Scottish Children’s and Young Person’s Commissioner supports trans children

unitedrights

The Scottish Children’s and Young Person’s Commissioner submitted to the recent Scottish consultation on Gender Recognition outlining the clear legal reasons why transgender children cannot be omitted from a route to Gender Recognition.

The Commissioner’s role is “to protect and safeguard the human rights of children and young people in Scotland, with particular reference to the United Nations Convention on the Rights of the Child (UNCRC)”

The Commissioner provided important context to the consultation

Background of this proposal: It is important to understand what is being proposed by this legislation. This does not impact upon children and young people’s right to affirm their gender identity in day to day life, including in schools. These rights are already enshrined in law via the Equality Act 2010 and many young people in Scotland have transitioned already. Likewise, these proposals do not impact on children’s right to access and consent to medical treatment, which was enshrined in Scots law by the Age of Legal Capacity (Scotland) Act 1991.

The current consultation focuses solely on the legal process through which that transition is formally recognised by the state and it is vitally important to young people who are transgender, non-binary and intersex because of the rights and protections that formal recognition of gender identity affords.

The Commissioner then outlined relevant international legislation:

The UNCRC and gender recognition: The UNCRC does not directly address the issue of legal recognition of gender identity. A number of articles are nonetheless relevant to this consultation. In particular:

  • Article 3: This requires that in all matters concerning a child, their best interests shall be a primary consideration.
  • Article 6: States parties are obliged to ensure to the maximum extent possible the survival and development of the child.
  • Article 8: Outlines children’s right to preserve their identity.
  • Article 12: Requires States to provide all children who are capable of forming their own views with the right to express them and for due weight to be given to their views in accordance with their age and maturity.
  • Article 16: Provides children with a right to privacy.
  • General Comments 12 (on the right of the child to be heard) and 20 (on the Rights of the Child in adolescence) and the concept of developing capacities through which children exercise their rights. Both General Comments elaborate on the concept of the evolving capacities of the children, a concept which is explored in full in the UNICEF Innocenti/Save the Children publication The Evolving Capacities of the Child by Gerritt Landsdown .

Other Human Rights Instruments: The International Covenant on Civil and Political Rights (ICCPR) and the European Convention on Human Rights (ECHR) are also relevant to this consultation. Both contain articles providing rights to privacy that are extremely close to those contained within Article 16 of the UNCRC. Article 8 of the ECHR has been successfully used to establish a right to legal recognition of gender through the European Court of Human Rights. As all other human rights instruments apply equally to children and adults, this can be interpreted as providing children of all ages with an equal right to recognition.

The Yogyakarta Principles: Although the Yogyakarta Principles do not have the same status as international law as human rights treaties, they affirm existing human rights in the context of sexual orientation and gender identity. They are an important means through which existing treaties can be interpreting and set an international standard of good practice with regards to LGBT rights. They were agreed by a panel of experts, in 2006. In 2017, 8 Additional Principles were added to the original 29. Of these, Principle 31 is relevant to this consultation. It states: Everyone has the right to legal recognition without reference to, or requiring assignment or disclosure of, sex, gender, sexual orientation, gender identity, gender expression or sex characteristics. Everyone has the right to obtain identity documents, including birth certificates, regardless of sexual orientation, gender identity, gender expression or sex characteristics. Everyone has the right to change gendered information in such documents while gendered information is included in them.

While sex or gender continues to be registered: iii. Ensure that no eligibility criteria, such as medical or psychological interventions, a psycho-medical diagnosis, minimum or maximum age, economic status, health, marital or parental status, or any other third party opinion, shall be a prerequisite to change one’s name, legal sex or gender;

The Scottish Consultation

The Scottish Consultation asked two specific questions on under 18s:

Question 5 The Scottish Government proposes that people aged 16 and 17 should be able to apply and obtain legal recognition of their acquired gender. Do you agree or disagree?

The Commissioner’s answer was:

AGREE

In 2016, the UN Committee of the Rights of the Child issued General Comment 20 on the implementation of the rights of the child during adolescent. General Comment 20 outlines the way in which adolescents use “increasing levels of agency to take responsibility for their rights” in line with their evolving capacities as outlines in Article 5 of the UNCRC. Whilst this proposal increases the opportunity for transgender children to realise their rights, it is out of step with existing Scots law with regard to the recognition of capacity in children and young people, which more commonly presumes capacity from the age of 12 and provides children below that age the ability to exercise rights where they have capacity. This is discussed further in our answer to question 6. Notwithstanding that, the extension of these rights is particularly important for this group who are at a stage of life when they are transitioning from school to college, work or university; from childhood into adult life. It allows them to make these transitions with the protections that legal recognition of their identity provides them and reduces the potential for accidental outing, for having to explain their transition and from the additional administrative burden that accompanies changing multiple administrative records.

Question 6 (This question asked “Which of the identified options for children under 16 do you most favour? Please select only one answer.

  • option 1 – nothing for those under 16
  • option 2 – court process
  • option 3 – parental application
  • option 4 – minimum age of 12
  • option 5 – application by capable child

The Commissioner’s answer:

We support Option 5 (application by capable child). This option is most in line with the Age of Legal Capacity (Scotland) Act 1991 and the Yogyakarta Principles and Article 12 of the UNCRC, as interpreting via General Comments 12 and 20 of the UN Committee on the Rights of the Child. Scots law, in the Age of Legal Capacity (Scotland) Act 1991, has a longstanding presumption that children have the capacity to instruct a solicitor and consent to medical treatment from the age of 12. It is possible for a child under this age to exercise these rights if they have the capacity to understand what is involved in that decision. Young people seeking legal recognition of their gender identity may already have exercised these rights, in other aspects of their transition including change of name and consenting to medical treatment relating to their transition. It would be illogical for parental consent to then be required for legal recognition of a transition the young person has been able to effect without it. Article 2 of the UNCRC states: States Parties shall respect and ensure the rights set forth in the present Convention to each child within their jurisdiction without discrimination of any kind…” Denying transgender, non-binary and intersex children the ability to exercise their right to legal recognition, or making it contingent on parental consent, may constitute a breach of article 2. Likewise, Yogyakarta Principle 31 (C iii) requires that States: Ensure that no eligibity criteria, such as … minimum or maximum age, economic status, health, marital or parental status, or any other third party opinion, shall be a barrier to change one’s name, legal sex or gender. Save for capacity, children and young people should not be subject to different or additional tests than adults. The process must still be self-declaratory. We are aware that Ireland has introduced a process for under 18s that differs significantly from that for people 18 and over. We would be very concerned if this was the approach taken in Scotland. Any test of capacity should be consistent with those in section 2(A) and 2(4A) of the Age of Legal Capacity (Scotland) Act 1991. We have consistently expressed out concern with the test of capacity associated with the extension of right contained within the Education (Scotland) Act 201612. Implementing addition tests for children with additional support needs is a breach of article 2 of the UNCRC and we believe potentially indirect discrimination under the Equality Act 2010. The same would be true were any addition test of capacity be used in relation to transgender, non-binary and intersex children through the proposed legislation. Were application for a gender recognition for 12-15 year olds to be subject to parental consent, it is essential that provision be made to enable children with capacity to exercise their rights in cases where: • a young person’s views differ from those of their parents, • where parents are in disagreement with each other; • where the young person is looked after • where there is no one with parental rights and responsibilities. The operation of such a process must be subject to additional consultation, including work with transgender, non-binary and intersex young people. The process should be grounded in children’s rights. We believe that courts are not the appropriate place to decide these matters and children report very mixed experiences of courts listening to their views in other matters.

Other relevant questions:

Question 10 Are any changes to section 22 (prohibition on disclosure of information)?

This is one protection which young people would gain access to with legal recognition of their transition and supports their right to privacy under Article 8 of the ECHR and Article 16 of the UNCRC. It is particularly important at points where information is being transferred from one service provider to another. Education records are covered by section 22 so this would increase the protections to young people’s rights to privacy as they move from school to further education, work or higher education.

Question 12 Should Scotland take action to recognise non-binary people?

YES We support the recognition of non-binary gender identities. Non-binary has become an accepted part of young people’s understanding of gender identities. An increasing number of young people identify as non-binary and should be entitled to the same legal recognition of their transgender peers. Yogyakarta Principle 31 (C ii) requires states to make available “a multiplicity of gender marker options”. This proposal also supports non-binary children’s right to an identity (article 8 of the UNCRC). This proposal also provides the opportunity to ensure that the births of intersex children can be registered promptly without them being assigned as male or female. Article 7 of the UNCRC states that “the child shall be registered immediately after birth”. Together with the extension of legal recognition to children with capacity, this would enable intersex children to assert their identity as they wish, using a social rather than medical model of gender.

International and national law is clearly on the side of the right of trans children to their identity.

This accords with the World Professional Association for Transgender Health’s 2017 Identity Recognition Statement:

The World Professional Association for Transgender Health (WPATH) further recognizes the right of all people to identity documents consistent with their gender identity, including those documents which confer legal gender status. Such documents are essential to the ability of all people to enjoy rights and opportunities equal to those available to others; to access accommodation, education, employment, and health care; to travel; to navigate everyday transactions; and to enjoy safety. Transgender people, regardless of how they identify or appear, should enjoy the gender recognition all persons expect and deserve.

Medical and other barriers to gender recognition for transgender individuals may harm physical and mental health. WPATH opposes all medical requirements that act as barriers to those wishing to change legal sex or gender markers on documents. These include requirements for diagnosis, counseling or therapy, puberty blockers, hormones, any form of surgery (including that which involves sterilization), or any other requirements for any form of clinical treatment or letters from doctors. Further, court and judicial hearings can produce psychological, as well as financial and logistical barriers to legal gender change, and may also violate personal privacy rights or needs.

WPATH advocates that appropriate gender recognition should be available to transgender youth, including those who are under the age of majority.

FYI We reviewed the Scottish consultation and the case for rights for transgender children to gender recognition here https://growinguptransgender.com/2018/01/18/scottish-gender-recognition-for-under-16s/

 

Dr Jo Olson-Kennedy on puberty, blockers and hormones

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Dr Jo Olson-Kennedy, world leading expert in support for trans children, recently gave a talk at Gender Odyssey in Seattle. She provided with great clarity a wonderful overview of puberty, blockers and hormones for trans children and adolescents. The talk was recorded, and for the benefit of those interested in best practices in healthcare for trans children, I’ve written a transcript of sections of the second half (any errors in transcription are mine).

This was a talk aimed, in part, at parents of trans kids. Note the level of knowledge and the effort to explain complex topics to parents. We never hear anything like this level of sophistication combined with practical guidance from the ‘experts’ in the UK. In part this is because the UK ‘experts’ do not see their role as one of education, and in part it is because the UK ‘experts’ do not have anywhere near this level of knowledge.

Two other things you’ll note from Jo Olson-Kennedy’s presentation that you never hear from UK GIDS. 1: Respect and 2: Individualised care.

Note how each child is treated with respect and dignity. Note how each child is provided with individualised care intended to meet that child’s need. No rigid, harmful, one-size fits all protocols. No defensive or transphobic practices either.

The UK children’s gender service is run by psychologists, psychotherapists and psychoanalysts with a few psychiatrists and social workers on the team. Not one paediatrician. Jo Olson-Kennedy, on the other hand, is a paediatric Medical Doctor. Similarly, the head of the Australian Children’s Gender Service, Michelle Telfler is a paediatrician.

It is time to move UK trans children’s healthcare out of the hands of psychologists, psychiatrists and psychoanalysts. Being trans is not a mental health condition. We need medical doctors and affirmative counsellors to build resilience, along with family therapists, the latter as much to support and educate parents, as to support the child. Mental health specialists only getting involved to support either where there is a mental health issue, noting that gender identity is not in itself a mental health condition, or where a client expresses a desire for psychotherapy.

Supported trans children have good levels of mental health and do not need engagement with a mental health service. Instead, they need knowledgeable experts with empathy, ability to build resilience and confidence, and paediatric medical doctors with the ability to treat trans children with dignity, care and respect. Moving trans healthcare from specialist mental health facilities to medical doctors (eg in primary care) is common place in other countries (including parts of Canada) and could easily be introduced here.

On to Jo Olson-Kennedy’s presentation, first on puberty tanner stages:

“Everyone is born at tanner 1, there is no zero. For people with overies tanner 2 is the differentiation of the nipple areola complex from the rest of the chest and there are palpable buds that feel like buttons, that is tanner stage 2 of chest development. Tanner 3 is actual chest tissue that is different from the fat chest wall. For people with testes T2 is testicular enlargement to 4 ccs, we use an orchiometer to assess testes size, 1 inch long half an inch wide.

Pubertal timeslines are different in overian and testicular puberty. For trans masculine kids we’re talking about 9, 10, 11 (these estimates are for white kids, people of colour go through puberty at earlier ages). Preventing puberty is needed earlier for trans masculine kids.

Peak growth velocity is also different and happens at different stages of puberty. For people with ovaries the greatest changes are in stages 2 and 3 of puberty. For people with testes the greatest changes are at tanner 3 or 4. When we think of the timelines for preventing pubertal changes we have to pay more attention to our trans masculine kids than our trans feminine kids because the changes that are really horrible for trans girls are later, you don’t go to tanner 2 and get a moustache or facial hair, your voice doesn’t even drop, those are all later.

What precedes gonadal puberty is adrenal gland development. This is critical. Because 6 to 18 months before your gonads started chugging away, your adrenal glands start, in all bodies, putting out a hormone (DHEA?) which is an androgen like hormone. This causes pubic hair, axillary hair, body odour, and parents who have kids who have transitioned at 5 will have body odour panic, pubic hair panic ad I want you to know that if this is happening at 7 or 8 years old it is probably not gonadal puberty it is probably adrenal gland development, and there is no way to block that and we would not want to, the adrenal glands are super critical to life.

What happens when puberty starts?

When puberty starts your hypothalamus talks to your pituitary gland through a hormone called gonadotropin releasing hormone (GNRH), and gonadotropin releasing hormone is called that because it causes the pituitary gland to release gonadotropins, which are lutinising hormone (LH) and follicle stimulating hormone (FSH). This is true of everybodies body. This stimulates your gonads to release their sex steroids. Early in puberty and throughout puberty you secrete gonadatrophin releasing hormone in pulses, it is diurnal, once in the morning, once in the evening, LH and FSH come out in pulses, and sex steroids come out in pulses, all these things are on a feedback loop, when there is a lot of sex steroid it feeds back to reduce production.

If you have ovaries you get oestrogen and progesterone and breast development, wider hips, periods. If you have testes you get facial hair, adams apple, broadening of shoulders etc.

Case study: 10 year old assigned female at birth, socially transitioned at 5. 5 months before I got the phone call the kid’s chest development had started and they would not come out from under their bed and go to school. 10 years old. Horrific anxiety. These kind of cases. There’s really no challenge to them. They are not complicated. This kid needs blockers.

How do blockers work?

We give a biosynthetic or analogue version of gonadotrophin releasing hormone. It is called a blocker but really that is an erroneous term, it is actually an analogue, instead of getting it in pulses, instead the body gets it in a steady state, the receptors get down regulated and now no signal to the gonads to make sex steroids. It is specific to this particular pattern of development. Does not impact your thyroid. Does not impact your growth hormone. Does not impact your social development or your cognitive development. We mimic the action of GNRH and down regulate those receptors and you do not now have a message from your brain to your gonads. When you go onto continuous GNRH you get a giant pulse and then it comes down after those receptors are down regulated. That is really important because if your kid is going to go on to a blocker, they may have 4 or 5 weeks of crappy. They may have 4 or 5 weeks of emotional lability because they are getting a strong message to release their endogenous hormone and that can be really upsetting to people.

How do we know they are reversible?

Because we use GNRH analogues for a whole load of other medical conditions, we use GNRH analogues for people who start puberty at 6, 7, or 5, we don’t want them to go into puberty at 5 for a whole host of reasons. We use GNRH analogues whenever we want to shut down the hypothalamus pituitary gonad axis, so if you have a hormone dependent tumour, we want to stop the production of hormones eg prostate cancer. Also for endometriosis.

Kids have puberty panic when they are trans ‘oh no I’m going to wake up with a beard’ – so it’s real important to talk to kids and say puberty is a process, you don’t go from tanner 1 to tanner 4 in a day, that’s not how that happens. But they are very vigilant and I have a lot of trans girls in my practice who are ‘I’m pretty sure I have facial hair’ and their voice is super high and I’m like ‘no, that’s not the order of that, that’s not how it goes’, so it’s important to have those conversations. But if you’re that panicked you actually can’t participate in your life, because this is taking up a lot of bandwidth.

So how do we do this? One is injectable and the most common one we use in the USA is Lupron. There is a subcutaneous one but doesn’t have an intermediate dose so can be challenging, then there is an implant that has a medication called Histrellin which is also a GNRH analogue, Histrellin is a really small implant, goes under the arm, lasts for 2-3 years, we take them out at 2 years as our surgeons find they become more embedded after 2 years and are harder to get out.

No blockers are FDA approved for trans care, not because we haven’t been using hormones for one hundred years because we have, but because there are levels of discrimination at our highest places.

Histrellin implants are sold as two brands, one has a pediatric indication in precocious puberty – 50mg histrellin secretes 65 micrograms a day. The other one has an adult indication, it has 50 mg histrellin secretes 50 mg a day. Both are equally efficacious in suppressing puberty in kids with gender dysphoria, there is a significant difference in cost. None of these are FDA approved so you may as well get the cheaper one which is $4,000, the other one is $35,000. Equally effective. I’m about to publish a study on this.

We have a discrepancy between the Endocrine Guidelines recommendations about blockers and what actually happens on the ground. So the Endocrine Guidelines recommends puberty blockers early to avoid development of secondary sex characteristics that are undesirable at tanner 2, tanner 3. But then they also recommend hormones at 16. The newest Endocrine Guidelines address this and says there are compelling reasons to start earlier than 16.

