervention, tailored to younger and less able children. The number of assessment appointments offered per family increased. We focused more on ethical issues. We set aside extra time for debate on the tensions arising in the team: there were more frequent and longer discussions; externally facilitated reflective staff groups. But as we engaged with greater numbers of young people whose presentation taxed us clinically and ethically, the team – composed of psychologists, child psychotherapists, social workers, family therapists, nurses, psychiatrists and endocrinologists – began to fissure. Some were concerned that parents who took a strongly affirmative stance were actively harming their child. Some felt that a denial of same-sex sexuality accounted for a child’s rejection of their body. We all got tangled in the contradictions of trying to assess a child for puberty blockers when the treatment was already being provided by a private doctor. Many staff experienced genuine moral dilemmas: how best to offer care when the intervention they saw as harmful was exactly what the patient and their caregivers were asking for? Perhaps unsurprisingly, there were times when clinicians grew frustrated with families who would not make use of what GIDS had to offer – a chance to reflect, discuss, review, to slow things down.

If any preoccupation linked the entire team, it was an awareness of the increasingly impossible demands being made of us. We were under pressure to cut the waiting list, but burdened by huge caseloads; overwhelmed by the complexity of the cases, but not able to expand the service; confounded by families rejecting the skills we brought, but with no guidance on how to work with families who were also receiving treatment privately. Through all this turmoil, GIDS was still expected to meet the contractual obligations of an NHS specification designed for a simpler era. 

We confronted the basic limitation (or paradox) of healthcare commissioning: it tends to be capable only of describing what is already known and knowable. This makes it intrinsically unsuitable for designing and delivering services that are working on the edge of knowledge. The support and funding for such services needs to be flexible, reflecting new learning in an effective feedback cycle. Perhaps we should have refused to carry on until more and better assistance was available. But clinical managers do not readily down tools. Besides, those of us in mental health, like many in the health service, are used to working in impossible circumstances. And excellent work was still continuing with many children and families. These were the conditions that led to the damning internal report of 2018.

It’s worth pausing here to consider what would have been required to keep the service and its staff from buckling. First, acknowledgment of the immense difficulties and uncertainties of our work from the trust and NHS England, given in a spirit of professional respect and solidarity. Second, the rejection of simplistic narratives of blame and a readiness to consult with patients and their families, and to seek expert specialist help, including the commissioning of new research. Of course, if there was genuine disquiet about professional failings at GIDS, those suspicions should have been reported through the institutional channels that exist to oversee and regulate clinical work. Similarly, clear (and mandatory) routes exist for the reporting of suspected harm to children.

If I had been asked what kind of institution was capable of co-ordinating all this, I would have said the Tavistock Clinic. How we failed! Instead, critics from within the trust became involved in a deeply antagonistic project. After the critical report was circulated, a review of GIDS was launched by the trust. The review, carried out by the trust’s medical director, Dinesh Sinha, didn’t identify any immediate issues in relation to patient safety, or criticise the overall approach taken by GIDS. It outlined a number of areas that required change, many of which related to documentation and data collection, and called for greater consistency across the service. Far from assuaging fears, the review led to more fury, amplified through leaks and negative briefings to an almost universally hostile media. It came as a relief to hear of the application for judicial review: an adversarial fixture, but also an opportunity for more careful argument. Unsurprisingly, this did not lead to a win for either side. The subject turned out to be … complicated.

I will offer only a few brief reflections on some of the issues over which GIDS has been most vociferously attacked. The first contention is that there wasn’t enough research evidence to enable GIDS to offer medical therapies to young people with confidence. This is an important challenge, but it relies on an idealised conception of medicine as offering effective and safe interventions, based on a wide range of randomised-control studies with extended evaluation. The problem with this view is that many paediatric medical interventions are not backed up by such studies, but depend on confidence in the existing, broader knowledge base (often from studies on adults) and are justified by the concern to relieve suffering.* Whether there are sufficient studies to support any particular intervention and whether those studies are themselves ‘good enough’ are matters of judgment. Very many mental health treatments (medical and psychological) are poorly evidenced by these standards, including those routinely offered at the Tavistock to both children and adults. But compassion demands that we provide forms of treatment that are grounded in theory and in the experience of well-trained and accredited professionals, and which correspond to the values of the patient. Put simply, many questions around treatment are not settled by science alone, because scientific knowledge is itself social knowledge. When we devise treatment plans, we inevitably work within what society considers a just response to suffering; our research is based on culturally derived ideals about what constitutes a worthwhile life; treatment decisions reflect prevalent notions of self-determination, including of the rights of minors.

