Trans kids in 2023: Optimism and defiance

Caring about trans kids in 2023 continues to be heart-breaking. Worry and far too many tears.

Over the past 4 years, most ‘spare’ hours in my day (or more usually in the night) have been focused on my PhD: “Cis-supremacy: Experiences of trans children and families in the UK”. I chose to embark on a PhD in frustration at the bad science that informed policy and practice across the UK, frustration borne from failed attempts to advocate for trans children’s rights since 2015.

I have now submitted my PhD (phew), having already published 12 peer reviewed articles on the experiences of trans children and supportive families (research that has to date been ignored by UK media, NHS and policy makers…).

At this point of transition from PhD to what comes next, I’ve been taking stock on the last 7+ years of trying to advocate for trans children in the UK.

At first, my reflection was rather subdued. Since 2015, year upon year, across a host of different indicators of progress, the situation in the UK has got worse. Healthcare for trans kids has gone from abysmal to worse than abysmal. Media coverage has got worse. Discrimination appears harder to combat. Guidance for schools has got worse.

Having tried for so many years to help build a better world for trans kids than the one I saw in 2015, it has been beyond dispiriting to see everything year upon year seem worse. Year upon year it has been harder to make room for hope.


That is not the end of the story.

I was actively searching for the signs of optimism that I need to keep up the fight.

The thing I ended up on, our greatest strength, (and the reason why we will win) lies in supported and self-confident trans kids.

Since 2015, year upon year, more and more trans kids are being supported by their families. Amidst private forums, the numbers of affirming families continue to rise. Families whose kids know that they are respected, valued and cherished for who they are.

Year upon year I have seen families supporting trans kids at a younger age, families waiting shorter and shorter periods before affirming and embracing their trans kids, requiring trans kids to fight less hard for parental love. Year on year I have seen more families react with instant positivity, affirmation and love to a child sharing their identity. A noticeable shift from even 5 years ago when that was a rarity.

Year upon year I have seen majority discourse within family support groups shift from a focus on ‘loss’ or worry about a child’s identity to love and pride.

Year upon year I have seen more families stand up alongside their child at any age and argue for their equal rights.

Year upon year I see more trans kids who can speak up and claim their rights even in primary school (not that I think trans kids should carry this burden…)

Year upon year I see more families and kids demand genuine equality and respect from their wider families, schools and communities, not settling for tolerance or segregated accommodations.

I see within communities of trans kids the difference that this trans positivity makes. I meet trans kids who have been supported, who have grown up expecting to be treated as genuine equals to their cis peers. Trans kids surrounded by love and support can grow up without the heavy blanket of shame that so many older folks carry through our lives (see toxic shame).

When I look back over the past years of advocacy, the issue that gives me most pride is every family who I have in some small way supported to gain the knowledge and confidence to support and advocate for their trans kid. Every single supported trans kid makes a difference.

Those supported trans kids go out into the world a bit stronger, a bit less kicked down by this trans-hostile world. Many such trans kids and trans positive families end up providing a safe space for trans kids without affirming families. Many trans kids (whether supported at home or not) end up supporting a whole network of trans youth, providing peer advice, validation and mutual aid.

Every trans kid makes the world a better place.

This is why transphobes are so afraid of social transition.

Because trans kids who are supported young are less likely to grow up overwhelmed by shame or self-hatred.

Trans kids with self-respect will fiercely demand their rights. And they will fight even harder for the rights of their friends.

Trans kids are no longer isolated and alone.

Some trans kids stand on many strong pillars of support and trans-positivity. Some trans kids wobble on only a few. Every bit of support and trans-positivity matters.

Transphobes, including in the NHS, are trying to formally discourage social transition. To deny trans kids support. To deny them connection. To instil in them shame.

But, in the internet age, that boat has already sailed. Trans kids can’t be kept in the dark any longer. Their route to self-knowledge and self-actualisation cannot be controlled by the NHS, the media, transphobic parents or transphobic politicians.

Families of trans kids are now able to connect to each other. Amongst private parent support groups the case for social transition is recognised fact. Family after family after family report what is glaringly obvious to any trans person. Trans kids need love and support, and with love and support they can thrive.

So yes, the UK context is dire. It is dire in a way that continues to cause immense harm to trans people, especially trans children.

But, the fight does not primarily lie in legislation or in policy or in the NHS. Those fights are vitally important and will continue.

But even while those fights are slow, demoralising, unjust and depressing as hell, the real victory is coming from every single trans kid who grows up without being overwhelmed by shame. From every trans kid who grows up expecting equality. From every trans kid who believes there is space for them in this world.

That is where the real battle lies. And that is where we will win.

Because trans kids are easy to love. They are easy to respect.

Trans kids who have love and respect will claim their place. Trans kids can and do have childhoods filled with excitement and joy.

Trans kids change the world, family by family, school by school, community by community.

Happy trans kids change the world. Pissed off and angry at all the bullshit trans kids change the world.

Every single time you show love and support for a trans kid (or for a family struggling to stick up for a trans kid) you are shifting our world towards a better place. Towards a kinder place.

So, for everyone beaten down by cis-supremacy and transphobia – think how many individual lives you have touched in some way with trans-positivity. That matters.

For every family who is struggling to keep their trans kid happy and safe – know that being affirmed and celebrated in childhood is setting your kid up for the future, and that is a huge part of this fight.

It is so easy to be overwhelmed by fear and stress.

It is so easy to see no light at the end of the tunnel.

Focus on the trans kids in our world. They probably don’t even want to go through that tunnel anyway. Follow their lead (with swords at the ready).

Keep up the fight.

Diagnostic Overshadowing

In this short blog I want to draw our attention to the term ‘diagnostic overshadowing’ and its use by anti-trans actors to mask attempts at conversion practices.

Diagnostic overshadowing is a medical term used to describe the situation where one medical condition or diagnosis ‘overshadows’ another one, leading to mis-diagnosis.

Trans communities will recognise the concept in the well documented ‘trans broken arm syndrome’. Transphobic or inexperienced medical practitioners can go into panic when treating a trans person, and mistakenly attribute completely unrelated medical issues to a person being trans or taking gender affirming hormones.

Trans patient: Look, my arm is clearly broken in several places, I need a plaster cast.

Emergency care Dr: Oh, you are trans! Are you on HRT? I don’t know how to treat you, we’d better send you to the psychologist.

In trans communities this type of ‘diagnostic overshadowing’ is recognised as a problem that we want and need medical providers to acknowledge and avoid. Trans people should not receive poorer medical care from professionals who presume their transitude is at the root of unrelated health conditions.

In these cases, diagnostic overshadowing is a problem, and something to be avoided.


Transphobes like to use the term diagnostic overshadowing in a different way, one that we need to be aware of and protect against.

Transphobes do not recognise self-identification as trans. They focus on transness as a diagnosis or medical condition, with an emphasis on people suffering from the condition of ‘gender dysphoria’. Rather than considering a trans person ‘being trans’ with affirmative healthcare are a route to self-actualisation and gender euphoria, they focus on a person ‘suffering from gender dysphoria’ with affirmation one of many potential ‘treatments’ for that distress.

 Transphobes then use the term diagnostic overshadowing in a manipulative way that masks their true intentions.

For a transphobe, a trans child or teen is likely to have ‘mis-diagnosed’ themself as suffering from gender dysphoria. They are likely to ‘misattribute’ their anxiety, depression or suicidal ideation as being wrapped up in their mis-diagnosis. They are likely to argue that gatekeepers should ‘protect’ trans youth from mis-diagnosing their depression or anxiety as being linked to dysphoria or to being trans in a transphobic world. Transphobes argue that the first step in any service is to look for other causes and other ‘treatments’ for anxiety or depression before enabling affirmation. They argue that an affirmative approach (where clinicians accept a child’s identity) is going to result in ‘diagnostic overshadowing’ of other past traumas or mental health issues. Transphobes do not accept that being trans is a healthy part of human diversity, and do not recognise the mental health burden of being trans in a transphobic world. Importantly, their transphobic approaches to ‘treating’ gender dysphoria by denial of affirmation are already proven to be harmful, unethical and ineffective.