What happens is a lot of 13 and 14 year old trans masculine kids come (to the service), they are already through puberty, because they started at 10. When they go on to GNRH analogues, because that is what the guidelines guide you to do, they go in to menopause. They are in chemically inducted menopause, which means they have hot flashes, they will have insomnia, they will have short term memory problems, they will have exacerbation of depression. This is not really addressed and I wish more people, as they do this clinical work, are going to understand that this is 100% true. So we in my practice we actually add in low dose testosterone for kids who are around 13, 14 or so, because it helps mitigate those symptoms and I think that is really important.

Weight gain. Super common in kids going on blockers because of the complicated interaction of all of the hormones of puberty. Emotional lability – some kids just do not do well and I will tell you that I have more people having challenges with injections than implant. I just think it has to do with not getting a steady dose and getting blocker wearing off towards the end of the 3 months. Also, your kid does not need to go to the OR for an implant, it is a ten minute out patient procedure to numb the kid’s arm and put it in.

Transfeminine folks on GNRH analogues and small doses of oestrogen. Argh! I feel like in some ways we suspend those kids in the worst part of female puberty. It’s like ‘hey sit here for 6 months – none of your friends will be but here you go’ and it’s really hard on them, so the dosing can be problematic. I’m going to talk about that in hormones 201 this afternoon.

Bone density is important to keep an eye on. Bones density is the amount of bone material inside the bone – it starts going up much more rapidly at puberty, so when you go on blockers you now do not have that rapid increase so getting bone density scans at baseline to make sure someone isn’t starting with really low bone density is important, but also every year. Some people think we don’t need to do that, but there hasn’t been an awful lot published on this so we do it from a safety perspective.

Growth velocity slows down when you’re on blockers and here’s why. Kids still grow on blockers but don’t grow as rapidly as they would if they had not gone on blockers. This was a study which came out of the Netherlands which showed when you add in cross sex hormones there is a jump in bone density.

It is really hard to predict linear growth. I can show you my growth charts which have only increased my consternation about this. For trans masculine kids remember, most people with ovaries get to their final adult height 18 months after their first period, so in general if you are making mostly oestrogen in your body you are going to close your growth plates faster. Most people who have a testosterone driven puberty grow well on into adolescence.

Here’s an example growth chart for a trans masculine kid, they had their period here, and would have stopped growing 18 months later. But they went on to blockers and grew slowly and then went on to low dose Testosterone and that growth velocity picked back up again. This is a boy’s growth chart because that is what we are looking at, the growth of a trans boy on a boy’s growth chart.

Here is a trans girl’s growth chart. Here she is growing at a pretty rapid growth. Goes on a blocker, it slows down. Goes on a low dose oestrogen, look at this – holy moly! So that kid was completely panicked, the kid by this point was 15 and a half and some folks would be like ‘you can’t put that kid on an adult dose of oestrogen’ but yes you can and so I did, and it flattened out, I don’t yet know if this kid’s growth plates have closed or not.

When you measure growth velocity per year, pre-puberty 9 cm a year, on the blocker moves down to 7, then moves up to 13 cm (on low dose oestrogen), so that’s really fast for oestrogen. Oestrogen, both for oestrogen and testosterone driven puberty is what accelerates growth but then is also what closes the growth plates. Complicated.

Here’s another case study: This kid started blockers – most of my trans girls start blockers around 11 and a half or 12. On blockers growth slows down, put this kid on an escalating oestrogen and then growth goes up really high, then I said we need to up the dose of oestrogen to flatten out the growth curve, which it looks like we have.

In assigned females peak growth velocity occurs in tanner 2 in 40% individuals and 30% in tanner 3.

In assigned males peak growth velocity occurs in tanner 3.

Also growth isn’t stopped in all parts of the body simultaneously. Hands and feet fuse first, then arms and legs, followed by spine. When we do a bone age we do a hand scan and that might be premature for our trans boys.

Can we use blockers in later pubertal adolescents and young adults? Absolutely. Especially if parents or kids are not ready for hormones yet, if they are like ‘no I don’t want to do that yet’ or if the parents are (not on board), so there can be a role for blockers in kids who are not in tanner 2 or 3. But you have to be careful, especially about menopause.

You can use blockers alongside gender affirming hormones. This is important, because trans girls always have to be blocked, somehow, until they have no testes. But if someone is not planning to have that surgery, they will always need to be blocked, because they always have the potential for producing testosterone.

Non-binary. So many of my non-binary are ‘can I be on blockers forever?’ No. you cannot. Hormones are sadly binary. I am cool with non-binary kids being on blockers for maybe 2 years, around, but then I get nervous about bone density so we have to have that conversation.

Here are two case examples. Both 14 year olds, showing everyone needs an individualised approach. 14 year old assigned female had period year before I saw them, came out a year ago as male, some menstrual and chest dysphoria, no suicidal attempts, was socially transitioned living as himself. Same week, 14 year old assigned female. Happy childhood. Typical very common story for transmasculine kids, tom boy, sporty, at age 11 tanked, when puberty hit multiple suicide attempts, multiple hospitalisations, also socially transitioned living as male, kid felt very strongly about needing peer concordance, was already at tanner 5. First kid said ‘I want to be on blockers’. Second kid said ‘I want nothing to do with blockers I want to be on testosterone’. And that was right for him and he’s done great.

[Editor’s Note: earlier in the talk Jo Olson Kennedy makes reference to a WPATH presentation last year, where an unnamed person, said that almost all the kids they see who go on blockers continue in the service and they have no idea why. Jo Olson-Kennedy said she does know why those kids continue in the service – because they are trans! In the final section Jo Olson-Kennedy provides two case studies of examples she has come across when kids have decided to come off blockers.]

Let me tell you about 2 kids who went on blockers and chose to stop.

This kid, assigned female, started saying ‘I a boy’ at 18 months. At 3 years old the kid was in an enormous amount of distress saying I’m a boy. At three kid socially transitioned, started living as a boy. Lived as a boy – also liked dolls and sparkly shoes. Asked ‘if I’m a boy and I like girl’s clothes, am I cross-dressing?’ Said ‘I will live as a boy at elementary school, as a girl at middle school, and by high school I’ll know what’s right for me’. The kid decided to live as a girl at 9. 2 months later called me saying I have breast buds, I need a blocker. Said didn’t want breasts and wanted time to think. Went on blockers for 2 years. 2 years later came in and said I want blocker removed, I want to go through female puberty. I said ‘what is happening with your gender?’ They said ‘well, I don’t know yet’. I said ‘well what if it lands on boy’. The kid said ‘It’s 2017, who says boys can’t have boobs’. Touche small child, I will take your blocker out. So I took the blocker out and the kid continues to live as a girl. A year later calls to say ‘do you know where I can get a binder’. And I was like ‘oh your mum wants to pole her eyes out right now’. So this kid is extraordinary and their gender is still happening. And I asked them, do you think your parents should have supported you to live as a boy for so long, and they said, ‘I wouldn’t be here now if they hadn’t’. So that is testament to what it means to socially transition, go on blockers, come off blockers.

Another kid, assigned female, got blocked at 9, started testosterone at 13, discontinued both a year later, went through their endogenous puberty identifying as non-binary and a year later came back to start testosterone again.

So all of this is ok, and it’s all good and everyone’s going to go on their journey whether we want them to or not and we can make it easier”.

 

 

The Gender Identity Disorder Service

NHS Transphobia

The Gender Identity Disorder Service

The NHS is transphobic at heart

Viewing gender as a disorder for a start

They don’t care about our trans kids

Anything would be better than GIDS

We get experts who hate trans folks

Who think trans positivity is a joke

Pathologising, outdated, offensive

Slow, damaging, defensive

They philosophise, try to define

They deny, dismiss, undermine

They want them depressed and broken

Not resilient, strong and outspoken

Not good enough! so no more

Will we leave our kids weak, on the floor

So parents of trans kids will roar

And our kick-ass trans kids will soar

UK GIDS Failing Publicly

The heads of the UK Children’s Gender Identity Service (GIDS) have just published a new journal article, featured in the British Medical Journal ‘Archives of Disease in Childhood’:

“Assessment and support of children and adolescents with gender dysphoria” Gary Butler (Consultant Paediatric Endocrinologist), Nastasja De Graaf (GIDS researcher), Bernadette Wren (Head of Psychology at GIDS), Polly Carmichael (GIDS Director).

This latest article from the heads of the UK children’s gender service (GIDS) sets out the UK service’s position and deserves close scrutiny. Here goes:

Introduction

The article is intended for “professionals” who:

“may be unsure how best to provide supportive care, how to access the national Gender Identity Development Service (GIDS) for children and adolescents, or how to deal with a transgender young person presenting with another clinical problem unrelated to their gender transition”

Referencing fringe figures

The first reference they have chosen to include is co-authored by Ray Blanchard and Kenneth Zucker, two controversial figures, the former whose theories have been rejected by mainstream practitioners and who is known for speaking about trans people with disrespect, and the latter who was sacked from his clinic in Canada for work that could not be distinguished from conversion therapy and who has compared trans children to animals.

Conflating behaviour with identity

For a guide intended for non-specialists, the publication from the very start confuses and conflates behaviour, expression and identity:

Gender atypical behaviour is common among young children and can be part of general development”.

They omit any publications (e.g. Hidalgo et al 2013Olson et al 2015, Ehrensaft 2016Fast & Olson 2017)  that evidence the existence of trans children at a young age – with an insistent, consistent, persistent gender identity different from the one assigned at birth. They also omit to mention that trans children may or may not have non-traditional behaviour or expression. Gender identity and behaviour/expression are different things, and any publication intending to educate, should have be clear on this. This omission is a fundamental failing.

Focus on exponential rate of rise, not on actual numbers compared to population prevalence

The first paragraph focuses on the ‘exponential’ rise in referrals since 2011. The language is alarmist, with the focus only on the rate of increase, with no discussion of the actual numbers. The actual numbers are extremely low and as with all low numbers, can easily show exponential growth.

The section on prevalence contains no discussion on how these low actual numbers compare to estimates of prevalence across the population. There is an alarmist focus on the growth rate without mentioning the numbers for 2011 were only 200 children a year (from the UK population of 60 million) and in 2016 were only 2,000 children a year. 2,000 children a year from a under 18 population of about 14 million children in the UK is still a very small percentage. So yes from 200 to 2000 is an exponential rise, but it is still only a tiny fraction of the under 18s in the UK.

This section does not mention that recent population prevalence surveys have put the trans population at around 1%, which would mean up to 140,000 of those currently under 18 might identify as trans. Referral numbers rising from 200 a year to 2,000 a year should not be a surprise in this context.

There is also zero discussion of the wider context, not only the rise in visibility and awareness of trans people in general, but the specific context in the UK – GIDS mentions a rise in referrals since 2011 with no mention of the arrival of the Equality Act in 2010, legislation that protected trans children and enabled families like mine to feel safe enough to get support at school and in other areas – protection that allowed families to be more open, protection that enabled families to support their child.

Australian gender specialists describe a rise in referrals in a completely different manner:

“Spurred on by increasing acceptance of transgender individuals in society (and normalisation of the right for anyone to question their gender identity), the number of young people seeking support is likely to increase further”

UK GIDS cannot seriously claim the rise in referrals is unexpected – a rise in referrals was predicted by GIRES back in 2009 and they themselves .

Focus on rise in ‘birth registered females’ 

GIDS continue:

“A striking feature of this increase is the large proportion of birth-registered females from 2011 onwards. This increase and the change in sex ratio is also seen in other countries. 

Let’s break this down. Again the focus on rise in referrals. From 57% assigned female in 2011 to 69% assigned female in 2016. From about 100 assigned females in 2011 to about 1,400 in 2016, from a population of 64 million people in the UK. Any analysis of trans prevalence would acknowledge that the 100 referrals of assigned females under 18 years old in 2011 was a gross under-representation. A rise in assigned female referrals was predicted by GIRES in 2011. A less transphobic service would celebrate the fact that more assigned females are getting listened to, getting referrals and getting support.

The Fig for the accompanying graph states “referrals by birth-registered gender”. In the UK birth certificates state ‘sex’ not ‘gender’. GIDS should be aware of this.

Here appears the second academic reference in their paper. The first was co-authored by Zucker and Blanchard. Who is their chosen second reference? Oh, of course, it is another paper co-authored by Zucker.

Inclusion of unsubstantiated speculation

“The reasons (for rise in assigned females) are not fully explicable and a number of questions arise. Is this increase due mostly to the greater tolerance of gender-diverse expression in westernised society? Is male status still regarded as preferable?

We are still in the paper’s first proper paragraph, in a paper intended to educate professionals, who are not gender specialists, in evidence based medical consensus. At this point in the paper, GIDS decides it is appropriate to engage in unevidenced speculation about the reason for a rise in assigned females. It chooses to include unevidenced speculation that matches a fringe theory proffered by transphobic lobby groups: “Is male status still regarded as preferable?”.

This unqualified speculation implies that children and adolescents are choosing to be trans. That trans boys choose to be trans to benefit from the enhanced status that comes with being seen as a trans boy. This suggestion woefully minimises the very real challenges facing trans boys and trans masculine children in a transphobic UK. But most importantly it is not supported by evidence. This is a GIDS publication in a medical journal. Do NHS professionals in medical journals routinely apply speculation on medical care eg. for reasons for a rise in asthma? Why are professional standards for trans children’s medical professionals so dire?

And more:

“What are the benefits, as well as the possible harms, in supporting and helping these young people at different stages of development?”

GIDS are not talking about the nuances of different treatment pathways here – they are saying that ‘supporting and helping’ young people has the potential to cause harm. Implying that there are circumstances when it is better to not ‘support’ and not ‘help’ young people.

Noticeably, despite extensive evidence of the harms of withholding care to trans adolescents (See Giordano and here ), they choose not to include any reference to the known harms associated with not helping young people. The then Chair of the NHS Clinical Reference Group for Gender stated that “not treating people is not a neutral act. IT WILL DO HARM”.

“Not treating people is not a neutral act. It will do harm: there are a number of studies that report evidence of suicide and self-harm among trans people who are unable to access care.”
John Dean, MBBS, FRCGP, Chair, National Clinical Reference Group for Gender
Identity Services, England

Here is the 2017 Australian Standards of Care for trans children (now also published in the Lancet) on withholding treatment:

“Avoiding harm is an important ethical consideration for health professionals when
considering different options for medical and surgical intervention. Withholding of
gender affirming treatment is not considered a neutral option, and may exacerbate
distress in a number of ways including increasing depression, anxiety and suicidality,
social withdrawal, as well as possibly increasing chances of young people illegally
accessing medications”.

GIDS omits any reference to evidence that withholding care causes harm.

Criteria for the diagnosis of Gender Dysphoria

GIDS describe the diagnosis of Gender Dysphoria (from the 2013 DSM-5) and focus on descriptions of behaviour.

There are many problems with the DSM-5 diagnostic criteria that GIDS are either unaware of, or choose not to discuss.

Contrast this with the astute approach Johanna Olson-Kennedy takes to DSM-5 gender dysphoria diagnostic criteria.

Dr. Olson-Kennedy critiques the adult Gender Dyspohria diagnosis that requires a trans person to have “a strong conviction that one has the typical feelings and reactions of the other gender”.  Olson-Kennedy ridicules this describing her “big book of typical feelings and reactions, the blue pages are male and the pink female”.

The DSM-5 gender dysphoria diagnostic criteria for children is even more absurd. In order for a child to be diagnosed with gender dysphoria, they HAVE to say yes to at least one of these three outdated, stereotyped criteria:

  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.

  • A strong preference for playmates of the other gender.

  • A strong rejection of toys, games and activities typical of one’s assigned gender.

If a trans child such as mine, likes a wide variety of toys and plays with all children (and how can that possibly be a bad thing?) then that child CANNOT be diagnosed as gender dysphoric according to DSM-5. The diagnosis is obviously nonsensical.

It is a stereotyped and confused mess of a diagnostic tool, yet the GIDS paper presents this without critique, qualification, or apology, instead accepting and endorsing its focus on behaviour rather than identity. Perhaps this endorsement is because GIDS are content with a confusion between gender identity and behaviour – confusion that is consistently used by vocal transphobic lobbyists to argue against support for trans children.

The GIDS article states: “for children, cross-gender behaviours may start between the ages 2 and 4, the same age at which most typically developing children begin showing gendered behaviours and interests”.

Why are they focusing on behaviour and interests? If the authors had any understanding of gender, they would examine how and why behaviour and interest do not equal identity. This omission is astonishing.

Again, no mention of Olson 2015 or Fast 2017 that found: “Transgender children do indeed exist and their identity is a deeply held one” providing evidence that “early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.” This research literature from the US is completely omitted from the GIDS paper.

Do GIDS feel it is appropriate to disregard academic literature that challenges their (unevidenced) beliefs?

The language contrasting trans children with ‘typically developing children’ is also cisnormative and pathologizing. My child is developing typically. She just happens to be trans.

Cisnormative and outdated terminology

GIDS include a glossary of ‘useful terminology’. The definitions they have chosen to use, and those that are missing, evidence their cisnormativity and lack of sensitivity or awareness of trans inclusive language and risk alienating their service users.

“Transgender: Transgender refers to the broad spectrum of individuals who identify with a gender other than that associated with their birth sex”.

The phrase ‘birth sex’ is outdated – ‘assigned sex’ is used for a reason. Especially given the 2017 Endocrine Society guidelines has a whole section on the substantial evidence of a biological underpinning to gender identity (something GIDS do not reference in their paper).

Here’s a better definition, from the Australian Standards of Care: “Trans/Transgender: A term for someone whose gender identity is not congruent with their sex assigned at birth”

“Non-binary: Non-binary is a lack of identification with conventional maleness or femaleness. Non-binary people may express features of both genders or neither.”

This muddled definition places more emphasis on gender expression than on identity. It is also ironic, in a definition of non-binary, to use the phrase ‘both genders’. A better definition would focus on identity not expression: “Non-binary: A term to describe someone who doesn’t identify exclusively as male or female”.

“Transman/transboy: A person born phenotypically female (natal female), registered (assigned) female at birth, who identifies as male. Also known as female to male.”