A second point of attack is that the service was in the grip of an ideology, one that has taken hold in government, academia, medicine and the law. I disagree. GIDS’s patchwork of pragmatic, values-based commitments, its agnosticism about causality and its hesitancy over the absolute normalisation of gender transition in young people, strike me as far from ideological. What’s more concerning is the absolute certainty that characterises the debate at either extreme. GIDS didn’t trade in firm convictions. We tolerated a degree of uncertainty in our professional judgments and accepted, at times, the accompanying moral unease.

What is true – and perhaps the ideology attack is trying to get at this – is that GIDS, from its modest start, was a justice project as well as a therapeutic project. By justice, I mean it aspired to widen the circle of people whose experience of the self is listened to with respect. This meant not automatically deeming a child’s atypical gender identification problematic, and not striving to modify that identity in the direction of a more orthodox body/mind relationship. It also meant not evading the fact that trans, non-binary and queer people have been (and often still are) dismissed as knowledge holders within healthcare systems; that they are subject to ‘epistemic injustice’, since society as a whole lacks an adequate interpretative framework to understand their experiences. For some advocates, this justice-based approach extends to the demand that all gender-diverse people, including the young, should have the unquestionable right to make fully autonomous treatment decisions – the full freedom, we might say, to make their own mistakes. This has never been GIDS’s position. But this is the argument being debated in the courts at the moment: can children and adolescents realistically consent to these treatments? If yes, how is their competence ensured? If no, is this decision within the scope of parental discretion? And if young people, with or without their parents, are deemed competent, where does the responsibility lie if there are subsequent feelings of regret?

Some critics of the Tavistock proposed a stance of neutrality, in which a clinician’s values do not influence the patient. But ‘neutrality’ has a strong rhetorical function here. A clinician who is convinced that profound psychic disturbance is at the root of every trans identity is not engaging neutrally with her client, but working with a definite end in view. The danger is that her conviction will intrude on, and even overwhelm, her curiosity. Besides, such purported neutrality ignores the historical oppression of sex and gender minorities as well as their precarious social status. Transgender people have only very recently secured formal equality before the law. It is hard to imagine effective clinical engagement that does not have some reference point in this history. Critics who speak wildly of an ideological takeover at GIDS might reflect on the backlash from Christian conservatives, which is gaining real traction in Romania, Poland and many US states. They promote a legislative programme, explicitly rooted in dogma and ideology, that endorses a fundamentalist view of sex dimorphism, inflexible male and female social roles (and bodies), restricted abortion rights and the stigmatisation of same-sex sexuality.

A third, and related, issue raised by critics is the belief that all gender-diverse young people are ‘disturbed’. The charge is not that GIDS fails to acknowledge the presence of some extremely troubled and traumatised individuals among its patients, or that it ignores the clear evidence of high rates of anxiety, depression and self-harm in these young people, due in part to their disquieting experience of body/gender mismatch. GIDS clinicians have spoken and written widely about these things. The charge is that GIDS doesn’t believe that sanity lies in accepting the male/female binary and that gender identity is therefore a myth. We have a model that ‘tolerates body/psyche discontinuities’, as the psychoanalyst Avgi Saketopoulou writes. It is this idea to which GIDS’s internal challengers, drawn from both the GIDS team and the wider NHS trust, were and are opposed.

Jacqueline Rose wrote that ‘psychoanalysis affirms nothing.’ But at the Tavistock, whose main role has been in training new recruits, some affirmations, some certainties, must surely be taught. The danger is that the psychoanalytic framework is passed down to trainees in its most socially conservative mode. It is certainly the case that until the mid 2000s, when an LGBT group was established by staff and trainees, many at the Tavistock found it hard to speak openly about their same-sex sexuality, let alone a trans or non-binary identity.† Stephen Frosh’s phrase ‘the bourgeoisification of psychoanalysis’ comes to mind here to describe a set of ideas so reassuring to the believers that they can survey the current gender landscape – which looks to others so epistemically, morally, legally, clinically and empirically complex – and see exactly where trouble lies, exactly the benefits of different courses of treatment, and exactly who is doing good and who is doing harm.