Transphobes then wield the term ‘diagnostic overshadowing’ to criticise affirmative healthcare. They say that any healthcare professional who accepts a child or teenager’s ‘self-diagnosis’ of transitude or dysphoria or transphobia as at the root of their mental health problems, is practicing ‘diagnostic overshadowing’ – allowing a self-diagnosis of gender dysphoria to explain other mental health issues (that, transphobes claim, are instead driving their gender confusion). Transphobes argue that to avoid ‘diagnostic overshadowing’ health professionals and teachers and parents need to take a ‘critical’ approach to a youth’s self-understanding. Clinicians need to look for ‘causes’ and ‘treatments’ for all areas of trauma, neurodiversity, depression, anxiety etc BEFORE enabling affirmation.

Florence Ashley’s scholarship is relevant here see (here, here and here)

The Danger

Diagnostic overshadowing is already recognised as a ‘bad practice’ in healthcare. Something that we all want to avoid.

So, when transphobes say ‘we want to avoid diagnostic overshadowing’ this can easily be interpreted as something benign, as something positive.

BUT they are manipulating the term, to enable conversive practices. To enable harm to trans youth.

I am therefore extremely concerned to see the term used multiple times by Cass, including in her recent response to the draft NHS service specification.

I am extremely concerned at a lack of community push back to Cass’ use of this term – I have spoken to folks who didn’t really understand the term and simply assumed it was something benign, which is why I wanted to publish this blog.

I do think ‘diagnostic overshadowing’ is a genuine problem in trans healthcare. But in a transphobic NHS it is primarily a problem leading to denial of trans healthcare. Youth who are neurodiverse, disabled or mentally ill routinely experience ‘diagnostic overshadowing’ with clinicians focusing on their co-existing differences as a potential driver of their gender distress, with neurodiverse, disabled or mentally ill trans youth denied affirmative healthcare.

 Cass is not tackling this type of ‘diagnostic overshadowing’. Instead, she is presuming that the NHS at present is allowing self-identification as trans to ‘overshadow’ other mental health problems or allowing mis-diagnosis as trans to get in the way of more pressing need to ‘treat’ anxiety or depression (without gender affirmation).

This interpretation is baked into the proposed service specification.

A service that was trying to ensure neurodiverse, mentally ill, disabled or traumatised trans youth have equitable access to trans healthcare would be designed with steps to ensure those youth have equitable access without their diversity counting against them. The new service spec does the opposite.

The new service spec instead looks for ‘solutions’ and ‘treatments’ outside of affirmation and affirmative healthcare.

This way conversion therapy lies.

Cass is enabling this without clearly saying so, using the term ‘diagnostic overshadowing’ to justify a marked shift to a conversion therapy adjacent model.

Cass is dangerous because she is enabling conversion practices by saying ‘we need to avoid diagnostic overshadowing’. This unclear term leads most people to just nodding in agreement, assuming the NHS knows best, always underestimating the power of institutional transphobia and trans-pathologisation.

When folks caution about the rise of fascism they remind us that fascism doesn’t (always) come with Heil Hitler salutes and swasticas, it comes with calls to protect family, nation, tradition.

We need to similarly recognise that a return to conversion therapy doesn’t come with a banner saying ‘Conversion here’. It comes wrapped in ‘gender exploratory therapy’ and a call to avoid ‘diagnostic overshadowing’.

I’m deeply concerned for trans children and teens under the NHS

I’m sick of folks (and organisations) giving Cass the benefit of the doubt just because she avoids inflammatory rhetoric.

Trans kids deserve better – they have a right to evidence-based affirmative healthcare. They have a right to safety from harmful conversive practices.

Supporting Trans Children in Schools: Findings and Recommendations

This blog summarises Key Findings & Recommendations for supporting trans children in schools. This summary is based upon newly published research which reviews the literature & policies for supporting trans pupils & provides recommendations for schools & allies:

Findings and recommendations from a 2020 Frontiers of Sociology article on LGBT inclusive education (open access). Thriving or surviving? Raising our ambition for trans children in primary and secondary schools Cal Horton, Goldsmiths, University of London

Finding: Trans pupils face stigma and invalidation at school, often alongside discrimination and harassment.

Recommendation: Affirmative language, respect and trans-positivity are critical.

Finding: Trans pupils experience persistent stress, navigating systems that delegitimise and exclude them. An anti-bullying approach may underestimate the emotional and psychological impact on trans pupils of cisnormativity*.

Recommendation: Schools need to address the cisnormative practices that negatively impact on the wellbeing and mental health of trans pupils.

Finding: Schools respond to individual requests reactively, with trans pupils shouldering the burden of negotiating their own inclusion.

Recommendation: Schools need to move from individualized accommodation to proactive and sustained adaptation.

Finding: A culture of silence surrounds trans lives at school – minimal trans representation can be perceived as excessive. Trans pupils denied representation in school experience shame and low self-esteem, and are forced to educate their own peers.

Recommendation: Trans representation and visibility needs to become common and unremarkable, enabling trans pupils to grow up with a sense of belonging and self-worth.

Finding: Trans pupils may experience ignorance and hostility from school staff, causing significant harm. Even one supportive and trusted teacher can make a profound positive impact on a trans pupil’s experience of school. Teacher trans-positivity is significantly correlated with pupil well-being.

Recommendation: Schools need to recognize and address the pressures and barriers to teacher action. Clear leadership is essential, and can be driven by governors, head teachers and individual members of staff.

Finding: Schools lack ambition for trans pupils, aiming for the low bar of protection from harassment and abuse. Trans pupils need equality of opportunity, in schools where they can excel and thrive.

Recommendation: Trans pupils should be affirmed and welcomed, in schools where they are represented, validated and respected as equals.

Finding: Teacher education and training needs to move beyond basic education on transphobic bullying, to helping staff understand the ways in which cisnormativity privileges cisgender individuals and makes life harder for trans pupils.

Recommendation: Trans pupils need at least one adult who can advocate for them, help them understand their rights, and help them navigate cisnormative cultures. Teacher allies need to understand and challenge the systems and approaches that delegitimise and marginalise trans pupils.

Finding: Trans children have a right to an educational experience that is safe, inclusive and affirming.

Recommendation: Schools should listen to trans pupils and centre child rights. Schools also need to consider their institutional responsibilities, ensuring schools are fulfilling their duty of care to trans pupils. 

Cisnormativity*: When systems, policies and people assume that everyone is (or should be) cis (not trans). Cisnormative schools place trans pupils at a disadvantage, requiring them to navigate systems designed to exclude them.
Trans: The term trans is used here to include people who are transgender, non-binary and/or gender diverse.
This text is from the Infographic, ‘Supporting Trans Children in Schools’ available to download here for FREE in various web ready and Print formats
Supporting Trans Children in Schools, Infographic summarising research paper: ‘Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools’


Supporting Trans Children in Schools – Peer Reviewed Education Resource


image blog

I’m pleased to share the publication of my new peer reviewed journal article. The article synthesises the literature on how to best support trans children in primary and secondary schools, together with analysis and recommendations on school guidance.

Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools


Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools

The article is free to read and or download here

1 Page Infographic Resource and Poster

For teachers and schools there is a short infographic with some key recommendations (available to download or share in A3 or A4 versions linked below):

Infographic summarising article findings and recommendations. Yellow background with images of children and text in boxes.

A Free to Use Infographic providing findings and recommendations on how trans children can be enabled to thrive in schools.


Please view and download the Supporting Trans Children in Schools infographic here in your preferred version:

Web Version

Infographic PDF A3 Web Version

Infographic PDF A4 Web Version

Print Version

Infographic PDF A3 Print Version

Infographic PDF A4 Print Version

This infographic is free to use and share.