Many trans people consider the lack of space between trans and man or boy offensive. Trans is an adjective. ‘Transman’ is a term frequently used by those who wish to other trans people. It is used by those who argue that trans men are not men. The definition is also cisnormative – the phrase ‘identifies as‘ would never be used for a cis man.

The GIDS definition of a ‘transman’ states ‘a …female….female….female who identifies as male’. The term ‘female’ appears three times in their definition before the word male.

Further, the term ‘natal female’ is widely considered outdated and offensive by trans people. The Endocrine Society states there is clear evidence of a biological underpinning to gender identity. Trans boys are not ‘natal females’. Many medical professionals already use gender affirming terminology, with even the Endocrine Society using the term transgender male to refer to trans men – there is simply no justifiable reason to use the term ‘natal female’ when talking about trans men.

“Transwoman/transgirl: A person born phenotypically male (natal male), registered (assigned) male at birth, who identifies as female. Also known as male to female.”

As above – where is the space between trans and woman or ‘girl’?  ‘Transwoman’ is a term used by those with deep seated hostility to trans women to attack and discriminate. It is considered by many to be deeply offensive. Are the authors so unaware that this language is deprecated?

Again, in their definition of a trans woman (transwoman), they repeat the word male three times before saying ‘who identifies as female’.

The text suggests that the term ‘male to female’ is a noun and a synonym for trans girl. Not helpful.

Cisgender

GIDS do not include a definition of the word cis or cisgender. The words cis or cisgender are not used ONCE in their paper. Through these definitions and omission GIDS erase and ‘other’ trans people and their service users.

Appropriate assessments prior to referral

“The GIDS is an unusual multidisciplinary service in that the initial assessment … is aimed at understanding the young person’s development and gender identification in the context of their family background and life experiences It takes account of how they feel about their gender and their body now and in the past, the context in which the gender dysphoric feelings arose and intensified, how these feelings are being managed in everyday life, and what hopes are held for proceeding in the future”.

GIDS focus is on ‘the context in which the gender dysphoric feelings arose’. They place causation at the centre (a later section of the paper discusses their quest for a diagnostic test for ‘transness’ – asking a child their identity apparently didn’t occur to them.

There is no discussion of the 2016 Lancet publication which states that parenting has no impact on gender identity. There is no mention that gender identity is resilient to external influence, and no mention that past attempts to externally change a gender identity are considered unethical and ineffective. These omissions are damning.

Compare the Australian standards of care which  explicitly covers those issues which are ignored by GIDS:

 “In the past, psychological practices attempting to change a person’s gender identity to be more aligned with their sex assigned at birth were used. Such practices, typically known as conversion or reparative therapies, lack efficacy, are considered unethical and may cause lasting damage to a child or adolescent’s social and emotional health and wellbeing”.

Autism

“Around 35% of referred young people present with moderate to severe autistic traits”.

GIDS provide no published detail, nothing of their methodology and no discussion of the number of children who have ‘moderate’ versus ‘severe’.

This sentence also smacks of ableism. The statistic about autism is given without any discussion of how their service supports and cares for neuro-diverse trans children. For a brief summary of current literature on the intersections of gender diversity and autism see this 2017 review by Gender Analysis.

Assessment

“The assessment period usually takes 6 months or more over a minimum of four to six sessions”.

Earlier in this paper GIDS have already confirmed that they follow the NHS service specification. Their own service specification clearly states on page 13:

“an initial assessment process which will be specific to the person in terms of duration and will typically be over three to six meetings depending on the individual”.

GIDS’ own service specification commits to individualised care, yet here they are stating a minimum of four sessions regardless of circumstance. In a service where waiting lists for a first appointment (once a family manage to secure a referral from a GP) have risen to 18 months!

These illegal and unethical waiting periods have a direct negative impact on young people and their families.  There are reports of families re-mortgaging homes to afford private care outside of the UK. There is a growing practice of (dangerous) self-medication. These problems are entirely avoidable and are a direct consequence of a lack of individualised care and the appalling waiting lists created as a result.

Trans teens are a highly vulnerable group – making a highly distressed trans teen entering puberty wait 18 months for a first appointment and then inflict an inflexible protocol requiring a minimum 4 sessions, spread months apart, before any consideration of a referral (with further assessment and delay) to the endocrine service, for fully reversible, safe, puberty blockers, is both unnecessarily CRUEL, and a gross dereliction of duty of care.

“At the end of the assessment, it may be possible to confirm or exclude a diagnosis of GD”.

Note the arrogance and where the power lies. The clinician can ‘exclude’ a diagnosis of Gender Dysphoria. There is no practical recourse, no appeal, and no power to challenge the monopoly service authority over trans children.

Rates of referral to pediatric endocrine clinic

For several years GIDS have been talking about rates of continuation to medical intervention, without ever providing any published data.

Head of service Polly Carmichael spoke on the Victoria Derbyshire Show on the 7th August 2017:

Polly was asked by the presenter Victoria Derbyshire:

“How often might you see a child at a young age, 3 or 4 or 5 who as they grow or mature eventually change their mind?”

Polly answered:

“Those that are referred to the service at 5 years old it will only be 6% of those who ultimately go on to seek physical interventions to change their body”

Following this national media appearance parents asked GIDS to SHOW US THE DATA.

Radio silence. GIDS confidently, publicly, state a statistic about a specific group (only 6% of 5 year olds will go on..) on national television, ignoring the negative impacts this may have on families with trans children, and then fail to publish anything to support their claim.

This is a gross abuse of their power.

For years parents have been asking GIDS to publish data to support claims that they have been stating on national television morning breakfast shows, in newspapers, at medical conferences. These claims that are interpreted by viewers and readers as exceedingly high rates of children ‘changing their minds’.

Finally, in this paper, GIDS have included data, and within the respected British Medical Journal. How exciting! Let’s take a look!

What does their data actually show?

“Following psychosocial assessment at the GIDS, on average 38%–40% of all clients attend the joint endocrine clinics, although this varies across the age range.”

That seems a clear statistic. It appears that 38% of children go to endocrine. It is strange that they have chosen to provide an average percentage across all age ranges, when they are only taking data over a 4-7 year time window. They acknowledge, straight up, that the 38% figure is an underestimate as the older cohort (who are more numerous) proceed to adult services for endocrinology. They do not however, acknowledge that the youngest cohort are too young to be eligible for endocrinology making the 38% figure even more of an underestimate. It is strange then for them to have chosen to lead with this largely meaningless average percentage number.

GIDS do not provide all the data, but do provide a graph which will assist with testing this 38% figure.

figure 2 Butler paper

The blue bars track the age at initial referral. The mean age of referral to GIDS was age 14.4 years (the mode would be a more useful statistic in this graph).

The orange line tracks the proportion who had been referred to endocrinology by 2017.

While the underpinning evidence is unfortunately missing, we can use the data visually presented in the graph in order to test the accuracy of the 38% figure for different age groups.

In the graph we are given a single combined data set for the period 2010-2013. For the sake of a simple calculation, we’ll take a single yaer within this (2012) and assume that everyone has been referred in 2012 (rather than 2010-2013 – taking the latter of the mode numbers, as referrals have risen each year).

4 year olds (age of referral) in this data set

4 year olds referred in 2012 are 9 years old in 2017. Unsurprisingly zero out of approximately 10 of these children have been referred by 2017 (they are too young to be at tanner stage two, especially as those children referred at age 4 were more likely to be assigned males who typically start puberty later than assigned females).

6 year olds in this data set

For 6 years olds referred in 2012, who are age 11 in 2017, roughly 3 out of 20 have been referred to endocrinology. Again, this is not surprising. The majority of referrals at 6 are assigned males and most assigned males have not started tanner 2 at age 11.

9 year olds in this data set

For 9 year olds in 2012, who are 14 years old in 2017, we can see around 50% have been referred (20 out of 40 children).

12 year olds in this data set

Children referred at age 12 are age 17 in 2017, and we can estimate about 80% of them have had a referral. Similar for those referred at 13 and 14 years old,

15 year olds in this data set

For children referred at 15 years old, 50% have had a referral to endocrinology a drop compared to 14 year olds at referral.

For 16 and 17 year olds  the referral rate drops further. As GIDS explains in their paper, many 15, 16, 17 year olds will have limited benefit from blockers, and many prefer to wait until adult services (transfer at 17) where they are allowed to go on to HRT without the children’s service mandatory year on just blockers.

Some assigned females presenting to gender services at age 16 choose to go on the pill through GP rather than blockers through GIDs and go direct to adult services as they know those being referred at 16 will not get referred for Testosterone in the children’s services. Adolescents presenting in late puberty have less benefit from blockers and service users reports indicate a greater reluctance of GIDs to prescribe for those entering the service at ages 15-17.

Wait just one moment here!

Let’s look again at exactly what head of service Polly Carmichael, co-author of this paper, said on national media on the 7th July 2017 [10:20 am]:

When asked by the presenter Victoria Derbyshire

“How often might you see a child at a young age, 3 or 4 or 5 who as they grow or mature eventually change their mind?”

Polly responded:

“Those that are referred to the service at 5 years old it will only be 6% of those who ultimately go on to seek physical interventions to change their body”

We are now able to check Dr Carmichael’s statement against this newly published data:

For 5 year olds referred in 2010-2013, we are not given the number who have received referral to endocrinology by 2017, but from looking at this graph it is a very low number, it may  well be as low as the 6% stated by Dr Carmichael. What does this 6% mean? Let’s dig deeper into this exact issue, using both the above graph and GIDS own referral statistics from their website:

Year  Number of 5 year olds referred

 Age in 2017

2010 3 12
2011 3 11
2012 8 10
2013 10 9
Total: 24
Average age: 9.95

The entire data set for 5 year olds is 24 children. The average age of their sample in 2017 is age 9.95 years old.

If we were to make the assumption that 100% of these children would wish to access puberty blockers, how many of those 9.95 year olds would reasonably be expected to have accessed puberty blockers in 2017?

GIDs own figures suggest younger children (including 5 year olds) are by far more likely to be assigned males – with 4 times as many assigned males as assigned females at this age.

What then, is a common age for assigned males to start puberty? This 1980 publication states that puberty for assigned males begins at age ranges 9.7 to 14.1 years.

We would therefore expect a very small number of our 24 children to have started puberty. So we would expect a very small number of our children to have reached the stage of being eligible for puberty blockers. The figure of 6% having been referred to endocrinology after the start of puberty sounds a reasonable figure given most will not yet have reached tanner stage 2 of puberty.

This data TELLS US NOTHING about how many 5 year olds referred in 2010-2013 will end up needing medical interventions.

This data DOES NOT justify the Head of GIDS going on national television and, in response to a question on whether young children ‘change their minds’ answering that ‘only 6%’ of 5 year old continue. It is dismissive and damaging.

This dismissive and damaging rhetoric from GIDS directly feeds into (and is a contributor to) the moral panic that we are facing in the UK today around trans children.

This dismissal and erasure of trans children feeds into the situation in the UK where transphobic groups hold meetings stating on camera ‘trans children do not exist’. Where transphobic groups write damaging schools guidance that has been compared to conversion therapy.

GIDS and their anti-fact media messaging is complicit in the harm that is being caused to trans children across the UK.

Misleading manipulation of data 

A person who reads this article quickly, glancing at the headline statistic and taking a cursory look at the graph will likely take away two things 1) that only 38% of children go on to endocrine treatment, and 2) that those most likely to go on to endocrine are those referred at age 15 (due to the authors decision to present a graph appearing to show a peak at age 15). These two conclusions would both be wrong. GIDS either lack basic competence at data communication, or are actively intending to misrepresent the data.

On a similar note, they are using their Fig 2 graph to discuss the percentage of children who have been referred to endocrinology. Why then are they showing us a bar chart of numbers entering the service and a line graph of numbers referred, and expecting the reader to guess the percentage. It would be far easier to simply provide a graph of the percentages. The apparent hump on their graph at age 15, fits their mantra that ‘almost all trans children desist at puberty’, whereas a graph showing percentages would have a peak at about age 11. This is manipulation of data to fit a misleading narrative.

‘Desistance’ during early puberty

Head of service Polly Carmichael has talked about the Dutch ‘evidence’ that nearly all trans children will change their mind and not go down a medical intervention path. This ‘evidence’ has been shown to be false multiple times and is now even rejected by the Dutch authors themselves who claim to have been wrongly interpreted. Polly Carmichael claims that GIDS’ own data corroborates the (now withdrawn) findings of the Dutch. She describes a ‘paradox’ that the vast majority of trans children stop being trans at puberty, whereas the vast majority of children referred after puberty do continue being trans. She has a ‘hypothesis’ that early puberty natal hormones are responsible for a change of heart in those referred pre puberty. On the basis of this ‘hypothesis’, the hypothesis that the majority of trans children ‘desist’ during early natal puberty, GIDS delays provision of hormones blockers, and tells service users that prompt provision of hormone blockers may ‘change the outcome’ and solidify a trans outcome.

We can now test this hypothesis using this new GIDS data. How can we test it? We focus on children who were referred before the start of puberty, selecting the older pre-pubescents for maximum age at time of sampling. We therefore focus on children referred at age 9. The majority of 9 year olds have not yet started puberty.

If the GIDS hypothesis is correct, and the vast majority of pre-pubertal children do not go on to medical intervention, we should spot this trend in those referred at age 9. We should see less than 20% of those referred at age 9 going on to referral to endocrinology.

Let’s look at the data. Children aged 9 in 2010 are 16 in 2017. Children aged 9 in 2013 are aged 13 in 2017. Looking at their referrals data, the average age of this group in 2017 is 14.2 What percent of 9 year olds (at referral) in this data set have been referred to endocrinology by 2017? 50%. Fifty percent.

THEIR OWN DATA CONTRADICTS THEIR HYPOTHESIS!

Their own data contradicts their hypothesis that the vast majority of children referred pre-puberty do not go on to endocrinology. Their own data shows that 50% have gone on to endocrinology by the time they are (on average) aged 14.

We know that 50% (20 out of 40 – estimate from looking at graph – actual data is not provided) have had a referral to endocrinology by 2017. Of the other 50% (20) GIDS tell us nothing (despite proposing their percentage as a noteworthy finding). Many questions are left unanswered. How many of those 20 who have not been referred to NHS endocrinology have skipped GIDS gatekeeping and gone to private healthcare services in the UK? How many of those 20 have gone to the USA? We do not know. How many of those not (yet) referred will go on to a referral to endocrinology but have not yet reached tanner stage 2 of puberty (remember, nearly half of this sample are aged 13 or under in 2017). How many are wanting a referral but have not been approved by GIDS, having not yet jumped through the right hoops in their answers or cooperation. How many are denied  due to co-existing challenges or circumstances that allows GIDS to deny or delay referral (eg being out of school, being neuro diverse, being too depressed or suicidal, being insufficiently binary, or having a presentation that doesn’t match with GIDS expectation of what a child who is trans will look or act like). How many are wanting a referral but have not had the support of their parents for referral to endocrinology? We must remember that the majority of parents of children at the GIDS are unsupportive, and unsupportive parents can block (and certainly delay) a referral to endocrinology. How many are of these ‘desisters’ are *still trans* but have decided against taking puberty blockers at this point in time due to other life factors, such as exams, travel, other medication. None of this is explored in this paper.

A reflection on data reliability: GIDS data doesn’t appear to be reliable. There is a discrepancy between the total referral figures shown on their website, and their assigned-gender disaggregated figures released through a 2017 Freedom of Information Disclosure. For the year 2012-2013 the former states 3 five year olds (the FOI lists 0 five year olds). For the year 2013-2014 the former states 10 five year olds (the FOI lists 6 five year olds). These discrepancies bring into question GIDS data management.

Pubertal status

On the timing of puberty blockers, GIDS states:

“It is a requirement, according to the Endocrine Society and WPATH guidelines and UK service specifications, that a young person has commenced puberty before any intervention is agreed, as the GD may resolve once puberty commences.

First, Endocrine and WPATH guidelines (SOC7) do of course require puberty to start before prescribing blockers (blockers serve no purpose pre puberty). However, the endocrine society’s position is misrepresented. The Endocrine society says:

“We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage 2”.

“At” tanner stage 2. The Australian SOC is even more clear:

“Puberty suppression is most effective in preventing the development of secondary
sexual characteristics when commenced at Tanner stage 2″

“At” Tanner stage 2. The difference between recommending blockers at tanner stage 2 and a requirement that a young person has commenced puberty before any intervention is agreed may sound inconsequential, but this emphasis has profound implications for UK trans children. GIDS have no urgency about prescribing at tanner 2 – indeed they actively encourage delays, believing that a longer period of ‘natal’ puberty is a good thing.

“It is a requirement, according to the Endocrine Society and WPATH guidelines and UK service specifications, that a young person has commenced puberty before any intervention is agreed, as the GD may resolve once puberty commences.

The GIDS statement ‘GD may resolve when puberty starts’ does not appear in either the endocrine guidelines or WPATH (SOC7).

GIDS is fraudulently linking their pet theory (GD resolving when puberty starts) with the more respected evidence from the Endocrine Society / WPATH. This is misrepresentation. No evidence is provided for this claim.

This aligns with Polly Carmichael’s pet theory of natal pubertal hormones making trans children turn cis. A theory she has been speculating about for over a decade. A theory she has never provided a shred of evidence for.  Here she is a decade ago saying the same non-evidenced theories she clings to to this day:

“if you halt your own sex hormones so that your brain is not experiencing puberty, are you in some way altering the course of nature?”

A decade ago she was saying the same thing that she says to the media today, that there is not enough long term data on the outcomes of puberty blockers:

“The Dutch data looks promising. But they have not been doing it for so many years that you have long-term follow-up. The data is not over a long enough period of time and that concerns endocrinologists.”

<https://www.theguardian.com/society/2008/aug/14/children.youngpeople>

Her position has not changed in one decade. Her position has not changed because she is not listening to trans people, she is not listening to parents of trans children, and she is ignoring medical experts who disagree with her.

In both psychiatry and social work the term “defensive practice” is used to describe a deliberate practice of risk averse decisions, strict adherence to protocols and lack of learning. Defensive practice is also associated with an organisational culture in which leaders are not challenged (Whittikar & Havard 2016).