The work of GIDS was perhaps always going to come into conflict with some of the Tavistock’s time-honoured psychoanalytic convictions. I nevertheless remain deeply troubled by the violence of the internal attack on it by people who were trusted colleagues in other areas of work. I have tried to understand the antagonism as an expression of the view that GIDS was dangerous, but sustained public denigration can only lead to fundamental and long-lasting damage. Judith Butler’s recent work is significant here, not on the topic of gender, but violence: ‘Violence does not exhaust itself in the realisation of a just end; rather, it renews itself in directions that exceed both deliberate intention and deliberative schemes.’

To understand the antagonism GIDS aroused internally, it’s necessary to take a longer view of the shifting dynamics of voice, influence and reputation at the Tavistock. Before the introduction of the NHS internal market in 1988, it had taken an independent path. There were always splits and fissures, some irreconcilable, between disciples of different ideas. But for seventy years, even after making the compromises required to enter the NHS in 1948 and to remain in the public sector, the clinic was to a significant extent autonomous. The achievement of mental health trust status in 1994 was meant to provide a degree of financial independence, along with opportunities for growth and development. But for such a revered institution, with its long tradition of psychodynamic (and latterly systemic) practice and training, it meant, under the new NHS internal market, a loss of the protected income that had underwritten its standing and distinctive approach. After decades of self-governance, it began to cede control to NHS commissioners, whose ideas about what the clinic should provide – and at what cost – fluctuated. As some departments attracted fewer commissions for explicitly psychoanalytic services, they found it harder to cover the costs of the very senior staff on whom the international reputation of the trust depended. On top of this, the usual practice of departmental cross-subsidy was frowned on by NHS accountants, so some sections were left languishing, at least for a time, while other new and rapidly growing services, including GIDS, with its disconcerting client group and eclectic model of practice, played a larger and larger role in trust finances. 

Still, it seems extraordinary that there was no proper encounter between GIDS and its internal critics. What kind of discussion would have been possible when each side felt that the principles of the institution were being disregarded? I imagined the kind of moral discussion, as Stanley Cavell describes it, in which the protagonists not only disclose and defend their positions to others, but most of all to themselves. We need help to see the implications of our conduct and our commitments. Angry and troubled GIDS staff would have required support to speak up to GIDS leaders, who themselves would have needed help to appraise their own biases. It is precisely the painstaking character and quality of such interactions that helps to ground and legitimise any new understandings that emerge.

One key feature of moral argument is that defensible ethical claims can be made on both sides. In many scenarios, there may not be one single right course of action, but incompatible yet equally valid stances. In the tradition of virtue ethics, as derived from Aristotle, some moral dilemmas are ‘tragic’. They occur when two agents largely agree on the virtues relevant to a situation yet come to different conclusions as to the best way to act. Acknowledging this can avoid a breakdown in the relationships between people who may have been colleagues, and who have played their part in a valued community and a shared institutional history. An internal moral debate of this sort at the Tavistock would necessarily have been distinct from the long-overdue debates in the public realm, but no less essential. 

There’s an old belief in mental health services that clinicians are seen as sharing the social and moral status of the patients with whom they work. Clinicians in learning disability services, for example, often feel unheard and unnoticed. The GIDS team has been characterised in the media as deviant, as misguided and even delusional, as lacking in reason and insight, and, finally, as lawless and dangerous. I’m aware that I have attempted to present myself and my former colleagues in a better light. I see the GIDS team as attempting, often against the odds, to embody some of the necessary clinical virtues of moral seriousness, realism, humility, open-mindedness and authenticity. People will quarrel with this picture. It is certainly not the picture the media require. A few years ago, I was invited by the BBC to talk about the provision of puberty suspension to children on Moral Maze. On the morning of the recording, I spoke to the producer and outlined the stance I would take. By lunchtime I had been told I was no longer required. I have twice been stood down by Newsnight at the last moment for the same reason. The editors prefer more polarised discussion.

If a whistle-blowing report on GIDS was needed, I wish I’d written it myself. It would have highlighted the isolation of a group of conscientious clinicians who were trying to cope, in the absence of adequate support, funding and external expertise, with complex clinical, empirical, legal and procedural challenges while an upheaval in cultural narratives of sex and gender took place across the country. GIDS became the scapegoat in a society that needs to look more boldly and intelligently at how we should accommodate a great many new forms of pressure for change. There are pressures arising from the widening scope of medicine in the service of identity and well-being, and from biomedical technologies that enable novel adaptations of the body, as well as those arising from new societal demands for special rights or protections, and from the dethroning of traditional experts (this has come with a greater than ever demand for mental health support). And then there is the desire of young people for greater self-determination under the law. All these issues have been thrust into the spotlight by the refusal of trans-identifying youth to accept the limits of the society into which they were born.