15 Bad Faith Arguments Against Puberty Blockers.

  1. “They are new and untested”

They’ve been used since 1988 for trans adolescents, with follow up studies over twenty years. There are over 30 academic papers summarised here:

  1. “Kids are too young to have blockers”

They are used on trans adolescents. Somehow there’s no big controversy in their use for precocious puberty, which is at a much younger age. They are used to block puberty, which, funnily enough, means they are used at the start of puberty.

  1. “They are powerful cancer drugs”

They are used to stop testosterone and oestrogen. This can be useful to stop puberty, or also can be useful when certain cancers are exacerbated by testosterone or oestrogen. Calling them a cancer drug is bad faith misleading scaremongering.

  1. “They are not reversible”

They are medically and physically reversible. If you stop taking them, puberty continues. Sometimes people then go on to say “we do not know their psychological impact” or “if adolescents have blockers, they can’t turn back time to have never had blockers”. Well unless you invent a sliding doors time machine, every single action we take is irreversible. This is such a bad faith argument.

  1. “They are experimental / not licensed for use in trans adolescents”

Lots of medication is not specifically licensed for that purpose – this argument is bad faith as debunked in detail in this article:

  1. “The existing evidence is not high quality”

Sample sizes in the studies are small, because very few trans adolescents have been treated to date. Want larger sample sizes? Then you have to prescribe to more trans adolescents.

  1. “There has not been a Randomised Control Trial”

A score of experts have time and again stated that a Randomised Control Trial is unethical, and would not be feasible. Some bad faith commentators even ask for a Blinded RCT – as if trans adolescents wouldn’t notice progressing through puberty! Bad Faith.

  1. “Z Value Bone Density decreases when adolescents are on blockers”

It took me a long while to understand why this is so bad faith. Z value bone density compares bone density to expected age-based norms of the assigned gender for cis children. Bone density rises during puberty, those on blockers do not have this bone density rise at the same time as their peers, so their bone density compared to same age cis peers decreases (even where actual bone density continues to rise, albeit more slowly than their pubertal peers. Puberty is the thing that causes bone density to increase. If you delay puberty, of course trans youth don’t get this rise in bone density at the expected age.

  1. “We don’t know the impact on brain”

Again, really bad faith. There are many many things we do not know about brains. Puberty blockers have been studied for their impact on many different variables, their impact on kidney function (fine) their impact on well-being (improves it), their impact on mental health (improves it), their impact on dysphoria (stays same, HRT is the thing that makes the difference to dysphoria). They even have been studied for effect on executive function (no negative impact). There is much evidence of benefits and no evidence of harm. And we make decisions based on the current evidence.

  1. “Just do nothing until there is much more evidence”

Doing nothing is not a neutral decision. Puberty for trans adolescents causes significant harm. Puberty blockers are proven to be beneficial. Withholding beneficial medical care is not a value neutral ethical decision.

  1. Other signs of bad faith include quoting fringe medical sources including the American College of Pediatricians. Quoting transphobic former GIDS psychoanalysts (with no medical qualifications). Having more interest in the brain scans of pubertal sheep than in the well-being of trans teens
  2. Further signs of bad faith include: Citing your own non-peer reviewed opinion piece in the journal you used to work at as evidence to justify a BBC prime time show. Using BBC funding to hire someone with no expertise in caring for trans adolescents to write a critical summary of the literature raising the bad faith concerns listed above.
  3. Further signs of bad faith include: Failing to report the clear well-being benefits of timely blockers including teens not in acute distress and pain, teens not dropping out of school, teens not failing at school, teens learning and growing and enjoying their adolescence.
  4. Yet more signs of bad faith include failing to state the global medical consensus backing puberty blockers including from the Endocrine Society, the American Academy of Paediatrics, the World Professional Association of Transgender Health, and many, many more.
  5. The final bad faith sign I’ll list here, is failing to clarify if your preferred medical outcome for trans youth is denial of medical support and instead psychotherapy to help them ‘accept themselves as they are’. This is conversion therapy. It causes immense harm and there is no place for it in modern medical practice.

Just admit you don’t like trans people already.

Puberty Blockers – Overview of the research

Nicola Sturgeon Opens Glasgow Pride

The UK media is full of scaremongering about puberty blockers (GnRHa) and the evidence or supposed lack thereof in support of their use for trans adolescents. Opinions abound, but few, however, have the opportunity or access to read the academic literature. In this article, a comprehensive overview of the studies and academic literature on puberty blockers are presented, providing improved access to this evidence. Links to the papers are provided throughout, supported by a full bibliography.

Puberty blockers are a recommended intervention for trans youth at the start of puberty (when such interventions are requested), endorsed by the global Endocrine Society and WPATH (the World Professional Association for Transgender Health). Within medical and clinical service provider communities, strong consensus in support of puberty blockers has grown, with endorsement from the world’s largest paediatric health body the American Academy of Pediatrics, providing access to blockers throughout the USA, and national health services around the world including centres in Spain, Australia & New Zealand. Authors from the conservative UK NHS children’s gender service (GIDS), wrote a position paper in 2016 (Costa) stating that “Despite a limited number of studies, the existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence”, with a more recent 2019 UK paediatric endocrinologist authored piece (Joseph) affirming that puberty suppression “is now a recommended treatment option”.

Puberty blockers have been used since the 1970s for children with precocious puberty, with extensive studies for this cohort (Eun Young Kim provides an overview of the literature), on their long-term use “considering evidence of impact on height, reproductive function, obesity and metabolic syndrome, bone mineral density and bone markers, polycystic ovary syndrome, psychosocial problems”. “Long–term studies on the recovery of reproductive function in precocious puberty patients of more than 6–20 years are being reported”. “Puberty was recovered within 1 year after GnRHa treatment discontinuation, and there were no abnormalities in reproductive function”. “Bone mineral density decreases during GnRHa treatment but recovers to normal afterwards, and peak bone mass formation through bone mineral accretion during puberty is not affected”. “Some studies have reported decreases in psychosocial problems after GnRHa treatment. Overall, GnRHa seems effective and safe for CPP patients, based on long-term follow-up studies.”

In trans youth, blockers have been studied since the late 1980s. An early paper published in 1998 (Cohen Kettenis) reported on the protocols followed for a 13 year old trans boy who was treated with puberty blockers, with HRT (Hormone Replacement Therapy) and surgery after turning 18. This was the first longitudinal case study, which documented a successful outcome from using early puberty blockers. As an adult, the subject was happy and satisfied with the outcomes, (though noted the delays between blockers and HRT were overly long).

The longest follow-up study is of a Dutch trans man who started on puberty blockers at age 13 in 1988. His health and well being was monitored\ regularly for over 22 years, when he was last followed up, aged 35 (in 2010) he was well-functioning with no clinical signs of a negative impact of earlier puberty suppression on brain development, metabolic and endocrine parameters, or bone mineral density (Cohen Kettenis, 2011).

Their use in trans adolescents has been well studied in the Netherlands. In 2011 (Kreukels) the then world leaders in what became known as “the Dutch Approach” wrote that they “believe that offering this medical intervention minimizes the harm to the youth while maximizing the opportunity for a good quality of life including social and sexual relationships, and that it respects the wishes of the person involved”. “Because the effects are reversible, this treatment phase could be considered an extended diagnostic phase. Knowing that the treatment will put a halt to the physical puberty development often results in a vast reduction of the distress that the physical feminization or masculinization was producing.”

Another 2011 study (De Vries) collected data from 2000-2008 of 70 trans youth (33 trans feminine, 37 trans masculine) capturing the time period when they were only receiving puberty blockers. Puberty blockers were started at an average age of 14.75 (youngest was 11.3). Youth received puberty blockers alone before starting HRT alongside for an average of 1.88 years (the shortest period on just puberty blockers was 0.42 years, the longest was 5.06 years). Whilst on puberty blockers there were improvements in behavioural and emotional problems, and reduced symptoms of depression, enabling healthy psychological development. There were not improvements in body image and gender dysphoria. “As expected, puberty suppression did not result in an amelioration of gender dysphoria. Previous studies have shown that only gender reassignment consisting of CSH (cross sex hormone) treatment and surgery may end the actual gender dysphoria”. All youths later went onto HRT (which did lead to improvements in body image and gender dysphoria as well as wider improvements to wellbeing (see 2014 study for follow up). In a clinic with a clear route to HRT (all youth in the study were later prescribed HRT) the authors speculate that improvements in wellbeing whilst on puberty blockers may be due to the youths on puberty blockers having confidence that a route to HRT is available.