This term accurately describes how the GIDS leadership have become stuck in defending their (outdated, pathologising, harmful, non evidence-based) ways of working. They have become defensive, and in defending, have failed to evolve, failed to adapt and failed to remember their primary responsibility – ensuring the best possible outcomes for their clients (trans children and families). Alongside defensive practices they bring an inherent cisnormativity and transphobia – in which their model actively aspires towards and prioritises a cis or ‘not trans’ outcome, above the well being and happiness of their service users.

Persistence

The GIDS paper moves on to talk about persistence (the problematic history of this term, and implication that ‘persistence’ is undesirable, is not explored in the paper):

“Fig 2 demonstrates the low absolute numbers and proportion of prepubertal children with persistent GD.”

FIG 2 DOES NOT SHOW THIS.

Fig 2 shows the percent of children referred to GIDS between 2010 and 2013 who by 2017 had been granted by GIDS a referral to the paediatric endocrine service.

It shows about 80% of those referred at 10 years old are granted a referral to endocrine. For the younger children, those aged 5 in 2012 are only aged 9.95 in 2017 and most of them have not yet started puberty. This study tells us nothing about how many of those 5 year olds will receive a referral to endocrine at some point during their adolescence.

Importantly, this study does not tell us anything about how any of these children identify. It tells us nothing about their dysphoria.

FIG 2 does not tell us the proportion of prepubertal children who have ‘persistent’ Gender Dysphoria. THIS IS FALSE.

By conflating a referral rate with a ‘persistence’ rate, it also equates requirement for endocrine interventions with identity – ignoring the diversity of needs amongst trans children, including those who absolutely ‘persist’ in an identity different to the one presumed at birth, but do not need/choose to take hormone blockers/medical transition.

By conflating a referral rate for persistence, it also overlooks (as far as we can tell from the limited information they publish), those who seek private treatment or pursue treatment overseas.

The data completely ignores the issue of gate-keeping. GIDS are extremely conservative about referrals to endocrinology, and known to discriminate against children with mental health issues, those who are neurodiverse, those who present later, those who are non-binary. We do not know how many of those who have not been referred to endocrine desperately want a referral, but have not yet been granted one.

Finally, we know that two thirds of teens in the service are not supported by their parents. Teens who are unsupported are much less likely to get a referral to endocrinology. How many of those counted as not having been referred to endocrinology have had their referral blocked or delayed by unsupportive parents.

None of these factors are acknowledged in the article.

The article overall conjures up the unsubstantiated claim that ‘GD may resolve’, falsely creates an untrue 38% referral rate (which GIDS themselves clarify in the text is an underestimate of the reality), and mis-describes their referral rate as a ‘persistence’ rate. They use this to dismiss the existence of and undermine the rights of trans children.

Pathologising language continues

The next section provides an overview of the many tests they have carried out on trans children to look for reasons for being trans.

“Endocrine assessment of the reproductive axis of the birth-registered phenotypic male….”

The phrase ‘the birth registered phenotypic male’ is extremely pathologizing and othering language for trans girls. The phrase trans girl, trans feminine people, or people assigned male at birth would be a less offensive replacement.

“A search for sources of hyperandrogenism in adolescent birth-registered phenotypic females in an attempt to explain the dysphoria has not elucidated any differences from a control population”

“It therefore appears that GD is not associated with excess androgen production in postpubertal phenotypic female”

“our search for genetic, endocrine and radiological diagnostic markers of a dysphoria-related state has proven negative”.

How many of these children gave informed and voluntary consent to these unrequested, unwanted, pieces of research, with little relation to their care? Why have UK researchers been focused on a quest to find a diagnostic test for transness, and not on the key challenges, how can we help trans children to have good mental health and wellbeing?

GIDS are so detached from seeing trans children as important individuals with hopes and dreams and high potential. They fail our trans children time and time again.

Fertility preservation

“Various medical options are considered in case of a desire to revert to their birth gender in subsequent years after irreversible treatments have occurred, or in case assisted conception techniques might be called on in adult life to assist with starting a family”

This paragraph is strange. There is no information here. No evidence on what they are talking about re ‘revertion’ after irreversible treatment. No information on numbers.

Talking about a desire to revert after irreversible treatment is a subject that needs handling sensitively with careful context. Everyone working in this field is aware that a tiny number of examples of adults with ‘regret’ are used by anti trans lobbyists to undermine and deny care to trans children.

This report is not however, by anti trans lobbyists, but advice to non-specialists focused on working with children.

Partially irreversible treatment in the form of cross sex hormones is only available from around age 16, and GIDS only permits the children with the most straight forward diagnosis and a long history of gender dysphoria, who have already been on blockers for at least a year, to access HRT at age 16. The gatekeeping is extensive. How many children can they really have seen in the youth service who have had a clear enough history and presentation to receive blockers before 15 and HRT at 16, have had HRT long enough for irreversible changes, and have sought to reverse changes by age 17 before leaving children’s services. Knowing their conservative interpretation of the protocols, I do not believe this has happened in any significant numbers, certainly no evidence is presented in this paper or any other publications from GIDS that I am aware of.

If they are talking about data on regret from other services – they need to be providing a published reference for this statement. The fact that they do not provide a reference, suggests to a reader that they are talking from their own experience. They are scaremongering without providing any data.

Blockers

“In those whose GD is clearly established and long-standing and who have participated fully in the multidisciplinary assessment process at the GIDS, GnRHa is the recommended first-stage medical intervention”.

This shows how conservative they are at offering blockers. Adolescents need ‘established and long standing’ GD. These are subjective quantities. How many months or years is enough? How does an adolescent prove this? It seems like only the most straight forward (insistent, consistent, persistent, though they avoid these terms) are eligible. Yet blockers are intended to provide thinking time for those who are distressed about puberty and need thinking time to explore their identity. Children with the longest history and clearest presentation arguably do not have any reason to go onto (just) blockers, with practitioners in the US increasingly bypassing blockers to go straight to HRT for the simplest cases. It is those children who are less sure, who are questioning, who started to question (or vocalise) their gender at the onset of puberty, who need time to think and would most benefit from blockers. This is the very group who are ineligible.

Note also the requirement to have ‘FULLY participated in the multi-disciplinary assessment process’. There is a vast and unacknowledged power dynamic here. This evidences how GIDS wield their power and absolute authority. Adolescents and families are afraid to advocate for their rights, afraid to challenge clinicians who ask inappropriate questions, afraid to not complete pathologising  questionnaires that themselves induce dysphoria and have subsequent negative impacts on the mental health of adolescents. There is no service user autonomy. The powerlessness of children and families adds to stress and feelings of having no control over the future – a powerlessness that greatly harms the mental health of trans and gender questioning children and adolescents.

“The fact that between 73% and 88% of children attending gender identity clinics who present prepubertally, whether they have socially transitioned or not, are likely not to continue with their intention of changing their gender once puberty has started”.

They are listing the 2008 Wallien and Cohen-Kettenis study as their reference. We have discussed this at length in a previous blog.

Even if we just accept their data and overlook the methodological flaws in the Wallien and Cohen-Kettenis study, from the children initially classified as GD who were later re-assessed,  21/36 were ‘persisters’ and 15/36 were ‘desisters’. So even the data in this study shows a 58% persistence rate not the 27% rate that GIDS have quoted using this very reference.

Those who have been paying attention to the current discourse, will be aware that several articles have been recently published criticising the desistance rate myth (the myth that such enormous percentages of children desist from a trans identity). Ehrensaft published on this topic months before this paper came out (notably omitted from GIDS’s references). Since GIDS’ paper was in print, there have been three consecutive publications by a team including Kelley Winters, making clear that these high desistance statistics are simply false. Steensma and Cohen-Kettenis, the latter, one of the authors of the paper GIDS quotes, have also published a new article stating that their work has been misrepresented and does not support high desistance rates.

Here’s Steensma and Cohen-Kettenis in their recent paper (2018):

“The classification of GD [Gender Dysphoria] in the Wallien and Cohen-Kettenis (2008) was indeed based on diagnostic criteria prior to DSM-5, with the possibility that some children were only gender variant in behaviour. We have clearly described the characteristics of the included children (clinically referred and fulfilling childhood DSM criteria) and did not draw conclusions beyond this group, as has wrongly been done by others”.

Cohen-kettenis is here, the very author of the paper that GIDS quotes, stating clearly that others have been wrongly misrepresenting her own work (she is one of the two co-authors of the 2008 Wallien and Cohen-Kettenis study). Cohen-kettenis here, provides final clarity that her 2008 study includes children who are not trans and merely non-conforming.

Yet GIDS have taken this study and wrongly interpret as “The fact that between 73% and 88% of children attending gender identity clinics who present prepubertally, whether they have socially transitioned or not, are likely not to continue with their intention of changing their gender once puberty has started”

The study they use as the reference included children who were just non-conforming and not trans. It did not consider which children were socially transitioned. And it most certainly does not say that children who have socially transitioned (a group much less likely to include children who are just non-conforming ) have the same ‘persistence’ rates as children who have not socially transitioned.

Butler, De Graaf, Wren and Carmichael  HAVE FABRICATED THE STATEMENT ‘whether they have socially transitioned or not’.

They have not provided a single reference for this claim.

This is unprofessional, unethical and OUTRAGEOUS.

The ‘desistance’ myth (the myth that the majority of trans children become cis at puberty) has been propagated by Zucker and by the Dutch school, which includes Steensma and Cohen-Kettenis. The Dutch have now publicly distancing themselves from association with this myth, claiming to have been misunderstood and misquoted. Zucker clings to this myth, but is now disregarded as totally out of touch with modern evidence based practice.

GIDS, meanwhile, are clinging desperately to this myth. They need this myth to justify their pathologizing and cisgenderist approaches. If they acknowledge that they are badly mistaken on the assumption that trans children end up cis at puberty, they would have to start asking what else they have got wrong.

The leadership at GIDS, the authors of this paper, are not capable of this mental step – if they acknowledge how badly they have got this wrong they would also have to acknowledge the harm they have caused their whole career.

“Some may ‘desist’ completely, with their initially perceived dysphoric feelings pointing towards developing homosexuality”.

This statement is drawn from the thoroughly discredited ‘desistance’ literature. Furthermore, there is a lot of confusion (and hysteria) in the UK media about the difference between gender identity and sexual orientation. Credible clinicians would in this section state that transgender individuals have a variety of sexual orientations and that gender identity and sexuality are different things.

“GnRHa is prescribed in standard doses for a minimum of a year before additional medical interventions can be considered”.

This requirement to have a minimum one year on blockers, regardless of age or stage of puberty, is not supported by WPATH SOC 7, nor by the Endocrine Society, nor is it in the NHS Service Specification which GIDS are committed to work within. Parents who have complained of the health impacts of forcing 17 year olds to spend a year on just blockers before HRT are reassured that minimum one year is not an official policy. Yet here it is again in writing. This one year minimum on blockers without HRT for late puberty adolescents is not evidence based and is not an approach followed in other countries – not even in neighbouring Scotland. GIDS are here applying a rigid protocol, against their own service specification, unsupported by evidence. 18 year olds in adult services would not be required to have any time on blockers before HRT. 17 and a half year olds in GIDS are forced to have a year on just blockers, regardless of side effects, regardless of not wanting to take blockers.

GIDS uses their monopoly to wield absolute power over trans children and adolescents.

Psychological benefits of GnRHa treatment

“Most young people welcome the ‘blocker’ intervention as helping them to feel more comfortable in their bodies while holding future gender options open. However, our psychometric data suggest that although it permits further time for exploration, the impact on reducing psychological difficulties is limited. Further research is needed to determine whether GnRHa treatment is beneficial for young people of all ages, or whether some age groups may benefit more from this particular treatment than others, perhaps younger rather than older adolescents?”

The evidence is clear that medical intervention for distressed trans youth is the best way of securing improved mental health. It is not surprising that blockers alone do not provide an improvement – HRT (or surgery) are the treatments that distressed trans youth (trans youth who seek a medical transition) need – blockers are simply a delaying method, to ‘buy time’. While they mitigate the fear of future changes, blockers are not in themselves a treatment which treats dysphoria. They simply delay a decision.

Eligibility for cross-sex hormone/gender-affirming hormone treatment

“Cross-sex hormone treatment, currently referred to as gender-affirming hormone treatment (namely the induction of the opposite-biological sex puberty using testosterone in a phenotypic female and oestradiol in a phenotypic male)”

There is a reason why the term ‘gender affirming’ hormone treatment is used. There is a reason why ‘opposite biological sex puberty in a phenotopic female’ is not used. Stop pathologizing trans people!

“(HRT) may be considered once full commitment to the preferred gender has been confirmed”

It is not a ‘preferred’ gender. My child would ‘prefer’ to have her gender match her assigned sex.

“At the GIDS there are psychosocial criteria that need to be met, including that the young person shows some evidence of presenting coherently in the gender role with which they identify and that mental health difficulties are not escalating.

Coherent gender role! This sounds like some 1950s housewife stereotyping. It is 2018 GIDS!

“At the GIDS there are psychosocial criteria that need to be met, including that the young person shows some evidence of presenting coherently in the gender role with which they identify and that mental health difficulties are not escalating.”

Trans youth have to demonstrate distress to be eligible for HRT. But not too much distress. Just exactly the right amount of distress.

“The capacity to give informed consent is an absolute requirement prior to commencing sex hormone treatment… It is acknowledged by the Endocrine Society that a young person under the age of 16 may not have sufficient psychological maturity to commit to such a lifelong and life-changing decision”.

Here’s what the Endocrine Society actually says:

“Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old.”

The Endocrine Society states that most adolescents have maturity by the age of 16. GIDS changes this to “the Endocrine Society” says “under 16s may not have sufficient psychological maturity to commit to such a lifelong and life-changing decision”. GIDS has changed the emphasis and padded with additional spin. This introduces a focus on “life-changing” that is not in the Endocrine guidance. This is misleading.

The GIDS paper attributes to the Endocrine Society and to WPATH SOC 7 the statement:

“no evidence is available to understand the effects of giving gender-affirming hormone treatment before 16 years”

They do not include any reference to a key part of the Endocrine Society’s guidance:

“We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years”

And they have misconstrued what the Endocrine Society has actually said which is:

“there is minimal published experience treating prior to 13.5 to 14 years of age”

GIDS have completely changed the Endocrine Society’s position on age of eligibility for sex hormones and have claimed the Endocrine Society says there is no evidence for under 16s, when in fact the Endocrine Society says there is no evidence under 14.

Further the GIDS paper fails to mention that the WPATH SOC7 states:

“Adolescents may be eligible to begin feminizing/masculinizing hormone therapy, preferably with parental consent. In many countries, 16-year-olds are legal adults for medical decision-making and do not require parental consent”

“Refusing timely medical interventions for adolescents might prolong gender dysphoria”

“withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents”

Gender affirming hormones and height

“The dose increase schedule is conducted more slowly in those who have never completed puberty in their birth sex to allow emotional and social maturation, as well as the completion of the adolescent growth spurt in height”.

Some trans girls are dysphoric about their height and fear further height will make their lives harder. They are nevertheless kept on a low HRT dose, and keep gaining height, without being told that an increase to their HRT dose could stop further height.

Over 90% go to adult services

“over 90% of those attending endocrinology clinics request further support from adult gender identity clinics”.

 

Surgery for adults

It is questionable why there is any discussion of surgery in a paper which is focused on children and adolescents, who are, by definition, ineligible for surgical interventions. A critical reflection leads to a conclusion this is included simply to provide further opportunity for scare mongering.

“Male-to-female feminising genitoplasty is a well-established procedure where the penoscrotal skin is refashioned to produce the vagina and labia with preservation of the glans and neurovascular bundle to form a clitoris capable of orgasm. Concern now exists that the early blockade of puberty may result in insufficient genital skin being available for this procedure”.

This statement fails to mention well established alternative surgical techniques being used for those who received early puberty blockers. Puberty blockers have been used since the mid 1990s, and hundreds of young adults around the world who received blockers have gone on to access successful gender confirmation surgeries with extremely high rates of satisfaction and extremely low rates of regret. Stating the concern without mentioning that trans adults who received early puberty blockers have already had successful surgeries, is unnecessary, un-evidenced scaremongering.

“In full male genital reconstruction, a penis can be formed from either abdominal, thigh or forearm skin flaps. A hydraulic implant is inserted in a newly fashioned scrotum to provide controllable erectile function. This approach requires several surgical procedures and leaves extensive scarring”.

The focus on scarring without any mention on levels of satisfaction with surgery, is unhelpful.

There is a brief mention that “the few longitudinal follow-up studies that have been published in the Netherlands have generally shown a high satisfaction outcome, particularly from those who have gone through surgical affirmation of their identified gender. It is useful here to also note a recent Dutch paper from Wiepjes et al (2018)

“6,793 people visited our gender identity clinic from 1972 through 2015 .. Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret” [note the Dutch, like GIDS, offensively use transwoman as a noun]:

Long-term outcomes

“In the UK, as yet there is little evidence of the longitudinal outcome from the GIDS”.

So do some proper research! Focus on topics that will inform clinical decisions. Design research in collaboration with service users and their families. Design research in collaboration with those already undertaking well-funded, large cohort, longitudinal studies in the USA and Canada.

Conclusion

“The UK, along with other developed countries, is seeing an increase in the number of young people who are questioning their gender and taking the decision to pursue social and medical transition in line with their identified gender which may be non-binary. While professionals need to treat young people with respect and to acknowledge the intensity of their gender identification, much is still to be ascertained about the impact of medical intervention. The best practice in this field currently involves close collaborative working in multidisciplinary teams”.

So the key conclusions they want their readers to take away are …. er…No. nope. Nothing clear or useful here.

We need to acknowledge that the vast majority of professionals, raised in a cisnormative and transphobic society, start with negative and sceptical views of trans children. How does this conclusion in any way helping educate and advocate for trans children?

References – hold on, this is interesting

The references are perhaps the worst part.

Some references are core texts that have to be referenced (DSM, Endocrine guidelines, WPATH SOC 7 and the NHS’s service specification)

Several are references from figures with a controversial history of transphobia (eg Blanchard and Zucker).

Most references are from their colleagues in the Netherlands.

There is an interesting article (not referenced by GIDS of course) called ‘Cisgenderism in psychology: pathologising and misgendering children from 1999 to 2008′. It talks of an ‘invisible college’ of gender specialists who often collaborate on joint publications, comprising those who worked most closely with Kenneth Zucker, and who until recently held enormous power over trans children worldwide. This collection of clinicians work was reviewed, and it was found that they held significantly more cisgenderist and pathologizing approaches to trans children than other professionals in this field.

I thought it would be interesting to check how many of the references that GIDS have selected include those clinicians know for cisgenderist and pathologising approaches to trans children.

I excluded the references that are core texts (DSM, Endocrine guidelines, WPATH SOC 7 and the NHS’s service specification)– and excluded those publications that are not about trans or gender diverse children).

No of references where one of the authors is from the  ‘invisible college’ ie Zucker or those who have published with Zucker – those who have cisgenderist and pathologizing tendencies 10
No of other references where one of the authors has worked at GIDS (including self-citations 2
No of references from other people in the Netherlands 4
No of references from other sources 2. (Both on fertility)

What references are not included

More interesting than what references are included is what references are excluded:

  • Almost all publications from experts in the US are excluded from this GIDS article.
  • Almost all publications from experts in Canada, Australia, are excluded.
  • Almost all publications from clinicians who support affirmative approaches are excluded

GIDS erase through omission any peer reviewed evidence that they instinctively disagree with.

This is not how science and evidence works. The authors completely omit an entire body of evidence from the USA which supports a gender affirmative approach helps trans children. Further, they omit any of the growing consensus of publications which criticise the UK’s delayed transition approach as harmful.

Peer review

The article was “Commissioned; internally peer reviewed”.

It is not clear who internally peer reviewed this paper. It is shocking that this has been accepted for publication. More shocking still is that this poor article is the ‘best practice’ that our children can expect from the heads of the UK children’s gender service.

This week a far better article was published in the Lancet. The Lancet article criticises as harmful many of the practices that are still core to the systematically transphobic UK children’s service. UK clinicians are well advised to learn from this new Lancet publication.

Instead of reading and learning from credible material published by those who are trying to help trans children to thrive, GIDS are choosing to look inward, reading and citing work by discredited members of their ‘invisible college’.

Caught in a defensive practice model, left behind by their international peers who support a gender affirmative model of care, GIDS are in an increasingly desperate state.

It is perhaps not surprising therefore that some GIDS clinicians are emboldened to publicly align themselves to the cause of anti transgender lobbyists who believe that transgender children both do not, and should not exist.  A ‘pay to publish’ book with the central premise of denying the very existence of trans children, recently received a glowing endorsement from a serving GIDS clinician.  The GIDS library later publicly announced the purchase of the same book via its official twitter account.

This book received a scathing review by the Times Educational Supplement who utterly discredited the “masquerade of a scholarly text”. Review quoted at some length below.

The messages of the book are bold. The first is that “transgender children do not exist”. Having dismissed the perspectives of youth, parents, charities, medicine, social policy and the law as “unproven” and “intellectually incoherent”, it suggests that trans youth are a discursive invention. “Transgenderism”, it contends, reinforces traditional gender binaries, propping up the patriarchy. This framework remains undeveloped and the chapters are inconsistent, offering a hotchpotch of pet clichés that sidestep the evidence-base. Trans youth are variously explained by tribal belonging; restrictive femininity; the distressing human condition; childhood trauma; male transvestites’ sexual desires; and really being gay.

Perhaps hopes were pinned on the highest-profile contributor, whose activism is currently aimed at blocking schools from accepting that children may be transgender. But of 57 sources cited in Stephanie Davies-Arai’s chapter, only seven are peer-reviewed research and these are cherry-picked and distort the wider medical and sociological evidence. Meanwhile, editor Michele Moore’s account of transgender theory leans on dated and inaccurate stereotypes of trans identities that make tiresome reappearances throughout. Nowhere is it acknowledged that many trans people experience binary gender norms as tyrannical, or that many (if not all) trans identities actively queer these binaries.

The second message is that children are “transgendered” by adults and that this is “abusive”. The book constructs an artifice of a society teeming with over-eager parents, whereas research consistently shows that trans youth are often rejected by their families and peers. While claiming that they are motivated by children’s well-being, the authors frequently misuse or ignore recent international studies that unequivocally show both high rates of depression, self-harm and suicide among trans adolescents and the safeguarding effects of gender-affirming support. Indefensibly, the book is almost silent on widely substantiated hate crime against trans youth.

Masquerading as scholarly text, this is epistemological chicanery, with the contributors adopting an already vocal repositioning as the silenced minority. In labelling “transgenderism” abusive, they don’t listen to the supposedly abused; in claiming to challenge “the seemingly unstoppable celebration of transgender ideology”, they present arguments neatly aligned with much recent media coverage. The irony is complete, the consequences no less serious.

In GIDS’ journal paper, Butler, De Graaf, Wren and Carmichael are guilty of many of the same techniques of misinformation, distortion, and cherry-picking literature.

This detailed analysis of the GIDS paper has revealed intentional or incompetent manipulation of data, entirely false claims, misquotations, use of pathologising language, and significant omissions of swathes of recent literature.

GIDS is a failing service stuck in defensive practice.

Our children deserve so much better.

Why does a biological underpinning to gender identity matter?

science

Biological essentialism vs social constructivism

Biological essentialism (or biological determinism), is the idea that behaviours, interests or abilities are biologically pre-determined, rather than shaped by society. In an essentialist interpretation, innate differences between men and women result in  ‘natural’ gender divisions  – with men inherently (innately) better at decision making and women better at nurturing.

Feminists, Freudians, and queer theorists have all challenged biological essentialism. Second wave feminists argued that gender-based inequalities and differences were not natural, and were instead socially constructed. Girls are not inherently worse than boys at physics (due to having pink and fluffy brains) but rather, are often denied the opportunities offered to boys. Social constructivists demonstrated the many ways in which observed gender differences between men and women are socially engineered. Some went a step further, arguing that gender is purely a learned behaviour or a performance.

Brains are complex, and social constructivists, like the popular science writer Cordelia Fine, have rightly debunked the simplified and shoddy science that underpins essentialist claims that men are from Mars with their manly brains, and women are from Venus, with feminine brains.

Gender identity and the neurology of ‘trans brains’

Where then does gender identity fit in?

Some scientists have conducted neurological imaging studies on trans people, exploring whether there are specific, sexually dimorphic areas of the brain in which trans people differ from their assigned sex (the sex they were presumed to have at birth).

Published research findings, often with low sample sizes, have been interpreted as indicating that trans women have a brain more similar to a cis (not trans) woman’s brain than to a cis man’s brain. Such findings have been publicised in newspaper headlines as proof of the existence of trans people.

Such scientific studies, and their shallow interpretation and presentation in the media, have received strong criticism from a wide number of transgender commentators. There are a range of extremely valid reasons for criticism:

  • The suggestion that one specific variable can define ‘transness’ is reductive and overlooks the ways in which society, culture and experience impact on every individual including on the structure of the brain.
  • The reliance on any study as legitimacy for human rights is extremely dangerous – if the study results are later rejected, what happens to these rights?
  • The idea that any brain can be easily classified as male or female is simplistic and overly binary.
  • The suggestion (made by inaccurate media representation of the studies) that one specific variable can be used as a diagnostic test for transness also fills people with fear that any such test could be used by gatekeepers to judge who is accepted as trans and who can be denied support and denied rights. Any such diagnostic test would be entirely at odds with autonomy, with respecting people’s lived experience, with self-identification and dignity.

These reasons for fearing how science will be politically used, or for criticising simplified interpretations of scientific data, make total sense and have historical antecedents – I understand the fear and upset.

Rejection of biology

However, such comments very often seem to take one step further, rejecting not only biological essentialism and the unhelpful simplified, ‘soundbite’ biology loved by the media, but also moving into a sweeping rejection of any mention of a link between biology and gender identity. A culture in which the very mention of biology is discouraged.

This is where as a cisgender (not trans) parent of a transgender child I feel uneasy. I’ll attempt here to explore this from my cis parent’s perspective.

Pathologisation of diversity

For many decades, psychologists and psychiatrists have been aware of trans children expressing distinct gender identities at an early age – 2 or 3 years old.

Across the twentieth century mainstream medical convention, with some exceptions, rejected out of hand any possibility of a biological underpinning to gender identity. The consensus then was that a trans gender identity was a delusion, a mental illness that could, and should, be ‘cured’.

For young trans children, misogynist male psychologists and psychiatrists, frequently working in the field of sexology, focused their attention on the mother.

Therapy and treatment for young trans children focused on presumed maternal abuse or maternal failings.

Does it even matter why trans adults are trans?

When I hear people say ‘does it even matter why people are trans’ – when I hear people dismiss as offensive and unnecessary any consideration of any biological influence on gender identity, I have an emotional response. I also see this reaction in some other parents of trans children (though certainly not in all).

The denial of any possibility of a ‘biological underpinning to gender identity’ is historically tied up with the denial of the existence of younger trans children. The erasure of the existence of younger trans children has caused untold suffering.

As a parent of a trans child who is loving life, it makes me think of the trans children from decades past (and present in too many places in the world) who were traumatised and institutionally abused by medical systems designed to prevent or convert their gender identity. Neither the genitals = sex = gender approach of simplified biology, nor the feminist ‘gender is a social construct’ mantra, left any space for younger children to be trans. Trans children did not fit with either theory so therefore could not exist.

Impact of denial on families

Denial of the possibility of some young children being trans makes me think of the consequences of this denial. It makes me think of the mums who were coerced into distancing themselves from their trans daughters, based on some unsubstantiated theory that an overly close mother-‘son’ bond might lead to a child ‘misidentifying’ as female. How unbelievably cruel to do that to a family.

Shon Faye, whose work I greatly admire, recently wrote that she disagrees with anyone who suggests gender identity is innate and that it should not matter why people are trans. CN Lester, another writer whose work, and excellent book, I’ve learnt a lot from, critiqued the reporting of the research study under discussion  and recommended reading work by Cordelia Fine, author of ‘Delusions of Gender’.

This particular recommendation makes me want to cry.

Delusions of gender as a book has real merits in its debunking of simplified biology,  in its understanding that gender-based inequalities are not natural, and that men are not inherently better at parking. So far so commendable.

However, Cordelia Fine replaces the simplified biology of biological essentialism not with nuanced and complex biology, but a nod to social constructivism. Her work is routinely used by those who argue that gender is merely a ‘performance’ and that trans identities do not exist, except perhaps as a non-conforming person’s misguided response to gender norms.

The view that gender is purely a construct and therefore not ‘real’ is pervasive and extremely dangerous. Adherents of this view may well tolerate trans adults – with a patronising assumption that trans adults made a ‘choice’ to ‘change gender’ as a response to their non-conformity. But whilst adherents of social constructivism may begrudgingly  tolerate the existence of trans adults to some degree, they allow no such tolerance for younger trans children.

The gender as purely a social construct contingent see social influence and gender stereotyping as the only reason for trans identities. They see no valid reason for the existence of young trans children.

Some of the more fringe, actively transphobic, elements of this group, throw their hate and bile at parents of trans children, accusing us of child abuse, demanding that the state take our children away, demanding that children be protected from ‘transing’.

The recommendation to read Cordelia Fine hit a particular nerve as ‘Delusions of Gender’ had a direct impact on my family. We had a family friend who was unable ‘ideologically’ to accept the possibility of the existence of a trans child. They rejected our child and through that rejection, our family entirely. In a parting gesture, they pleaded for us to read ‘Delusions of Gender’. This very book had been the germ of our now former friend’s belief that any trans identity is a delusion, and that pandering to childhood delusion is parental abuse.

Through my shock and upset, I was struck at the time by the unbelievable arrogance. The recommendation that instead of loving my daughter, I should ‘read up on Fine’ and learn that gender isn’t real. This was not to be the first such recommendation.

Fine’s work is populist and best selling, and over the years I’ve had countless similar comments from ‘well meaning’ individuals. It is not that I am ignorant or closed minded, far from it, I’d hazard I know more of Fine’s exploration of gender than those dabblers. I have read, considered, understood the theoretical position being proffered. The same cannot however be said of the Fine pushers. Their position is based on an assumption (from those who have no first hand experience of trans children) that trans children do not, indeed cannot, exist.

The recommendation to read Cordelia Fine is also, depressingly, front and centre in the advice that the UK Children’s Gender Service’s website provides for parents of trans kids. No space here for a clear and much needed message that ‘some kids are trans – get over it, try to be kind’. Instead they present a false dichotomy between simplified biological essentialism reduced to mention of “a boy’s brain in a girl’s body” and “academic psychologist Dr Cordelia Fine” and “gender as a social construct”, with differences based on experiences rather than biology. Parents wondering whether to accept and love their trans child are instead advised to read about the delusion of gender.

When parents and their children reach the children’s gender service in the UK, if they are allocated one of several apparently deeply transphobic clinicians (clinicians who hold so much power over trans children and families), they may then endure literally years of probing and questioning on parental views on gender, as the clinicians probe for the ‘root cause’ of gender diversity.

The social constructivist view also makes me think of the school teachers and class parents and wider community who argue that a child is too young to make a ‘choice’ to be trans and should wait until adolescence or adulthood. Who don’t see the harm of denying a child a happy childhood.

It makes me think of the people who look at us with suspicion, hostility, scrutiny, when I mention I have a trans child. Of the parents who steer their child away from ours, in case being trans is socially contagious.

It makes me think of the people who are no longer in our family’s life, who are unable to see a trans child as anything other than ‘social conditioning gone wrong’.

It makes me think of the people online and in person who target parents of trans children and accuse them of child abuse for loving their child. It makes me think of the haters who want trans children erased from our schools and communities. Who want trans children to be marginalised, made invisible, kept apart from other children.

The existence of trans children poses a challenge both to the simplified biology of biological essentialism and to social constructivism (the idea that gender is merely a performance).

Who cares whether or not biology has any role?

Many people argue that it should not matter whether being trans is partly influenced by biology or fully shaped by culture, society and upbringing. They argue that acceptance will not come through identifying a ‘cause’ for transness, but through people getting to know trans people.

I imagine and hope that acceptance will gradually emerge for trans adults. I think things are slowly moving forward.

What about trans children though? How do we ensure that gains in acceptance and visibility and legislative rights do not leave out trans children, the most vulnerable, those without a voice.

Too many advocates for the rights of trans adults are silent on the topic of young trans children. Many have no understanding or awareness that trans children exist. Others, consider trans children too controversial, too divisive to stick up for.

Trans children are nearly completely invisible. And whilst there remains a default assumption that gender identity is shaped not at all by biology but purely by culture and upbringing, then there will remain a reluctance to support younger transgender children.

Those who believe that gender is purely a performance, who believe that trans identities are socially constructed, do not believe in the existence of young trans children.

The erasure of trans children allows haters to paint themselves as crusaders saving children from being socially influenced or indoctrinated into being trans.

With no openness to the possibility of a trans child being part of natural diversity, they look for a reason. With young children it is blame the parents. With older children it is social contagion. In the first scenario they advocate removing children from abusive parents. With the second scenario they ask that trans identities never be mentioned, embraced or supported at school. For parents who are afraid and unsure how to react to a trans child, they advise conversion therapy.

Another way

Yet, as soon as people open their minds to the idea that there might be a (complex, messy, unattributable) biological underpinning to trans identities, that trans children exist, and have in fact, always existed, the whole deck of cards upon which the transphobes build their hate comes crashing down.

This opening of minds is possible. This opening of minds and shifting of world view happened to me.

Growing up as a gender non-conforming feminist, tired of sexist societal restrictions and expectations, I was instinctively drawn to a social constructivist view point. I had never met a trans person, but had subconscious, lazy, uneducated assumptions about trans people being enthralled to gender stereotypes. I have former friends who are still tied to this world view.

My world view was shaken when I had the good fortune to have a child who opened my eyes. An assigned male child who was insistent, consistent and persistent that she was a girl from the youngest age.

Learning to reset my assumptions

At first, I really struggled to accept my child as a girl. I told her she was wrong. Mistaken.

I did not believe it was possible for a young child to be trans.

I was certain that this child was too young to understand or reject gender norms or sexism or heteronormativity. I knew they were not making a choice, and certainly weren’t being influenced to be trans (she had never come across any representation of a trans person and I was unconsciously transphobic). She wasn’t even gender non-conforming in her interests. A suggestion I sometimes hear (from people who have barely met a trans person) that she was repressing internalised homophobia in infancy is absurd.

She had a persistent, consistent, insistent knowledge that she was a girl that withstood all forms of persuasion.

Like hundreds of parents all around the world who have experienced the same, I had to learn to reset my assumptions about gender identity. I learnt to love and accept my child for who she is. I have never looked back. She is happy and thriving.

I see how people who emphasise ‘gender as a social construct’ utilise that simplistic maxim to make my daughter’s life impossible. How they use it to argue against her rights. How they use it to accuse parents of abuse.

I see how people who claim genitals = sex = gender similarly use simplified biological essentialism to argue that my child is defined and invalidated by parts of her anatomy.

Neither the simplified biology of essentialism, nor simplistic social constructivism, leaves space for my daughter to exist.

Is there an alternative paradigm?

Holistic views of gender

I recently had a short email exchange with Julia Serano and she kindly shared a chapter she wrote on this topic back in 2013 (Excluded: Making Feminist and Queer Movements More Inclusive – chapter 13: Homogenizing Versus Holistic Views of Gender and Sexuality). What follows is what I took away from her chapter, adapted into my own words – I recommend reading her chapter first hand.

In this chapter, Julia critiques the failings of both simplified biology, (gender determinism) and social constructivism, which she terms gender artifactualism.

She outlines how biological essentialists and biological determinists, (often genital obsessed religious conservatist non-scientists), misrepresent and misunderstand biology and science. They present a simplistic last century school child’s version of human biology, assuming that a simple gene or hormone or chromosome works unilaterally triggering a domino rally of binary outcomes.