A summary position statement from Amsterdam in 2011 (Kreukals) outlined their view: “In our opinion, to deny these youngsters GnRHa treatment is unreasonable. Although the physical effects of puberty suppression are reversible, it has been argued that the effects on psychosexual develop ment are not reversible: the adolescents will miss puberty that is a result of their own natal sex hormones. However, in this sense, denying GnRHa treatment is equally irreversible: the adolescents will never know how puberty in accordance with their gender identity will be, because that is made impossible by the effects of their own sex hormones. Transsexual adolescents often consider not experiencing the puberty of their desired sex more harmful than missing their natal puberty. As puberty suppression therapy generally results in a physical appearance that makes it possible to live unobtrusively in the desired gender role, withholding GnRHa treatment is also harmful because of the potential life-long social consequence s (such as stigmatization).”

Hembree (2011) reviewed other studies noting increased suicidal ideation where blockers were not given.

A 2012 paper (Edwards Leeper) from a major paediatric treatment centre in the USA, emphasised a key reason for puberty blockers – “44% of transgender youth presenting for medical intervention had been previously diagnosed with a psychiatric disorder, the most common being depression, anxiety, and bipolar disorder. Thirty-six percent of these patients had been prescribed psychotropic medications and 9% had been hospitalized psychiatrically in the past. These psychological problems often intensify when transgender children reach puberty”. They also note that “it is not uncommon for these symptoms to decrease and even disappear once the adolescent begins a social and physical transition. The previous diagnoses of major psychiatric disorders, especially mood disorders (e.g., major depressive disorder, bipolar disorder) in these patients are often secondary to their gender identity issue and many patients are “cured” of these disorders through medical intervention for the gender issue.” The authors emphasise multiple psychological benefits of pubertal suppression, especially through avoiding needless emotional and psychological suffering, which can be severe for some adolescents (e.g., self-harming behaviors and suicidality). Delamarre , in an earlier 2006 paper, highlights that once trans adolescents are on puberty blockers, their anxiety at physical changes is taken away, enabling them to concentrate on other issues, enabling them to better develop and socially connect with peers.

A 2014 study (De Vries) of 55 trans youth (22 trans feminine and 33 trans masculine) followed them over an 8 year period from before starting blockers (mean aged 13.6 years), through to start of blockers (average age 14.8, youngest 11.5) through to HRT (mean age 16.7, youngest 13.9) and at least one year after gender reassignment surgery for those who wanted surgery (mean age 20.7). This monitored not only psychological functioning (gender dysphoria, body image, global functioning, depression, anxiety, emotional and behavioural problems) but also tracked wellbeing (social and educational/professional functioning; quality of life, satisfaction with life and happiness). Psychological functioning steadily improved. Well-being improved to similar or better than same age young adults from the general population. “GD (gender dysphoria) and body image difficulties persisted through puberty suppression and remitted after the administration of CSH and GRS (at T2) (significant linear effects in 3 of 4 indicators, and significant quadratic effects in all indicators)“ “None of the participants reported regret during puberty suppression, CSH, treatment, or after GRS. Satisfaction with appearance in the new gender was high, and at T2 no one reported being treated by others as someone of their assigned gender”. “All young adults in this study were generally satisfied with their physical appearance and none regretted treatment. Puberty suppression had caused their bodies to not (further) develop contrary to their experienced gender”. “Psychological functioning improved steadily over time, resulting in rates of clinical problems that are indistinguishable from general population samples (eg, percent in the clinical range dropped from 30% to 7% on the YSR/ASR30) and quality of life, satisfaction with life, and subjective happiness comparable to same-age peers. They note that this support gave “these formerly gender dysphoric youth the opportunity to develop into well-functioning young adults. These individuals, of whom an even higher percentage than the general population were pursuing higher education, seem different from the transgender youth in community samples with high rates of mental health disorders, suicidality and self-harming behaviour”.

Paediatric endocrinologist Rosenthal outlined key endocrine considerations in 2014, highlighting the potential negative impact on bone health of extended pubertal suppression and arguing for earlier introduction of HRT, stating that delaying HRT until age 16 can be “detrimental to bone health”. In addition he stated the negative impacts on emotional well-being of denying trans youth the opportunity to progress through puberty at the same time as their peers, and thereby isolating them. For this reason, gender centres are “studying the impact of cross-sex hormone treatment initiation at 14 years of age (which approximates the upper end of the age range for normal pubertal onset in natal males and 1 year beyond the upper end of the age range in natal females”).

A 2014 paper (Khatchadourian) summarising treatment in a Canadian clinic emphasises the high rates of suicidal ideation before treatment, in a cohort not treated until an average age 16. “Importantly, 10 of the 84 patients (12%) had attempted suicide with a resultant visit to an emergency department before being seen in our clinic”. “The older age of our cohort of patients compared with the Dutch cohort (mean age 16.6 vs 14.6 years, respectively) may also explain differences in frequency of psychiatric comorbidity, as our patients had more time to develop these comorbidities.” They note a decrease in suicide attempts or visits to emergency departments for suicidal ideation once engaged with the clinic (from 10 incidents before treatments, to 4 after). “Although our numbers are quite small, this finding suggests a lessening of emotional problems and suicidality when puberty blockers or cross-sex hormones are started. This is further corroborated by findings in the Dutch cohort, where an improvement in psychological functioning in areas such as depressive symptoms was demonstrated in adolescents with gender dysphoria treated with GnRHa for nearly 2 years.” This study also emphasises youth who do not need to undergo interventions like painful electrolysis or chest surgery, as early treatment prevented unwanted pubertal development. The authors conclude that “most experts in transgender care would agree that initiation of GnRHa therapy at an earlier stage ofpuberty is preferred, because preventing the development of unwanted secondary sexual characteristics can alleviate distress.”.

A 2014 paper (Fisher) outlines the negative consequences in Italy where puberty blockers were not offered – 23 youth, (14 trans feminine, 9 trans masculine, average age 16.3 years old), who had been diagnosed with gender dysphoria but who had not been granted any medical intervention, had low levels of wellbeing, and high levels of emotional and behavioural problems. They also noted that a high proportion, 42%, had dropped out of school early. The authors from Italian clinical services consider ethical implications of prescribing or denying blockers. They discuss fertility, referring to wider studies and concluding “several studies report that fertility potential is not impaired by long-term treatment with GnRHa even when used in younger subjects, before age 7, to treat precocious puberty. In addition, GnRHa treatment seems to have a protective effect on the reproductive outcomes, as fertility problems were more prevalent in subjects with precocious puberty that were not treated when compared with those treated. Professionals should inform patients that sperm production can be satisfactory after cessation of GnRHa or with gonadotropin treatment (both associated with body virilisation. FtM individuals have to be informed that no adverse effects are expected in relation to their fertility when treated with GnRHa” They argue that the current (2014) clinical evidence as well as international clinical guidelines suggests that prompt prescription of puberty blockers provides the best outcome for trans adolescents. They note experience from Italy that later pubertal changes can be unbearable, changes that “are usually profoundly humiliating for transgender youth”. They add that unwanted pubertal changes “often perceived as devastating, may seriously interfere with healthy psychological functioning and well-being”, being associated with worsening gender dysphoria, distress, depression, self-harming behaviour, anxiety, low self-esteem, social isolation and suicidal ideation. They emphasise that “although there are cases of comorbid psychiatric disorders, these psychological symptoms are often a result of the discomfort that Gender dysphoric individuals feel in their own bodies and of the social rejection they experience”. They go on to outline eight reasons to endorse blockers including 1) immediately reducing suffering 2) enable better decision making on further medical intervention 3) the physical effects are fully reversible 4) outcomes for physical transition are enhanced if unwanted secondary sex characteristics are not developed 5) Future surgeries are less likely to be needed 6) Can prevent emotional and psychological suffering that can have short term and longer term risks for well-being 7) provide better psychosocial functioning 8) avoids unsupported youth turning to illicit un-prescribed medication. They conclude that the “current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behaviour, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.”