She also outlines the failings in social constructivism. For decades children’s gender services were dominated by social constructivists who believed that children could not really be trans and that such children could be engineered into accepting their assigned gender. Yet these efforts failed. Medical consensus is now absolutely clear that conversion therapy is unethical and ineffective – conversion therapy did not change a person’s gender identity, merely produced shame, self-hate and depression. Julia notes that gender identities are often ‘profound, deeply felt and resistant to change’. She notes that some people have a fluid gender identity, and that some people do experience a shift in their identity over time, but that such shifts do not result from external pressure and are ‘almost always inexplicable, unexpected’.

She advocates rejection of both simplified biology (biological determinism) and social constructivism (gender artifactualism). In its place she presents a holistic model of gender.

This holistic model of gender acknowledges that biology is complicated. Human biology is not the simplistic yes/no on/off approach that non-scientists and biological essentialists like to pretend. Real biology is complex, multi-faceted, interactive. Just because some people misuse (simplified) biology, does not mean biology itself is essentialist, deterministic, reductionist or sexist.

Julia notes that ‘the human genome has 20,000-25,000 genes. Any given gene or hormone is affected by countless different interacting factors. Because genes and other biological factors act within intricate networks, any given factor will push a system in a particular direction, but will not single-handedly determine a particular outcome’.

Julia argues that ‘while our brains are shaped by learning and socialisation, they are not infinitely plastic ie they are not blank slates. Some traits have a strong intrinsic component’. She notes that though ‘socialisation has a significant impact on brains and behaviours’ it ‘cannot fully override certain intrinsic inclinations’.

She makes a comparison with left-handedness, which is observed in utero before any socialisation. Even with societal pressure to conform to right-handedness some individuals maintain a preference for using their left-hand.

A holistic model of gender allows space for a biological underpinning to gender identity. A holistic model of gender considers the complex interactions between biology, society, experience.

Biological underpinning to gender identity

A wide number of scientific studies have concluded that there is a durable biological underpinning to gender identity.

This supports what other parents with experience like mine have been saying for decades from their lived experience. This backs up what some trans adults remember from their earliest childhood memories.

There is increasing evidence of trans children who have clear gender identities at a very young age. This evidence of young trans children is present in diverse countries and cultures across the world.

The growing scientific consensus of a biological underpinning to gender identity led to the global endocrine society publishing a position statement last year:

“The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.”

(for the full position statement and more on the studies see here)

I welcome this consensus. I view it with hope that it will help open eyes and minds and hearts to the existence of trans children like my daughter.

I would happily share this scientific consensus on a biological underpinning to gender identity with a wider audience – I see in it hope of greater acceptance and support for trans children.

However I note that since the publication of this evidence based position statement from the medical establishment, I cannot recall having seen this printed in the media or even referenced in the few articles commissioned by trans authors. Indeed quite the opposite – more often there is a strong resistance to any mention of biology.

Do we have to reject biology?

I understand the scepticism around how biology can be misused, but surely that does not mean this should be rejected outright?

Whilst supporters of trans rights shy away from biology and science, it allows transphobic groups to present themselves as champions of science and rationality. Claims that couldn’t be farther from the truth.

Transphobes focus on gender as performance, as fake, as a delusion. Whilst a huge part of what we call gender is socially constructed, my child’s gender identity is not a choice, is not a delusion, is not a product of societal or parental persuasion.

Transphobic groups like to focus on what they simplistically call biological sex. They describe biological sex as a simple binary reality, with gender identity operating on some parallel dimension outside of biology. My daughter is 100% biological. She does not have a magic gender identity spirit disconnected to her biological body. Her biology is no less real or valid than the biology of cis girls. It is not essentialist to claim that her identity is an integral aspect of her biological reality. The true essentialists are those trying to present a simplified and fraudulent version of biological science, utilising distorted, cherry picked and biased pseudo-science to support a transphobic position.

Acknowledging biology without essentialism

The argument that we should avoid science in case it is essentialist or in case it is used against trans rights is a false logic.

  • It is possible to acknowledge the biological underpinnings of gender identity whilst acknowledging that a person’s felt and expressed gender identity is a complex interplay of biology, culture, socialisation and experience.
  • It is possible to acknowledge the biological underpinnings of gender identity whilst simultaneously recognising that identity is neither fixed, nor binary.
  • It is possible to acknowledge the biological underpinnings of gender identity whilst arguing very strongly against diagnostic testing for ‘transness’ or biological gate-keeping and identity policing.
  • It is possible to acknowledge the biological underpinnings of gender identity whilst maintaining that the only way to know someone’s gender identity is to ask them, and that a right to self-identification is a basic part of dignity

My daughter is real and valid and deserving of rights, equality, respect and dignity regardless of our current understanding of science.

But science already has plenty of evidence that trans children exist and that there is a biological underpinning to gender identity and I see no reason not to talk about this. Having a trans child (or being a trans child) does not mean rejecting science.

We should embrace science

My daughter is growing up with a love of science. A thirst for knowledge. I’ll teach her all the science I know, on microbiology, on chemical reactions, on photosynthesis, on plate tectonics. On neurology, on genes, on hormones and gender identity. On sample sizes, on causality, on peer review, on rigour, on interpretation and data manipulation.

Biology is rich and complex and we have so much still to learn. If she carries on with a love of science she will learn things far beyond my knowledge. Science (high quality science) is full of wonder and excitement and discovery.

We should not be afraid of saying loud and proud that we support science. We should be clear that those attempting to attack or dismiss transgender children and adults not only lack empathy and kindness, they also lack sophisticated understanding of science, of biology, of complexity.

Trans children exist.

They know it.

Parents know it.

Science knows (a bit about) it.

Stand up for trans children

 

 

I am (and always will be) learning. Friendly feedback is welcomed.

 

 

Girl Guides: How to radicalise hate against trans children in 10 easy steps

supporting trans members

Tomorrow, following a short but successful propaganda campaign, a UK Newspaper will publish an open letter asking Girl Guiding UK to suspend their policy of inclusion for All Girls, including those who are transgender.  Guides has always, quietly, been inclusive of trans children. While there was a small amount of sensationalist and transphobic media reporting in 2015 when the current policy was formally adopted, until six weeks ago, there has been no organised attack on the organisation which my daughter is a part of. Why now? What has changed to make Girl Guides, Brownies and Rainbows a target of action from transphobic groups? This is not a random act, but follows concerted attempts by trans exclusionary groups to influence thinking within the UK Labour party on whether trans women should be included on All Women Shortlists.

It is part of the wider context of a small but vocal and increasingly organised loose coalition of groups made up of Evangelical lobbyists such as Christian Concern, radical feminist academics, misogynistic Men’s Rights Activists, reactionary conservative voices, and a growing grass roots anti transgender rights movement which has formed around the parenting forum ‘Mumsnet’. There, with few restrictions on content, under a banner of free speech, these groups have found one another, have radicalised and organised without challenge or moderation, united behind a single purpose – preventing advances to the rights of transgender people in the UK.

The campaign against inclusion of transgender women on Labour Party All Women Shortlists was the first active campaign to find an audience outside niche anti transgender corners of social media. This anti-trans equality campaign included a crowdfunding initiative calling for legal challenge to Labour Party policy, petitions to the Government, multiple linked websites promoting (mis)information, national public speaking tours by trans exclusionary activists. It provided easy media pieces for an already transphobic UK media, satisfying the UK Public’s seemingly unquenchable interest in stories written about (but not by) transgender people.

Girl Guiding are the next and latest focus of this anti trans rights coalition. Strategically, Girl Guides are seen as a soft target. Transgender children have little support, are regularly maligned by the mainstream press and importantly have no voice or right of reply.

The campaign built against Girl Guiding has been so rapid, so honed, that without knowledge of the context and the anti-trans equality groups involved, it could be misinterpreted as representing the concerns of the guiding movement. Instead of what it actually represents, the latest target of existing transphobic political lobbying by a small but active group of dedicated anti trans equality activists.

Here I present a 10 step guide to ‘how this campaign against trans girls and Girl Guides has played out’. And in response, rather than engage with their hate, I’ve simply listed 10 more productive activities that our daughter, a trans member of girl guiding, and the target of this campaign, has been engaged in during the same period.

Ten Steps to Raising Hate against Trans Children

Step 1: Take a committed transphobe with multiple anti-transgender websites.

Step 2: Get invited onto The BBC Victoria Derbyshire show (05/03/18) to discuss reform of the 2004 Gender Recognition Act (Spoiler, this act and therefore this discussion has no relevance to trans children –  trans inclusivity is already covered by the 2010 Equality Act).

Step 3. Veer off topic with a hypothetical story about a predatory 14 year old boy pretending to be a girl to assault 11 year old girls at guide camp. Use this to publicly criticise Girl Guides for having a long standing approach welcoming All Girls, including those, who happen to be transgender.

Step 4: Create a thread on Mumsnet (home of transphobic discussion) to stir up hate and radicalise a wider population against a vulnerable minority (trans girls).

Step 5: Set into action existing anti-trans children websites and social media platforms, spreading fear and hate.

Step 6: Launch new anti-trans-children Facebook groups specifically to campaign against trans girls being accepted in Girl Guiding.

Step 7: Reinforce inflammatory talking points to enable radicalisation of people against trans children: focus specific attention on ‘child on child sex abuse’

Step 8: Send Mumsnet thread to friendly transphobic Times journalist for yet another attack piece in a long running campaign against transgender children. Have anti-trans-children story picked up by multiple other national newspapers.

Step 9: Inundate Girl Guides HQ with letters and emails, in an attempt to pressure Guiding to change their trans inclusive approach, adding veiled threats of legal action.

Step 10: Get your friendly anti-trans newspaper to publish a letter demanding that Girl Guides review their Transgender Policy (This Sunday, according to Mumsnet, the oracle on all things transphobic).

How to respond?

How can a mum like me fight back against such organised hate? How can I keep my daughter safe?

I write an anonymous blog. I have no power, no influence. I can count upon a tiny handful of allies willing to stand up for trans girls like my daughter.

There is no ‘powerful transgender lobby’ to defend us. I wish there was. There are no trans newspaper editors, no trans judges, no trans MPs.

It is hard to deal with so much hate. It is hard not to feel afraid. To feel like my country is not a safe place for my child. But life carries on.

Girl Guiding has been strong in their refusal to bend before a building anti transgender media, and have reinforced their commitment to All Girls in public statements. I am confident they will not waver in their commitment despite the latest media onslaught.

While incessant transphobes devote days upon days to making my (transgender) daughter unsafe and unwelcome, she’s been getting on with her life. Whilst they spread lies, misinformation, and hate, let’s see what my trans daughter has been up to:

10 better ways to spend your time

1: Learning British Sign Language to be able to better communicate with a deaf friend: https://www.youtube.com/watch?v=VRYQayi9czM

2: Going to school, learning stuff, (same as every other child)

3: Enjoying a Guides celebration of Mardi Gras (dancing, eating, painting)

4: Practicing tent building skills (indoors as it was snowing!)

5: Going to the cinema, eating popcorn

6: Attending a talk by local police officer on women in policing

7: Building a fire in the garden – attempting to make smores – giant mess

8: Reading Harry Potter (again!)

9: Eating too many Easter eggs (trading white chocolate eggs with younger sibling)

10: Laughing, smiling, talking, sleeping, loving, dancing, dreaming, living.

 

It is easy to paint trans girls as a scary menace.

My child is not a risk. She is not a threat. She is not scary.

She loves camping with her friends, staying up late, eating marshmallows (& smores) and telling ghost stories.

Anyone who knows a trans child like my daughter, can see how ridiculous anti-trans girl fear-mongering is. She is just like any other girl.

Those inciting anti trans fear, prejudice and hate know that the public don’t know any trans people, much less trans girl guides, brownies, rainbows. They rely on this ignorance.

Inciting hate against trans girls is not balanced ‘debate’. This is hate against a defenceless and vulnerable group of children.

No wonder trans children are at breaking point and the UK has become a dangerous place to be transgender.

No wonder, according to Stonewall’s School Report, 84% of trans children in school have self-harmed.

Anyone reading this who is a parent or carer – how would you feel if a child you love was the target of a cruel hate campaign? If they were being targeted just for being different.

My child is not a risk. She is not a threat.

She loves painting, hiking in the country, climbing trees, camping with her friends. She loves dancing like no-one’s watching.

My daughter is wonderful, kind, sweet (brave, clever, strong, and funny) and she loves Guiding.

Girl Guiding’s motto is ‘For All Girls’. Girl Guides is inclusive of deaf girls, girls with disabilities, girls from different ethnic or religious groups, and yes, trans girls too. Diversity. Inclusion. Kindness.

That includes my daughter.

Update 15/04/2018:

This morning the letter was published in The Sunday Times. Of the 100,000 volunteers in Guiding a paltry 220 people signed the letter who claimed to have some involvement in Guiding of whom a meagre 12 are current leaders. This demonstrates just how fringe these anti trans rights views are within Guiding, the wider British public and the UK Media led by the Times.

This last month and the last year or so has been a truly frightening time to be parents of a child who happens to be trans living in the UK. A week ago we were near to coming to the difficult decision to withdraw our child from Guiding as we were concerned her presence might not continue to be welcome. This would have been giving in to the bullies something we have raised our daughter, supported by Guiding to stand against.

We want to thank all those who have sent messages of support by email, Facebook, twitter from all corners of the world. Girl Guiding truly is a global movement and we’ve been overwhelmed by the positivity and solidarity in the face of these bullies.  Thank you to Girl Guiding UK, Chief Guide Amanda Medler, and the UK media communications team. Thank you to the incredible leaders, both locally and throughout the UK who have helped us stand strong, either because they have a trans child, sibling or family member, have a trans child in their section, or who simply because they wanted to help spread the message that Guiding is for all girls.

Thank you,

thank you,

thank you.

 

#ForAllGirls

Watchfully waiting; UK continues to harm transgender children

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Today the UK Royal College of Psychiatrist’s launched a brand new position statement “supporting transgender and gender-diverse people”.

Their statement endorses ‘watchful waiting’ for trans children.

“The College believes that a watch and wait policy, which does not place any pressure on children to live or behave in accordance with their sex assigned at birth or to move rapidly to gender transition, may be an appropriate course of action when young people first present.”

It does not acknowledge that a watchful waiting approach, as commonly understood, entails a blanket one-size fits-all approach that recommends delayed transition for all trans children.

‘Watchful waiting’ does not make it clear what we are meant to be watching and what we are meant to be waiting for. In the experience of parents of trans children, watchful waiting means watching your child get sadder and waiting for them to become completely without hope.

When a child continually asserts their identity there is no ‘neutral’ reaction that does not equate to rejection and shame. What answer do the ‘watchful waiting’ proponents suggest a parent give when their child asks to be acknowledged for who they are? They don’t advocate we tell them they are wrong (aka conversion therapy) but what do they suggest? Should we just pretend we haven’t heard them? For how long? Shall we just change the subject? Every day? For how many years?

For insistent, persistent, consistent trans children who are very distressed at being rejected by their families, being mis-gendered and being forced to act out a lie, watchful waiting causes harm. It causes children to feel shame. It causes them to feel that they are wrong. Unacceptable. Un-loveable. It advises parents that they should not tell the child that they are not trans, but equally must delay accepting them as the gender they are asserting

Not accepting a child’s identity is the same as rejecting their identity. To that child. They notice their parent avoiding pronouns. They notice their parent refusing to call them a girl (for example). They notice their parent not sticking up for them at school. This rejection causes transgender children to put on hold their hopes of a happy and carefree childhood. Their one and only childhood. A childhood they will never get back.

I’ve seen my child move from a miserable child when she was being continually rejected and mis-gendered, to our now happy girl getting on with her life, loving school. I know so many other children who have flourished once given a chance to be accepted and acknowledged.

There is no medical intervention for young children so watchful waiting is nothing less than denying social transition. Denial of pronoun change. Denial of acceptance.

And for what? You’d better have some damn strong evidence to deny my child her happiness. Her childhood. Her education.

We know the benefits of social transition.

We know how children not supported by their families struggle.

We know few children revert to a cis identity – and even if they do, there is no harm in a second social transition so long as the child is listened to and respected. “Let the child lead the way”.

The Royal College of Psychiatrists position paper ignores available evidence supporting affirmative approaches, showing that affirmed trans children flourish, as so many parents have seen.

It does not provide a single piece of evidence that watchful waiting is better than affirmative care. What arrogance on behalf of the Royal College of Psychiatrists to condemn yet another generation of trans children to spend their one and only childhood in denied transition, leaving us parents to watchfully wait as their self-confidence crashes, as they stoop their shoulders in shame, as they drop out of education, as they self-harm and learn to hate themselves for being so ‘wrong’.

There’s increasing evidence of the appropriateness of an affirmative approach:

“being trans or gender diverse is now largely viewed as being part of the natural spectrum of human diversity” (RCH, 2017)

“there is a durable biological underpinning to gender identity” (Endocrine Society, 2017)

“Transgender children do indeed exist and their identity is a deeply held one.” “Early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.” (Olson, 2015 and Fast, 2017)

“Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex. (Olson, 2015)

“Social transitions are increasingly common for transgender children. This study examined self-reported depression, anxiety, and self-worth in socially transitioned transgender children compared with 2 control groups. (Socially transitioned) transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers and they reported marginally higher anxiety. Compared with national averages, (socially transitioned) transgender children showed typical rates of depression and marginally higher rates of anxiety. These findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. (Durwood, 2017)

“The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”. (RCH, 2017)

Where is the up to date evidence in favour of a watchful waiting approach?

Here is the American Academy of Pediatric’s position on watchful waiting, published in 2016:

Delayed Transition: Prolonging Dysphoria

Certain clinicians, along with non-expert critics of transgender advocacy, have taken a position that they describe as “watchful waiting.” They contend that most children with gender dysphoria do not become transgender adults and, therefore, early social transition may be unnecessary, even harmful. They advocate waiting until adolescence, or even adulthood, to permit any type of gender transition. Because watchful waiting is a general phrase that could also apply to affirming a child’s gender identity as they grow, we use the phrase “delayed transition” to more specifically describe this approach.