A 2015 UK study (Costa) compared adolescents supported with puberty blockers to those denied access to blockers. 201 Adolescents with gender dysphoria aged 12-17 (average age 15) were assessed for psychosocial functioning, using an assessment called CGAS. All the youth in the study registered low levels of psychosocial functioning at baseline (CGAS = 57). One group of 61 youth were not granted puberty blockers, instead having 18 months of just psychological support. Their psychosocial functioning improved after 6 months of psychological support (to CGAS = 60) but then plateaued and stayed significantly below the levels of children without psychological symptoms (staying at CGAS = 62). Another group of 60 youth were allocated blockers after 6 months of just psychological support. Like the untreated group, their psychosocial functioning improved when just receiving psychological support (to CGAS = 60). Their psychosocial functioning then improved more significantly at each six monthly check up whilst on puberty blockers. The psychosocial functioning of youth after 12 months of puberty blockers had improved to match that of children without psychological symptoms (CGAS = 67). Trans youth with puberty blockers were able to reach levels of psychosocial functioning the same as their peers.

Another 2015 study (Staphorsius) looked at the impact of puberty suppression on executive functioning in trans adolescents, using a well-established task called ‘Tower of London’ and comparing trans adolescents on blockers to trans adolescents not on blockers. They found no significant effect of blockers on performance scores (reaction times and accuracy) when comparing trans girls on blockers (8) to those not on blockers (10), or when comparing trans boys on blockers (12) with those not on blockers (10). “In conclusion, our results suggest that there are no detrimental effects of GnRHa on Executive Function.

A 2015 study (Klink) followed 34 trans youth through adolescence and into adulthood. 15 trans girls/women and 19 trans boys/men were followed from starting blockers at an average age of 15.0, through to starting HRT at an average age of 16.5, through to final follow up at an average age of 22.0. The paper analyses data on bone mineral density.
A 2017 study (Vlot) looked at the impact of puberty blockers and HRT on bone health. 34 trans boys and 22 trans girls were studied, providing data on impacts on different bone health related measures. These studies are followed up by a 2019 study (Joseph) below.

Very few studies focus on asking what trans youth themselves think about puberty blockers. One exception is a 2016 study (Vrouenraets) of 13 adolescents (5 trans girls and 8 trans boys), 12 of whom received puberty blockers, at an age range between 13 and 18, with median age 17. Asked about a lack of data on the long-term effects of puberty suppression the majority said that being happy in life was more important for them than any possible negative long-term consequence of puberty suppression “The possible long-term consequences are incomparable with the unhappy feeling that you have and will keep having if you don’t receive treatment with puberty suppression” (trans youth age 18)”. “It isn’t a choice, even though a lot of people think that. Well, actually it is a choice: living a happy life or living an unhappy life. (trans girl, age 14). Interviewed youth also understood that treatment has to be given in order to obtain long-term data, and were more than willing to be the person to test it.

A 2016 study (Schagen) aimed to evaluate the efficacy and safety of GnRHa treatment in trans adolescents, evaluating the extent to which (early) pubertal physical changes can be reversed, the need for monitoring of gonadotropins and sex steroid levels, and the need for screening of liver and renal function. Forty-nine trans feminine adolescents (average age 13.6, range 11.6-17.9) and 67 trans masculine adolescents (average age 14.2, range 11.1 – 18.6, 77% had started menarche) treated between 1998 and 2009 were included in the analysis. “None of the adolescents discontinued GnRHa treatment because of side effects. This is in agreement with the finding that GnRHa treatment is well tolerated by children and adolescents”. “Gonadotropins and sex steroid levels were suppressed within 3 months. Treatment did not have to be adjusted because of insufficient suppression in any subject”. “We did not identify any renal or hepatic complications of the treatment, and previous studies on GnRHa treatment in children with precocious puberty did not find such adverse effects. Therefore, it does not seem necessary to routinely monitor these parameters”.

A 2017 paper (Schneider) provided a case study of the brain of a single trans youth during pubertal suppression. “Brain white matter fractional anisotropy remained unchanged in a GD girl during pubertal suppression with GnRHa treatment for 28 months, which may be related to reduced serum testosterone levels. The global performance in the Weschler scale was slightly lower during pubertal suppression compared with baseline, predominantly due to the reduction in operational memory. Either a baseline of a low average cognition or the hormonal status could play a role in cognitive performance during pubertal suppression”. A major limitation is a sample size of one, and comparing white matter in a trans girl to post pubertal cis boys. Also, the adolescent in the case study suffered conversion therapy and associated depression at a young age, and studies show the link between memory and childhood trauma. A 2020 paper (Chen) conducted a brain study on a larger sample of 18 girls with precocious puberty – the study did not provide any clear recommendations, but simple concluded that this is adding to the body of research on the effects of GnRHa on brain function.

A 2018 paper (Wiepjes) summarised overall data on all people treated in Amsterdam up to 2015. Out of those referred to the clinic in before the age of 18 and treated with puberty blockers, they found that 4 out of 207 trans girls (2%) stopped puberty suppression without proceeding to HRT and 2 out of 370 trans boys (less than 1%) stopped puberty suppression without proceeding to HRT. Reasons for discontinuation of GnRHa were not reported. In addition to these youth, a further 112 trans girls and 148 trans boys referred in adolescence went straight to CSH without taking blockers.

A 2019 study (Joseph) of the impact of puberty suppression on bone mass  followed 70 adolescents, referred to the UK GIDS between 2011-2016. The sample included 31 trans girls and 39 trans boys aged 12-14 years, and all but two of the trans boys (95%) were postmenarchal. Two analyses were performed, a complete longitudinal analysis (n = 31) where patients had scans over a 2-year treatment period, and a larger cohort over the first treatment year (n = 70). All youth were required to stay without addition of HRT until age 16. At baseline trans boys had lower bone mineral density (BMD) measures than trans girls. There was no significant change in the absolute values of hip or spine BMD or lumbar spine BMAD after 1 year on GnRHa. BMD-Z scores were low, but the authors highlight the debatable utility of measuring and contrasting Z scores (which compares BMD to same age youth who are not on puberty blockers). Bone mineral density rises due to sex hormones at puberty, so those with delayed puberty will automatically not gain this rise at the same age as un-suppressed cis adolescents of the gender they were assigned at birth, and will automatically score low when compared to such Z scores. The authors highlight that their observations mirror the observations in studies by Klink 2015 and Vlot 2016 which also demonstrate no significant change in absolute BMD under pubertal suppression. They “propose that it may be clinically inappropriate to compare these subjects’ BMD with that of contemporaries who have not had pubertal blockade as the bone development in the GD subjects has been halted in comparison to those of their age group”. They suggest developing expected-BMD charts for pubertally suppressed adolescents, as a more useful way of tracking BMD. The authors note that there are no international guidelines for the surveillance of bone health in young people with gender dysphoria, that reference ranges may need to be redefined for this patient cohort, and that there needs to be clarity on treatment options where an adolescent is found to have low bone mineral density (BMD). More important than tracking bone health whilst on blockers, is understanding the long term impact on BMD once sex hormones are added. They conclude that absolute BMD and BMAD scores do not change substantially over a 3 year period in trans adolescents on GnRHa treatment and recommend that yearly bone scans while on puberty blockers may be unnecessary.

In a 2019 letter to the BMJ (Ferguson) Australian clinicians reviewed existing datasets of impact of puberty suppression on bone health. They outlined heterogeneity in the outcomes, and recommended identifying and tracking individuals who are more significantly affected in terms of bone mineral density, rather than reporting on the average. They note that regardless of the positive impacts of puberty blockers, clinicians have a duty to maximise bone health of trans youth on puberty blockers.

A 2020 study (Achille) tracked 50 youth (mean age 16.2) over one year of endocrine intervention (data captured between 2013 and 2018). 4 trans masculine youth were just on blockers, 8 trans feminine youth were just on blockers, 24 trans masculine youth were just on testosterone, 7 trans feminine youth were on oestrogen and blockers, and 4 trans masculine youth were on testosterone and blockers. Four different measures of wellbeing (depression, quality of life, suicidal ideation) were tracked, controlling for engagement in counselling, and all measures of wellbeing showed improvements with treatment. A key measure of depression showed a reduction from levels indicating clinical depression to below the threshold for clinical depression. (Mean baseline CESD-R score was 21.4 and decreased to 13.9 – A score less than 16 implies no clinical depression)”. The study concludes that endocrine intervention may improve mental health in transgender youth.

A 2020 cross-sectional survey (Turban) of 20,619 trans adults (aged 18-36) used multivariable logistic regression to examine associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality. 3,494 adults (16.9%) reported that they had wanted pubertal suppression, but only 89 (2.5%) had received it. After controlling for other variables, pubertal suppression was associated with decreased odds of lifetime suicidal ideation – 90% of those who had not received blockers had experienced suicidal ideation, compared to 75% in those who had had blockers at an average age of 15. The study adds to evidence on the relationship between pubertal suppression and positive mental health outcomes. It avoids the physical changes known to cause significant distress, and when provided in affirmative care may also protect against minority stress.

A 2020 study (Miesen) compared three groups for emotional and behavioural problems (internalizing, externalizing, peer relations, and suicidality), assessed by youth self-report. They compared 272 adolescents (mean age 14.5 years) who had been referred to a specialised gender identity clinic and were undergoing assessment but had not yet received puberty blockers, with 178 transgender adolescents (mean age 16.8 years) who were on puberty blockers and about to receive HRT – the two trans groups did not differ in scores at baseline (when first assessed in the gender clinic). These two groups were compared with a comparison sample of 651 Dutch high school cisgender adolescents from the general population (mean age 15.4 years). Results: Before medical treatment, clinic-referred adolescents showed more internalising problems and reported increased self-harm/suicidality and poorer peer relations compared with their age-equivalent peers. Transgender adolescents receiving puberty suppression had fewer emotional and behavioural problems than the group that had just been referred to transgender care and had similar or fewer problems than their same-age cisgender peers. Before treatment 31.3% of trans youth had clinical levels of internalising problems, whereas amongst trans youth receiving puberty blocker treatment and about to start HRT only 16.3 % had clinical levels of internalising problems, lower than in the cisgender sample (22.9%). Before treatment 17.3% of trans youth had clinical levels of externalising problems, whereas amongst trans youth receiving puberty blockers and about to start HRT 14% had clinical levels of externalising problems, similar to the cisgender sample (13.8%). In suicidality, this was reported by 27.2% of trans youth before treatment, whereas in the sample of trans youth receiving puberty blockers and about to start HRT it was 12.4% – similar to the cisgender sample (11.9%). Conclusions: Transgender adolescents show poorer psychological well-being before treatment but show similar or better psychological functioning compared with cisgender peers from the general population after the start of specialized transgender care involving puberty suppression. The study provides further evidence that trans youth could benefit from gender affirmative care. “A clinical implication of these findings is the need for worldwide availability of gender-affirmative care, including puberty suppression for transgender adolescents to alleviate mental health problems of transgender adolescents”. “This first study comparing a group of transgender adolescents just referred for gender-affirmative care, a group of transgender adolescents receiving treatment with puberty suppression, and a group of cisgender adolescents, from the general population showed that when affirmative care involving puberty suppression is provided, transgender adolescents may have comparable mental health levels to their cisgender peers. This type of gender-affirmative care seems thus extremely important for this group”.

A 2020 study from the Netherland (Brik) examined the trajectories of trans and gender questioning adolescents after initiation of blockers. Prior to 2016 the clinic protocol required adolescents to be 16, and on blockers for at least 6 months, before they could start HRT. From 2016 youth could progress to HRT at age 15 if they had been on blockers for 3 years, and from 2017 the protocol shifted again to allow progression to HRT at age 15 if they had been on blockers for 2 years. The study looked at 143 adolescents who were deemed eligible for puberty blockers, all of whom started blocker treatment between November 2010 and January 2018. This included 38 trans girls, median age for starting blockers was age 15 (range 11.1-18.6) and 105 trans boys, median age for starting blockers 16.1 years (range, 10.1–17.9). Treatment status as of July 2019 was reviewed.

From the sample of 143 adolescents, 11 were too young to be eligible for HRT at the point of the study (having been on blockers for a maximum of 2.8 years). One of these 11 had stopped blockers as his parents were unable to regularly take him to collect medication and get it injected and had instead switched to other medication to stop periods, being too young to be eligible for HRT).

132 adolescents were old enough to be eligible for HRT. 123/132 (93%) had gone from just blockers onto HRT. Median age at the start of gender-affirming hormones was 16.2 years (range, 14.5–18.6 years) in trans girls and 17.1 years (range, 14.9–18.8 years) in trans boys. The majority of these (103/132) had proceeded to HRT as soon as they were eligible. 19/132 had what the clinic called an extended amount of time on just blockers before going on to HRT. This extended time on blockers ranged from 0.8 years to a maximum of 2.4 years, with a median duration of 1 year. Reasons for spending an extended time on just blockers included i) lack of family support (n=6) ii) lack of safe home/school absenteeism n=5) iii) what the authors call a ‘comorbidity’ like autism or depression (n = 8) or iv) logistical issues (n=8). One adolescent was kept on blockers for an extended period for additional assessment due to being non-binary. Only one adolescent had additional time on blockers to allow the adolescent more time for decision-making about gender-affirming hormone treatment. Those delayed because of mental health or psycho-social issues had monthly mental health appointments during the extended period on just blockers. 1 youth had moved clinic and at age 17 had decided to stay on just blockers for a while longer, delaying initiation of testosterone until after exams, having been on blockers for 2.5 years.

From the 132 adolescents old enough to be eligible for HRT, 3 (2%) stopped taking blockers but later went on to HRT. 1 of these, a trans boy, experienced hot flushes, an increase in migraine and fear of injections in addition to problems and school and unrelated medical issues and wished to temporarily discontinue blockers. He restarted blockers after 5 months and later proceeded on to HRT.  One of these, a trans boy, interviewed at age 19, reported an increase in mood problems and suicidal thoughts and confusion attributed to GnRHa treatment and stated: “I was already fully matured when I started GnRHa, menstruations were already suppressed by contraceptives. For me, it had no added value”. The third case, a transboy, experienced mood swings starting 4 months after he had begun GnRHa treatment. A year later, he started to frequently feel unwell and miss school. After 2.2 years, he developed severe nausea and rapid weight loss for which no cause was identified. Because of this deterioration of his general condition, he wished to discontinue GnRHa treatment after 2.4 years. He gradually recovered over the next 2 years and subsequently started HRT.

From the 132 adolescents old enough to be eligible for HRT, 5 (4%) stopped blockers and reported no wish for gender affirming treatment at this time. Their identities and stories were individual. Two described non-binary identities. One had psycho-social problems. One found the period on blockers helpful in understanding a cisgender identity. One described falling in love and questioning his gender identity before identifying with his assigned gender.

In conclusion: Out of the 132 adolescents old enough for HRT, 126 (95%) were on HRT at the time of the study, 1 had chosen to extend their time on blockers before HRT, and 5 (4%) had decided not to have gender affirming treatment. The adolescents and parents were asked their views on GnRHa. All felt free to stop GnRHa.  Some stated it gave them time to think and feel who they were and what they wanted in the future and felt that without GnRHa treatment they would not have been able to make these decisions. Others stated that GnRHa should not be routinely offered before the start of gender-affirming hormones when adolescents are already fully matured, because of the lack of physical benefits. Instead, a consideration time of 6 months with psychological follow-up was suggested.