It is true that most gender-expansive children, and even some children with gender dysphoria, do not become transgender adults. Indeed, some children become more comfortable with their assigned gender as they reach adolescence. Unfortunately, delayed-transition advocates often support their claims with misleading interpretations of research. More important, competent clinicians generally can tell transgender kids apart from other gender-expansive children. Many delayed-transition advocates say this is impossible until a child reaches puberty, but their own studies contradict them, identifying early characteristics that predict whether gender dysphoria will continue. Persisters in these studies had more cross-gender behaviour and more intense gender dysphoria during childhood, as measured on various psychological tests. Interviewed later, they also described their childhood experiences with gender differently. For instance, persisters recalled insisting that they were the “other” gender, while desisters had said they wished they were that gender. Many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition.

As in most areas of medicine and life, there is no perfect test to predict what is best for each child. But delayed-transition advocates treat unnecessary or mistaken gender transition as the worst-case scenario, rather than balancing this risk with the consequences of the delay. There is no evidence that another transition later on, either back to the original gender or to another gender altogether, would be harmful for a socially transitioned child — especially if the child had support in continuing to explore their gender identity. More important, untreated gender dysphoria can drive depression, anxiety, social problems, school failure, self-harm and even suicide. Delayed-transition proponents have few answers for children and families in the throes of these symptoms. What’s more, we know little about the long-term consequences of prolonging gender dysphoria.

Those who advocate delayed transition say it allows a child to explore gender possibilities without pressure in a particular direction. While this may be their intent, the delayed transition approach actually makes it impossible. Children may be permitted to express certain gender-expansive behaviours, such as play preferences or dress, but they are prohibited from other forms of self-expression, like adopting a gender appropriate name and pronouns, that they may ardently wish to take. These constraints communicate to the child that being transgender is discouraged. Tragically, youth whose families fail to affirm their sexual orientation, gender identity or gender expression are at significantly increased risk of depression, substance abuse and suicide attempts.

While delaying a child’s gender exploration can cause serious harm, a deliberate approach is wise. Some children need more time to figure out their gender identity, and some do best by trying out changes more slowly. For these children, rushing into transition could be as harmful as putting it off. The problem with “delayed transition” is that it limits transition based on a child’s age rather than considering important signs of readiness, particularly the child’s wishes and experiences. A gender-affirmative approach uses this broader range of factors, with particular attention to avoiding stigma and shame.

“Waiting to transition…was not an option if we cared anything about [our son’s] health. The despair he went through…was not manageable. But when he did transition, it was like a light switch. We had a happy, healthy kid. And it has been that way ever since — four years and counting.” Peter Tchoryk Father of a seven-year-old transgender boy

Here is the ANZPATH (Australian Professional Association for Transgender Health) position as reflected in their 2017 guidance:

“increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved”.

Avoid causing harm”. “withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications”

“Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach”.

“for children, family support is associated with more optimal mental health outcomes”

“trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”.

“social transition should be led by the child and does not have to take an all or nothing approach”

“social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers”.

“The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

Key roles for a clinician of younger child:

Supportive exploration of gender identity over time

Work with family to ensure a supportive home environment

Advocacy to ensure gender affirming support at school

Education (to child and family) on gender identity and signposting to support organisations for child and for parents

If child is expressing desire to live in a role consistent with their gender identity, provision of psycho-social support and practical assistance to the child and family to facilitate social transition

Here’s the Australian Psychological Society’s Information sheet, produced in 2017:

“Support from families, as well as broader social support, is crucial to transgender and gender diverse children’s mental health.

Affirm your child’s expressed gender

It is essential to their child’s wellbeing that parents, caregivers and families support the child and affirm the child’s gender.

  • Support your child in his or her gender expressions in the form of dress and activities.
  • Use the names and pronouns that the child expresses (rather than those they were assigned at birth).

The degree to which parents and caregivers are positive and supportive has an impact not only on the child but also on all those around them, such as extended family, community, and schools, as they often seek their cues from how the child’s family is responding.

There is no right age for your child to let you know they are transgender or gender diverse. Some children know as young as three years old and others may only realise when they are teenagers. Often a child has known for a long time before they find the courage to talk to someone. There is also no right or wrong way to be transgender or gender diverse. Each child will be different.

Seek support from a mental health professional

Even though being transgender or gender diverse itself is not a mental health issue, getting some support from a mental health professional who affirms your child’s gender is likely to be helpful for children and their families as they navigate daily experiences and longer-term decisions. A mental health professional can help:

  • Affirm your child’s gender and help them to feel accepted and normal for who they are.
  • Help you navigate society’s expectations of gender that can cause anxiety and depression.
  • Assist with social transition as your child decides to show or let people know their preferred gender.
  • Assist with access to gender-affirming medical treatment. Having the option of treatment in the form of hormone blockers (to delay puberty) or gender-affirming hormones can have a significant positive impact on the mental health of TGD children in particular.

The Australian Psychological Society recommends mental health practices that affirm transgender people’s experiences.

The Royal College of Psychiatrists include absolutely no reference to the most recent publication on this topic, capturing the most up to date evidence (published in 2018):

Diane Ehrensaft, Shawn V Giammattei, Kelly Storck, Amy C Tishelman & Colton Keo-Meier (2018): Prepubertal social gender transitions: What we know; what we can Learn – A view from a gender affirmative lens, International Journal of Transgenderism, DOI:10.1080/15532739.2017.1414649

This new paper is a really important read. There is no excuse for clinicians at the Royal College of Psychiatrists not having read it and for not citing it.

The paper’s conclusion is:

“Newer research suggests that socially transitioned prepubertal children are often well adjusted, a finding consistent with clinical practice observations. Analysis of both emerging research and clinical reports reveal evidence of a stable transgender identity surfacing in early childhood.”

The full paper is essential reading for anyone interested in transgender children. it includes a direct critique of the ‘watchful waiting’ approach. But it is a journal article behind an academic paywall, a barrier to parents keeping up to date with the research (this is literally the job of the experts). To help those who are not in academia I will include a long quote – those less interested in the detail can skip to below the quote.

“Those transgender youth who have families that support their transitions and affirm their identities have significantly better physical and mental health outcomes than those who do not (Hill, Menvielle, Sica, & Johnson, 2010; Kuvalanka, Weiner, & Mahan, 2014; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Travers et al., 2012). It should be mentioned here that it is not specifically medical gender-affirming interventions that are the kingpin, but more generally all experiences gender expansive and transgender individuals are afforded—medical, psychological, behavioural, social, or legal—that facilitate a person to live in their authentic gender. As a result, most professionals, regardless of their theoretical orientation, have come to believe these interventions are necessary for the overall well-being of their patients.

The WPATH guidelines (SOC 7 from 2011) included a cautionary note on prepubertal social transition on two counts: (1) the persistence/desistence studies indicated a relatively low rate of persistence of gender dysphoria in children studied; and (2) transitioning back to one’s original gender role can be stressful for a child, based on evidence of one qualitative report of two youths who experienced distress when desiring to do so (Steensma & Cohen-Kettenis, 2011).

The cautionary note specifically invited families of children under the age of puberty to consider in-between solutions or compromises, rather than facilitation of a full social transition from one gender to another, with a message delivered to the child that they are always free to revert to their original gender position.

There is an inherent bias in SOC 7 toward the “watchful waiting” approach to pediatric gender care (Cohen-Kettenis & Pf€afflin, 2003), in which a child is given safe spaces to explore their gender but asked to wait until puberty to transition from one gender to another. This bias is evident in both counts of the cautionary note and the reliance on the studies of persisters and desisters in which most young children in the clinical studies were no longer evidencing gender dysphoria by adolescence. However, some of the persister/desister data have been reanalyzed to indicate that more children than originally cited in the data (Steensma & Cohen-Kettenis, 2011) were found to be persisters (Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013) and reevaluation of the data revealed early childhood indicators that could identify a group of young children who were asserting a gender identity that did not match the sex assigned to them at birth and would remain stable in that identity into adolescence, and beyond. Furthermore, the persister/ desister data which inform the SOC 7 guidelines on social transitions only measured children’s gender dysphoria, not their sense of their gender identity or the nature of their gender expressions, the latter two to be differentiated from each other and also measured separately from gender dysphoria (Ehrensaft, 2017). Lastly, the research results may include inflated percentages of desisters, as counted among their number were those who did not return to the clinic for care; therefore, reporting all patients lost to attrition as “desisters” represents an assumption that has never been validated, and rates of persisters and desisters cannot be verified unless these patients are tracked down. Ehrensaft (2016, 2017) guided by her own clinical observations of children, perceived that the studies were actually talking about two separate categories of children who could readily be identified early in life if the proper measures were employed: some young children would be centrally exploring their gender identities while others would be exploring or articulating their gender expressions. In fact, a reevaluation by the Dutch team of their research on persisters and desisters corroborated Ehrensaft’s perception by identifying early factors that differentiated persisters from desisters, including: the statement, “I ama…” rather than “I wish I were a…”; consistent, persistent, and insistent articulations of an asserted gender identity other than one that matched the sex assigned at birth; evidence of body dysphoria (unhappiness about the genitals they had); and an early history of gender-expansive behaviors, perhaps as young as the toddler age (Steensma et al., 2013). If we are to have SOC regarding social transitions that reflect the realities of transgender children who are clear from an early age of their gender identity and are persistent, insistent, and consistent in the articulation of that identity, they will best be based on both research studies and collated clinical observations that assess the more salient variable: the child’s articulated gender identity, whether or not it is accompanied by dysphoria.

Lastly, the reference in the SOC 7 to the problems of “desocial transitioning” for pubertal or postpubertal youth with an early social transition is based on the slimmest of evidence—a case study of two youths. In the youth referenced by Steensma and Cohen-Kettenis (2011) in their short note in Archives of Sexual Behavior, two girls in the desisting group of their study had transitioned, using their own terminology, to a masculine gender role in elementary school, desired to return to their original feminine gender role, but expressed fear of teasing and shame about having been wrong about their gender, culminating in an extended period of distress. Because of the above mentioned conflation of gender role and gender identity underlying the research protocols and lack of mention of a change in name and pronouns, it was not clear from the reported evidence whether these youths had completed a full social transition or simply presented as more masculine and now wished to evolve to a more feminine self in middle school. (Ehrensaft asserts that it is not clear from the paper whether the two girls had socially transitioned – from reading the underling PhD it is clear that they had not – they had not changed pronoun).

Further, the fear of being teased or shamed for having been wrong may be a response to external lack of supports, rather than evidence of an internally based problem. Such stress is typically dependent on social stressors, in this case a social milieu, evident throughout the world, in which there is no acceptance for a child to be fluid in their gender expressions. With that said, the more reasonable standard of care would not be to hold a child back from a social transition but instead ensure social supports for any child who may discover new aspects of their gender over time, including an alteration or shift in gender identity and expression of that identity, with no aspersion cast on their character. If such supports are not in place or achievable through therapeutic supports, within a comprehensive standard of care, the alternative approach would be to support the child in their self-knowledge of their asserted gender identity and communicate an understanding that the impediments to social transitions are externally located, that is, there are not adults available to support the transition, rather than that there is something wrong with the child for desiring the transition or simply desiring to have others mirror back to them their authentic gender identity.

The watchful waiting approach evolved from the first model of care for transgender children developed in the Netherlands, often called the Dutch Protocol. The Dutch Protocol is informed by the belief that gender dysphoria, or a transgender identity, persists into adolescence in only a small minority of people (Steensma & Cohen-Kettenis, 2011). As outlined earlier, this research suffers from potential methodological flaws and the way the data have been interpreted suggests that providers be more concerned about the rare cisgender child being treated for gender dysphoria at the expense of the many transgender and gender-expansive children who would be helped if social transition were an option. The result of this interpretation has the potential to have profound negative impacts on treatment practices in pediatric transgender healthcare (Winters, 2014). In general, the watchful waiting approach is a cautious practice in which assertions of gender diversity and the consideration of a social transition are either tempered or held as possibly true and beneficial, but not until it is determined that the child is capable of knowing their gender with great validity, usually sometime after the advent of puberty (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003). When a child’s gender identity is unclear, the watchful waiting approach can give the child and their family time to develop a clearer understanding and is not necessarily in contrast to the needs of the child.

For children who are clear about their gender but are prohibited from exploring or experiencing the benefits of affirming their gender through a social transition, the watchful waiting approach can create potentially harmful disruptions by negating a young child’s gender identity and delaying the development of their asserted gender identity, especially in cultures that do not support gender diversity.

Similar to the watchful waiting approach, the gender affirmative approach has a foundation of collaboration with children and families to understand and affirm a child’s gender and works to meet the child’s needs as they develop. In contrast to the watchful waiting approach, however, the gender affirmative model does not involve waiting for puberty or adolescence to facilitate a child’s affirmation of their authentic gender, instead endorsing prepubertal social transitions where appropriate (Ehrensaft, 2012; Hidalgo et al., 2013). Gender affirmative care places substantial significance on a child’s understanding of their own gender and allows the child, and their knowledge of their gender, to lead the way to interventions. Social transitions are viewed, explored, and supported as an important and effective intervention that nurtures a transgender or gender-expansive child’s health and well-being. The gender affirming approach has allowed for a salient “ex-post facto test” (i.e., response to intervention) that enables us to discern the profound and overwhelmingly positive effects a social transition can have for gender-expansive children. With the help of social transitions, some children previously struggling with serious mental health and behavioral issues, carrying multiple diagnoses and treated with various psychotropic medications eventually settle into a significantly more stable life free of such issues, (mis)diagnoses and medications (Nealy, 2017).

The Royal College of Psychiatrists exclude a number of critical pieces of evidence (particularly Olson 2015, Olson 2015, Fast, 2017, Elhrensaft 2018) that support the  benefits of an affirmative approach, the latter of which critiques the harm of a watchful waiting approach. And the Royal College of Psychiatrists do not provide a single scrap of evidence of why watchful waiting is better than affirmative care.

Remembering that watchful waiting entails denial of transition as long as possible until the child and family decide to ignore their experts. How is that expert advice? Wait until you no longer trust our advice and then start supporting your child. Wait until your child is desperate and self-harming? Wait until when exactly?

Those who advocate watchful waiting sometimes describe ‘affirmative care’ inaccurately. Affirmative care does not mean encouraging, much less forcing transgender children to socially transition. It does not mean social transition will be appropriate for every transgender child, and certainly not for every gender expansive or gender non-conforming child. Affirmative care just means listening to each child as an individual, respecting their identity and supporting those who need and wish to socially transition to do so without shaming them into living a lie, without forcing them to sit and wait as their chances of a happy childhood tick by.

The UK medical establishment’s un-evidenced commitment to ‘watchful waiting’ may be marketed as careful and benign, but it causes real harm.

The endorsement of ‘watchful waiting’ causes parents like me who love and accept/support our daughter to be painted as fringe or even reckless (despite this being absolutely mainstream advice from gender experts in other countries). The endorsement of watchful waiting directly makes my life harder, entrenching and emboldening those people who have accused me of child abuse in person, and daily on social media.

I can see how happy acceptance, support and social transition has made my child – so I take frequent accusations of child abuse on the chin. I take on the chin the fact that I have lost close friends over this, who genuinely believed support for social transition was harming my child. I take on the chin the responses of scepticism or hostility I get whenever I mention I have a trans child. I take it on the chin that I stand unsupported – with the enormous toll this has taken on my mental health, stress levels and well-being. I take it on the chin that I stand vulnerable to reporting to social services, and stand thankful that I’m not at the whim of a potentially ignorant judge in a child custody case against an unsupportive partner.

I find it harder to stomach the fact that the UK medical establishment’s endorsement of ‘watchful waiting’ makes life harder for my child. It makes it less likely that she will be fully supported by her teachers. It makes it less likely that she will be fully supported by her GP. It gives credibility to groups who campaign ardently to minimise her rights – groups who would rather transgender children just disappear. Adherence to a ‘cautious’ and ‘watchful’ approach, dissuades would be allies, including transgender adults, from sticking up for my child. It directly translates into the current situation where no one in the UK medical establishment ever advocates for transgender children in the UK media.

In countries like US, Australia, Canada, where experts adopt an affirmative approach,  advocacy for trans children in the media is standard practice and considered a standard part of their remit as people who are meant to help transgender children. See the media engagements of Ehrensaft, Spack, Olson, Lopez, Rosenberg in the US. See Telfer advocating for trans children in court cases in Australia. See experts from children’s gender services publicly endorsing a critique of a fake diagnosis in Canada.  This never happens in the UK, and the UK’s endorsement of ‘watchful waiting’ is a key reason why the UK never stands up for trans children in our hateful media.

I feel heart broken for those trans children living in the UK today who would never be supported by bigoted and transphobic parents – transgender children who are enduring childhoods of cruelty, rejection and loneliness. I hope they see that the future will be brighter, once they are older. I hope they can make it through the wait.

But my main emotion right now is anger for those transgender children who could be living supported and happy childhoods right this minute in the UK. But who are not. Whose parents are desperate to tell them that they are loved and accepted just as they are. Parents who with the right support and advice could accept and support their trans child. But parents who hold so much trust in the wisdom of UK ‘experts’ that they make their child ‘wait’. Parents who are encouraged to passively ‘watch’ as their child goes downhill. Parents who are watching and waiting for permission from UK ‘experts’ to go ahead and love unconditionally their child. Those children are being denied a happy childhood right now. And this is directly down to the cis-normativity, entrenched transphobia and ivory tower arrogance of the UK medical establishment and the UK College of Psychotherapists.

I know no one in the UK will care. Who cares about sad, depressed, lonely, shamed, hopeless transgender children? Does anyone in the UK medical establishment care even a tiny bit? And who outside of the UK medical establishment will hold them to account for their continual failings? It can’t just be me speaking up.

Will anyone stand up for trans children?