Continued questions

Despite the decades of studies, critics of blockers continue to claim they are new and experimental, a claim refuted by  Giordano and Holm in a 2020 paper. Critics also point to low quality evidence, especially lack of randomised control trials. However, a wide number of studies comment on the impossibility of conducting randomised control trials on this cohort. A 2011 paper (De Vries) by the leading practitioners at the time from the Netherlands states “Finally, this study was a longitudinal observational descriptive cohort study. Ideally, a blinded randomized controlled trial design should have been performed. However, it is highly unlikely that adolescents would be motivated to participate. Also, disallowing puberty suppression, resulting in irreversible development of secondary sex characteristics, may be considered unethical.” Giordano and Holm (2020) are stronger, being clear this “particular use cannot be investigated by a RCT ”. Rosenthal (2014) agrees “Furthermore, randomized controlled trials for hormonal interventions in gender-dysphoric youth have not been considered feasible or ethical ”.

The latest 2020 paper (Brik) similarly states: “A randomized controlled trial in adolescents presenting with gender dysphoria, comparing groups with and without GnRHa treatment, could theoretically shed light on the effect of GnRHa treatment on gender identity development. However, many would consider a trial where the control group is withheld treatment unethical, as the treatment has been used since the nineties and outcome studies although limited have been positive. In addition, it is likely that adolescents will not want to participate in such a trial if this means they will not receive treatment that is available at other centers. Mul et al. (2001) experienced this problem and were unable to include a control group in their study on GnRHa treatment in adopted girls with early puberty because all that were randomized to the control group refused further participation“.

Although global consensus for puberty blockers is strong, a variety of different views remain. A 2015 study (Vrouenraets) interviewed psychiatrists, psychologists and endocrinologists from 17 treatment teams worldwide, gaining insights into the views underpinning different attitudes towards treatment. Those opposed to treatment diverged from those who supported treatment in their view on whether gender dysphoria is natural variation or mental illness; the potential role of puberty in developing identity; the role of comorbidity; and the physical or psychological effects of enabling or denying intervention.

Ethics are discussed in a number of articles. Giordano reviewed the ethics for and against puberty blockers over a decade ago, in 2007 and 2008, noting the high risk outcomes in trans children who could not access medical intervention. They concluded that “suspension of puberty is not only not unethical: if it is likely to improve the child’s quality of life and even save his or her life, then it is indeed unethical to defer treatment”. Giordano and Holm followed up in 2020 with a review of the latest studies, highlighting the evidence of benefits and reinforcing the earlier conclusion on the ethical prerogative to provide treatment.

A 2017 article (Giovanardi) on ethics from a fly-by-night unrated journal is discredited for misrepresenting key literature (as discussed here, the researcher whose research is misrepresented made a complaint but the journal had folded before the paper could be retracted or corrected).

Lopez (2018) examines data on puberty blocker implants for precocious puberty as compared to trans adolescents. In a 2016 dataset blockers were used in 512 cases for precocious puberty at average age 8.9 years olds, whereas they were only used in 62 cases for trans adolescents at an average age of 14 years old. The age-based arguments against trans adolescents accessing blockers do not seem to apply for the much younger cohort in precocious puberty, suggesting it is not the medication or the age of use that people have a problem with, but rather its use for gender dysphoric adolescents.

A 2020 article (Pang) examines the ethics of extended puberty blocker treatment for an agender teen – a teen who started blockers at 12, is now 15 and wants to continue on just blockers till 18. One commentator contrasts the two main risks; impaired fertility in the future and low bone density, with the one key benefit: continued alleviation of gender dysphoria and anxiety. They quantify the bone density related risks: with a bone density in the lowest 2.5 percentile a person “has a 0.2% to 0.3% risk of sustaining a hip fracture and a 1% to 2% risk of other fractures in the next 5 to 10 years compared with a control with normal bone density (0% risk of hip fracture and 0.7%–1% risk of other fractures in the next 5–10 years).” They highlight that the adolescent and/or their parents may still decide that these risks are outweighed by the potential psychosocial benefits from relieved gender dysphoria. Another commentator, whilst recognising the clear benefits of puberty blocker usage, highlights that with shorter term use (2 years), bone density increases significantly once sex hormones are introduced, and recommends a shorter time on blockers to promote optimal bone density.


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Miesen, A. I. R. van der, Steensma, T. D., Vries, A. L. C. de, Bos, H., and Popma, A. (2020). Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. Journal of Adolescent Health 66, 699–704. doi:10.1016/j.jadohealth.2019.12.018.

Murchison, G., Adkins, D., Conard, L. A., Ph, R., Ehrensaft, D., Elliott, T., et al. (2016). Supporting & Caring for Transgender Children’. Human Rights Campaign Available at: [Accessed October 3, 2019].

Oliphant, J., Veale, J., Macdonald, J., Carroll, R., Johnson, R., Harte, M., et al. (2018). Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand. Available at: [Accessed October 3, 2019].

Pang, K. C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., et al. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics 145. doi:10.1542/peds.2019-1606.

Rosenthal, S. M. (2014). Approach to the patient: transgender youth: endocrine considerations. J. Clin. Endocrinol. Metab. 99, 4379–4389. doi:10.1210/jc.2014-1919.

Schagen, S. E. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., and Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. J Sex Med 13, 1125–1132. doi:10.1016/j.jsxm.2016.05.004.

Schneider, M. A., Spritzer, P. M., Soll, B. M. B., Fontanari, A. M. V., Carneiro, M., Tovar-Moll, F., et al. (2017). Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression. Front Hum Neurosci 11, 528. doi:10.3389/fnhum.2017.00528.

Staphorsius, A. S., Kreukels, B. P. C., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E. E., et al. (2015). Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology 56, 190–199. doi:10.1016/j.psyneuen.2015.03.007.

Telfer, M.M., Tollit, M.A., Pace, C.C., & Pang, K.C. (2018). Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Chil-dren and Adolescents. Melbourne: The Royal Children’s Hospital Available at: [Accessed October 4, 2019].

Turban, J. L., King, D., Carswell, J. M., and Keuroghlian, A. S. (2020). Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics 145. doi:10.1542/peds.2019-1725.

Vlot, M. C., Klink, D. T., den Heijer, M., Blankenstein, M. A., Rotteveel, J., and Heijboer, A. C. (2017). Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone 95, 11–19. doi:10.1016/j.bone.2016.11.008.

Vries, A. L. C. de, McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., and Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics 134, 696–704. doi:10.1542/peds.2013-2958.

Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., and de Vries, M. C. (2015). Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study. J Adolesc Health 57, 367–373. doi:10.1016/j.jadohealth.2015.04.004.

Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., and de Vries, M. C. (2016). Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth. Arch Sex Behav 45, 1697–1703. doi:10.1007/s10508-016-0764-9.

Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., et al. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med 15, 582–590. doi:10.1016/j.jsxm.2018.01.016.

World Professional Association for Transgender Health (WPATH). (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.

TGEU Rapid Response: Europe Failing Trans Children

Europe trans flag

Every year TGEU (Transgender Europe) releases an index of key indicators on trans rights, along with a map highlighting the performance across the continent (Europe and Central Asia).

The 2020 map, indicator and key stats are available here.

Frustratingly, in spite of requests for inclusion, there is still no analysis specific to trans children’s rights across Europe..

Taking the TGEU data, I’ve selected the six indicators that relate specifically to trans children, and highlighted the performance across the continent. These relate to the areas of Legal Recognition (3 indicators), Health (2 indicators) and Non-Discrimination (1 indicator). These six indicators are the only data collected by TGEU which have relevance for transgender children & young people and provide coverage of basic or fundamental rights.

The results are absolutely shameful.

RED: Actively hostile with little or no fundamental rights for trans children.

63% (31 out of 49 countries) meet 0 or 1 indicators with 9 scoring 0 for failing to provide even the very basics of non discrimination. The country is actively hostile to the very existence of trans children.

AMBER: Rudimentary rights for trans children.