And one side question. Now that we know there is a “biological underpinning to gender identity”. Now that we know that it is not a mental health disorder. Now that we know it is just another part of human diversity. Now that we know that transgender children’s identities are as real as cisgender children’s identities. Now that we know that transgender children who are affirmed, accepted, supported have good levels of mental health and wellbeing (similar to cisgender peers). Now that so many families are seeing the happiness that comes to their children when they ignore UK medical ‘advice’. Isn’t it about time to say that there is no place for psychiatrists in having any power over healthy, well-adjusted transgender children? My daughter does not need a psychiatrist. And I am done listening to transphobic ‘experts’ who don’t give a damn about transgender children.

 

GPs and trans children – BBC drama ‘Doctors’ and the UK Gender Identity Development Service

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BBC show Doctors included a trans teenager, and their mum meeting with a new GP. The show certainly had made an effort to provide an accurate and appropriate portrayal of a trans adolescent, so does score some points. It did also include some misleading stereotyping of trans children, and ignorance/misinformation on NHS protocols and timelines. I hope upcoming ITV drama Butterfly will do even better.

The first segment was the worst for misrepresenting the experience of parenting a trans child, and for perpetuating lazy stereotypes.

The child is described by the mum as ‘born a boy’ who ‘liked girly things’. The emphasis in the first segment is on the child’s interests, toy preferences, clothing preferences, not on the child’s gender identity. A later segment makes clear the child had identified as a girl her whole life, but this is not mentioned in the first segment.

The focus on non-conformity is misplaced – many trans girls I know are not especially feminine or especially in to girly toys – trans girls are not the cliché of femininity the media leads you to believe.

The first segment suggests that the child one day stated ‘I want to be a girl’ and the parent switched pronoun. It mentions that two years later the child is on puberty blockers. It makes it sound so straight-forward. This unlikely scenario is a misrepresentation of the current NHS pathway for gender variant or trans children and does not match the experience of many families who I know.

Let’s look at a more realistic scenario.

A child, assigned male at birth, states ‘I am a girl’. Frequently. Consistently. Insistently. Persistently. (sure some children are less insistent, some are more fluid, some less clear – in my experience only the ones who are extremely insistent are likely to be supported to socially transition at a young age – it is a huge step in this gendered and transphobic world).

The parent spends months or often years telling their child that they can be a non-stereotypical boy, as non-stereotypical as they like, so long as not trans. Perhaps they say things they will later regret, like it is not possible to be trans, or that your genitals define who you are.

The parent spends months or years reading and learning, working through their own ignorance, fear and transphobia (I have met very few cis parents who did not have to first work through a lifetime of unconscious transphobia).

During this time while the parent finds the knowledge and understanding (and courage) to listen to their child, the child gets increasingly distressed and withdrawn – being rejected by your family is hard on a child.

The parent finally takes what feels like a monumental step of booking an appointment with their GP. The media may have led them to believe that things happen quickly from that point, so the parent may have delayed visiting their GP until the child is in puberty and increasingly distressed.

In, as a rough estimate, half of cases the GP refuses to refer the child to the children’s gender service, sending the parent on an unnecessary 12+ month delay via children’s mental health services. Or the GP tells the parent to come back in a couple of years. Or to come back at age 16. Or the GP flat out tells the parents that kids can’t be trans and they shouldn’t pander to a delusion. This happens a lot.

Parents with transphobic or ignorant GPs go away without any help, only returning to the GP when their child is extremely distressed, depressed, self harming or suicidal.

If they are lucky enough to get a referral from a GP to the sole Children’s Gender Service (In England and Wales), and the referral is accepted, the parents then wait in limbo for a further 14 months for a first appointment. 14 months. For an increasingly distressed child.

Once they get to the gender service the approach is extraordinarily slow and conservative, frequently breaking international guidelines that recommend puberty blockers at tanner stage two. It is often 1-3 years before approval for blockers (even for children who reach the service when puberty is well underway).

Clinicians have all the power and are quite keen to emphasise that the teenager and their parents have no rights whatsoever on whether the service will ever prescribe puberty blockers. Trans children feel this powerlessness, adding greatly to their stress and anxiety at what is already a very difficult time of progressing puberty.

Puberty blockers, let’s not forget, are a safe, reversible and proven effective treatment that has been in use for cis kids (in precocious puberty) since the 1970s, that in countries with a less transphobic health system are prescribed to trans kids (or gender diverse kids distressed about puberty) promptly at the start of puberty. A treatment that is recommended by the international experts on these issues – WPATH (The World Professional Association on Transgender Health) and the International Endocrine Society. A treatment that has been shown to be effective for trans children since the early 1990s.

If approval for puberty blockers is eventually granted by the (monopoly) children’s gender service there is a referral (and further wait) for the endocrine service, with several further appointments (each requiring further trips to London and further days of missed education (and lost earnings for parents) for yet more 1 hour appointments) before prescription of blockers.

Then the parents and child are left to manage a drawn out discussion between the NHS endocrine service and their GP about who will administer the puberty blockers (a simple injection) and who will take on responsibility for the ongoing prescription.

The NHS endocrine service says the NHS GP should do this. The GP usually refuses, claiming that this simple injection, that has been deemed necessary by NHS specialists, that they already administer to cis children, is ‘specialist’ knowledge that they are allowed to refuse to administer (just because the child is trans). Parents are left to sort out this incompetency between different wings of the NHS.

In our realistic example, the parents are now trying to keep safe a desperate teenager  who has been waiting for years for the medically necessary treatment that they need and have a right to. Reports of self harm are common. These parents sometimes have to teach themselves how to administer an NHS prescribed injection as they can’t find any NHS workers locally willing to do this for trans adolescents. A simple injection that has been prescribed by NHS specialists which the local GP and nurses refuse to administer. Stressed adolescents are injected by a parent who has never before given an injection as their GP surgery has neglected their patient.

This is for a treatment that is already given as standard to 6 year old cis kids in precocious puberty. Because we can’t have a 6 year old cis girl with periods and breasts but that is fine for a 14 year old self-harming trans boy. Because we can’t have a 6 year old cis boy with a beard but that is fine for a 15 year old trans girl.

It is basic anti-trans children discrimination in health care.

The BBC show ‘Doctors’ includes a further brief reference to sex hormones. The mum states that the only way of getting hormones pre-age 16 is to go to the US. The GP shows a face heavy with scepticism and talks about safe-guarding. It would have been appropriate here to mention to Gillick competency, a concept familiar to all doctors. Across all areas of medicine adolescents are able to consent to complex irreversible medical interventions if they are deemed Gillick competent. The same benchmark should be applied to transgender adolescents.

The segment on sex hormones omitted to mention that provision of hormones before the age of 16 is deemed medical best practice in many clinics in the USA and elsewhere in certain circumstances – based on the benefits of peer concordant puberty (going through puberty at the same time as peers), due to recognition that children with a long track record of fixed trans identities are not going to suddenly change gender identities at age 15.

A well-informed GP would have also mentioned the global Endocrine Society’s 2017 guidance stating: “We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years”.

The mum in the BBC drama also makes a reference to “the operations” – a statement which is not clarified. There is so much ignorance about trans children in the UK that the fact that surgery is not considered for trans girls until adulthood does need stating.

One thing the show did portray convincingly is the parent pretty much begging a not-transphobic and slightly clued up GP to care for and advocate for her child. The programme ends with the GP in an ethical dilemma about whether to agree to be this child’s GP, and whether to be willing to state medical facts about accepted best practices for trans children’s care in a family court. Why is this an ethical dilemma? If the family were following any other medical specialist recommended health care, the GP would not consider it an ethical dilemma to defend this in family court.

The real ‘debate’ and ethical dilemma when it comes to GPs and trans children is why is there still such varied and poor practice? Why are desperate families encountering ignorance and transphobia from GPs? Why are GPs allowed to opt out of administering medically needed treatment that has been prescribed by an NHS specialist? Why are GPs treating trans children so much worse than cis children and why does no one care?

And if you want to a good indication of the wider institutional transphobia across the NHS that allows this poor healthcare for trans children to go unchallenged, look no further than the nonsense hokum that is “Rapid Onset Gender Dysphoria”. NHS children’s specialists have referenced ‘Rapid Onset’ in a presentation in a way that did not make it clear to service users and the general public that it is junk science.

In Canada, meanwhile, specialists working with trans children have endorsed a condemnation of Rapid Onset Gender Dysphoria as junk science, bunkum and quackery.

Where is the similar condemnation from the UK Gender Identity Development Service? I won’t hold my breath.

Given the poor state of the UK specialist service, whose protocols are outdated and not fit for purpose (with a 14+ month wait for current first appointments), we need GPs to step up and do more. GPs cannot continue to refuse basic care for trans children and adolescents. GPs cannot continue to claim that simple health care for trans adolescents is ‘too specialist’. It is discrimination clear and plain.

 

Update:

In episode 2 the GP goes to see a psychotherapist who tells him that the majority of socially transitioned 14 year olds change their minds. This is an outright falsehood.

Even the discredited Zucker/Steensma studies showed 14 year olds were extremely likely to maintain a trans identity.

The latest studies (Olson 2015 and Fast 2017) show that trans children have a clear identity at a very young age, that their identity is as valid and consistent as any other child’s.

The latest stats from Australia showed “From 2003 to 2017 96 percent of all patients assessed and diagnosed with Gender Dysphoria continued to identify as transgender or gender diverse into late adolescence”.

The ‘expert’ knows scarcely a thing of the latest evidence-based scientific consensus on care for transgender children.

My Daughter is that ‘Scary Trans Kid’ the BBC warned you about.

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I am crying and sad and afraid – watching yet more hate and fear-mongering thrown at trans children, specifically at girls like my daughter.

The BBC Victoria Derbyshire show (05/03/18) want a discussion on the Gender Recognition Act. An act that at present only applies to adults and only relates to birth certificates. Not, as they are discussing, access to changing rooms or toilets.

An act that bears zero relevance to the Girl Guides having a progressive policy of welcoming trans  girls.

Yet the BBC gives air time to the worst type of bigotry – raising fear about the threat my young daughter poses if she goes on a camping trip with her friends. .

No wonder trans children are struggling in the UK RIGHT NOW

Take any other minority. Take Muslim children, or black children or Jewish children, or neuro diverse children.

Would the BBC give air time to a person saying that Jewish girls are a threat to other girls? Would they say that parents need to be made aware of any Muslim girls going on a camping trip?

Would they allow such hate to go unchallenged?

Why is it fine to throw my child under the bus time and time again?

And to have this dangerous, scary, legally and morally wrong rhetoric of trans children being a threat utterly unchallenged?

With two trans panellists who were clearly out of their comfort zone on the topic of trans girls like my daughter.

One trans panellist even seemed to agree, focusing on the importance of careful ‘trans’ risk assessments before camping trips for children.

My child is not a risk. She is not a threat. She does not need a risk assessment. She is not to be feared.

She would love to go camping with her friends. She is a child.

She’d love to stay up late and eat marshmallows and tell ghost stories and play and laugh

How dare the BBC present trans girls in girl guides as a safety concern?

How am I meant to keep my child safe when even the lovely Victoria Derbyshire gives space to this outrageous hate and fear-mongering?

How dare the panel nod and agree that this scare-mongering against vulnerable children is balanced?

I don’t blame Rebecca Root or Clara Barker both incredible women.

They did a better job than I could of at staying calm in the face of such prejudice.

They were brought on to talk about the Gender Recognition Act not to talk about trans children.

But wake up people! We know that those opposed to trans rights are targeting trans children.

We know they quickly turn discussions to focus on children.

This is their standard approach. One of the panellists was even the public face of a website which explicitly states trans children are a ‘trend’ simultaneously denying their existence.

They do this because focusing on children is an easy win for those opposed to trans equality. They are defenceless.

They know that, like today, trans adults are often hesitant about speaking up for trans kids, possibly as the experience of socially transitioned trans kids today is outside of their direct experience.

They know that the UK public are totally ignorant about wonderful trans children like my daughter.

It is hard to stir up fear about trans women when sat opposite kind intelligent articulate trans women.

But without any young trans children on the show it is easy to spread fear about an unknown.

It’s easy to paint trans girls as a scary shadow.

The people who know trans children like my daughter see how preposterous this fear-mongering is.

She is just like any other girl.

But those raising anti-trans fear know that the public don’t know any trans girl guides.

They rely on this ignorance. They don’t care about the impact of this fear-mongering on my child.

Can you imagine being a 10 year old girl, happy to be moving up from Brownies to Girl Guides, excited to be going camping.

And watching the BBC describe you as a threat to your friends.

No wonder trans children are at breaking point in the UK.

The UK is not a safe place for my child and with every ‘debate’ which allows lies and misinformation to go unchallenged it becomes more dangerous.

How am I meant to tell my wonderful kind sweet (brave, clever, strong, funny) girl that everything is going to be alright when I just don’t have hope?

This country is a scary place to be a trans girl.

I am scared and I have had more than I can bear.

This is not balanced debate.

This is hate.

This is intent to incite fear and prejudice against a defenceless and vulnerable group of children and the BBC has once again provided the platform.

This is not ok.

This is never ok.

World. Be Better.

 

P.S. The photo is not my daughter. But is a wonderful trans girl (Rebekah) who deserves all the care and kindness and happiness the world can send. That girl’s mum (Jamie) blogs here

The Moment I Knew My Child Was Trans

 

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This post is featured in the Huffington Post

It’s 6am on a Saturday morning as I write this. I’ve been awake for hours, worried about the latest impact of a targeted campaign of hate directed at my child and those like her. Thinking about whether I can do anything to stem the tide.

I don’t have long.

Soon the kids will be tearing down the stairs, asking for TV, porridge, a game.

When the interruption comes, I’ll be glad of it.

I’ve been asked by Susie Green, CEO of Mermaids, to take a look at a document that has been put out by “Transgender Trend”, an organisation which claims to support parents who are questioning a ‘trend’ of children ‘identifying as transgender’.

This isn’t the first time I am left with my stomach in knots as I read lies and distortions about my child and our family. The idea that people spend so much time and energy making my daughter’s life harder, chipping away at the limited acceptance and support that she has, is frightening – I need to respond, I need to help her, she’s already faced so much.

The document, a Resource Pack for schools, is predictably awful in many ways. Outright lies, misinformation, fake news wrapped in a glossy veneer – the latest weapon of a long campaign aimed at making the lives of trans children impossible – painting them as mentally disturbed, as deluded, as a threat. It is so flawed it is hard to know where to begin. I’ve made a start, but having got to page five with pages of critique, the approach isn’t sustainable. Time is short.

How did I get here?

I’ve known Susie for years now. She was the volunteer who picked up the phone when I first contacted Mermaids looking for support.

I’d registered with Mermaids weeks before, and tried phoning several times, but, understaffed, and relying upon a small group of trained volunteers, the charity had taken a month to reach my application and phone to guide through their assurance process. Those weeks had been tough, my wife and I were at breaking point, worried, isolated, without support. The call from Susie was a life-line, reaching out through the dark. “Is now a good time, she asked?”.

It was evening, Susie had been working the late shift, and had pulled into a service station on her drive home to call. It wasn’t her usual time on the Mermaids rota, but after hearing several answer phone messages, and recognising a family in crisis, Susie had sacrificed her evening to come to our aid.

Over the next hour, glass of wine as crutch, my words rushed out. How our child, who we had presumed a boy, had been stating for years that they were a girl. How their happiness had disappeared, the joy gone from their eyes, how we had a deeply upset and depressed child who cried every night and was losing out on their carefree childhood. How we’d spoken to a psychologist, our GP, school staff – how we’d read every book and article we could find.  We had found stories of other parents with children like ours, but had never spoken to anyone who understood what we were going through. We felt utterly alone. Searching online for support we’d come across medical definitions of gender dysphoria on the NHS website including links to Mermaids.

I told Susie how our child had been growing increasingly miserable in recent months and had told us that the one thing they wanted in the world was for us to call them a girl. How we had continued to reject her night after night, saying we loved her but we couldn’t take that step. Yet our child was fading before us. We had finally made the earth shattering decision (for us as parents) to say yes, we can call you girl.

The words fell over each other as I talked to Susie, trying to keep my voice steady whilst emotions churned inside. I spoke about how no one else understood what we were going through, how we faced judgement and disapproval, how we’d lost close friends who wouldn’t understand. Susie listened.

“It’s ok”, she said, as I struggled to maintain composure, the tears silently streaming down, “I know”.

Susie told me about her experience, and her child, Jackie, who she had thought was a boy but who fought the world to be seen as a girl. Jackie and Susie had conquered prejudice, bullies, violence and the ultra-conservative UK medical system. It had been tough, but Jackie had come through, stronger and confident in her identity as a young woman.

“How is your child now,” Susie asked?

I took a gulp of wine, before speaking again,

I told Susie how since we had accepted our child as a girl, since we had stopped our nightly cycle of rejection and denial, the joy had come back into her life. How she had started talking about books and toys and animals again. How she had started to laugh and smile. How she had grown in confidence. How the stress and weight of the world on her shoulders had lifted. How a simple shift in pronoun had transformed our sad depressed child into one with the happiness of a child who has finally been seen by their parents.

“That’s your answer,” said Susie. “You found out, just as I did, what the scientific consensus supports, whatever you do, as parents, you can’t make a child be a gender they’re not”.

Years have passed since that phone call.

We’ve had our share of challenges, all related to how the world treats children like my daughter. We’ve been on a huge learning curve, and our friends, family and school have learnt alongside us. Support at school was critical. Great leadership from the head teacher and a proactive zero tolerance approach to bullying, including misgendering, meant that the school adapted quickly, accepting our daughter completely. Our child is now loving school, learning, growing and enjoying spending time with her friends – who love and accept her as a girl, and as trans.

Our focus has shifted – trying to help build a society that is ready for our daughter. A world that will love and accept her as we do – a world where she doesn’t face prejudice, discrimination and hate. A world where she can read a newspaper without seeing trans people mocked, feared, treated as lesser.

My daughter is still my daughter. She is happy. Thriving. Her being transgender is the least interesting thing about her. She’s just a girl.

I’d like to say more but the children are awake, my time is up. I’ve been called to judge a Lego-making competition. The weekend awaits.

My wife and I blog here. You can also reach us on Twitter: @DadTrans & @FierceMum