30% (15 countries) meet only a few of the basic rights of trans children (score 2 or 3), These countries are failing trans children. This includes the UK where there is no legal recognition, nor coverage of health indicators, including no anti-conversion therapy legislation, in spite of signposting for government prioritisation following the National LGBT survey of 2018.

YELLOW: Moderate fundamental rights for trans children.

The single country meeting 4 or 5 indicators is Luxembourg, which meets the basics for Legal protection and non discrimination but does not meet either of the indicators for health.

GREEN: Fundamental rights for trans children are met.

Only 4% (two countries), meet all the fundamental rights of trans children and young people with 6 indicators in all three areas. Spain and Malta.


Only 6% (3/49) of European countries have even moderate fundamental rights for transgender children and young people.

We need more people to care about this.

We need rights organisations (Stonewall, Amnesty, TGEU, Save the Children, UNICEF, Plan International) to collect data, and analyse this data, to help us hold government’s to account for the gross failings towards the rights of trans children across Europe. We need TGEU members to start asking TGEU to provide analysis specific to trans children and young people.

The six indicators above are a snapshot, taken from the TGEU 2020 dataset. There are other indicators that could be tracked that would give an even clearer picture of the ways in which Europe fails trans children. We need to start including dis-aggregated data in our analysis on trans rights, dis-aggregation that shows the specific ways in which trans children are failed. We need to start collecting data specific to trans children. We need dis-aggregated analysis of the data that we do have. And we need to start raising our voices about the rights violations that trans children face across Europe and beyond.

Who can help in this endeavour?

Mermaids – Time for Trans Accountability

Susie Green has been at the helm of Mermaids for more than 7 years, taking Mermaids from a tiny unknown, unregistered cis parent support group (with varied levels of trans positivity) to a substantial, internationally recognised, multiple award winning, formalised charity, with many trans staff members, a multi-million pound budget, and high commitment to the rights and well-being of trans children. I have an enormous amount of respect for Susie and how she has fought for trans kids against pressures and challenges that would have broken many other people.

Today it was announced that Susie is no longer in post, with a short statement from Mermaids reporting that an interim CEO will shortly be appointed.

Mermaids has been of vital importance to my family – to many, many trans kids and families. Mermaids remains an important stakeholder in supporting trans children and their carers, in advocating for trans kids’ rights to healthcare, to education, to safety, equality, and well-being.

At this moment in time, strong, trans-positive leadership from Mermaids is critically important.

The threats to trans children in 2022 are more worrying than ever. There are threats to trans kids’ rights at school, threats to access to healthcare, even threats to trans kids’ ability to socially transition and be safe from the harms of conversion practices.

We cannot afford to have weak or conservative cis leadership at Mermaids. We need a Director in post who understands the severity of the threats to trans children of all ages – a person who will stand up and be counted. We need a strong and trans positive leader of Mermaids, now more than ever.

I publicly call on the Mermaids board to take the opportunity at this exact moment in time to strengthen accountability to trans communities.

I call on the Mermaids board to appoint a Trans Advisory Panel to oversee the recruitment of the new Mermaids CEO.

One option for forming this Trans Advisory Panel, would be to seek guidance from existing trans led governance forums, specifically, the Good Law Project and the Trans Learning Partnership, both of which have effective Trans Advisory Panels and might take a role in establishing Mermaids’ own Trans Advisory Panel.

Mermaids needs to retain trust and confidence from both the trans community and the community of parents and carers of trans children, through this period of change. Taking this opportunity to improve accountability to trans communities would be a powerful signal that service users can maintain confidence in the future direction of Mermaids as a world leading trans support and advocacy organisation.

Please join me in this call for the Mermaids board to strengthen accountability and oversight to trans communities before appointing a new CEO.

NHS service specification: A dangerous attack on trans kids

NHS England has just released a consultation on a revised Service Specification for trans children and adolescent health care.

The revised specification is dangerous, ideologically-driven, and will cause serious harm to trans kids in the UK.

There are many many deficiencies and areas of outrage in the draft.

It has been written with dangerous bad intent (I wonder who in NHS England wrote it).

We need collective action to fight for trans kids’ rights, so I’m putting my work-in-progress analysis here for others to build from.

I have divided my feedback into 27 categories:

1. Inclusion of outdated and ill-informed presumptions on trans children’s identities.

2. Omission of modern & relevant evidence on trans children’s identities

3. Inclusion of outdated, mis-placed & mis-interpreted evidence on social transition

4. Omission of modern & relevant evidence on social transition

5. Cisnormative, pathologising, unevidenced approach to social transition being an ‘intervention’

6. Omission of harms of denied transition

7. Fails to condemn conversion practices

8. Pathologising & incompatible with ICD-11

9. Intrusive and inappropriate assessment

10. Redefining EA2010 protections to remove & medicalise rights for trans children

11. Misapplication of ‘safeguarding’ to threaten access to life-saving healthcare

12. Ignorant of flaws in dysphoria definitions

13. Ignorant of potential for harm in adding extra GP layer into referral

14. Ignorant of harms of denial of healthcare

15. No centring of child rights to healthcare

16. No centring of healthcare accountability or mechanisms to empower service users

17. Presentation of psychoeducation as treatment for dysphoria

18. No emphasis on psycho education to raise trans positivity

19.  No centring disability & neurodiversity rights

20. Failure to recognise gender minority stress as key driver of mental health differentials

21. Suggests intrusive search for causation

22. Leaves space for gender exploratory therapy

23. Uses dated and unscientific language for ideological purposes to illegitimise and disenfranchise

24. Emphasis on MDT

25. Failure to centre endocrine care pathways

26. Failure to engage with trans expertise

27. Under-planning for expected population

  1. Inclusion of outdated and ill-informed presumptions on trans children’s identities.

[Service spec page 1] “clinical support around the development of their gender identity”.

Framing support for trans children around ‘development’ of their gender identity is ill-informed, prejudiced against trans people, and unrepresentative of the modern evidence base (see point 2 below)

[Service spec page 2] “being mindful that this may be a transient phase, particularly for pre-pubertal children”.

This statement is unreferenced, and does not align with modern evidence (see point 2). Documents that do provide a citation for such a claim tend to rely on a number of very old citations that used old diagnoses that included children who were gender non-conforming rather than trans. A majority of these children did not end up trans because they were not trans in the first place. Using older research to claim that trans children’s identity is likely to be a transient phase is harmful bad science, at best a misunderstanding of the meaning of the older evidence base, at worst the knowing mis-representation of older evidence for ideological goals.  

[service spec page 8] “research will include” “prediction” “the course of gender querying”

The service’s research goals are aligned with cis people’s fears, not with trans children and adolescent’s needs.

[service spec page 8] “an individual’s route will be determined by…. The clarity, persistence and consistency of gender incongruence”.

This requirement discriminates against trans children who assert their identity at puberty, those who were not distressed in early childhood, those whose families do not recognise the period of their distress, those who need healthcare without being currently distressed, and those who hid their identity out of fears of rejection or societal judgement. It also fails to consider the timeliness of healthcare needs especially for those experiencing an significant increase in distress at the point of puberty, and the fact that interventions such as puberty blockers are particularly valuable for those adolescents who arrive at the service at the cusp of puberty with fear and distress requiring immediate access to puberty blocking support.

[service spec page 12] “assessments will focus on the child’s understanding of gender”

Trans children do not need to have a theoretical or conceptual understanding of gender and should not be expected to demonstrate to clinicians an understanding of gender. Existing research shows that children experience intrusive questioning on gender irrelevant, intrusive and harmful.

[service spec page 13] “psycho-education material for children, parents… will include information on gender identity development including research evidence and how to support an exploratory approach”.

Given how poorly this service spec reflects existing evidence, I would be extremely concerned about the materials provided to parents. Misguided and misinformed information sent to parents will cause harm and undermine support for trans children.

[service spec page 13] “the clinical approach in regard to pre-pubertal children will reflect evidence that suggests that… in most pre-pubertal children, gender incongruence does not persist into adolescence”.

The above cites the Endocrine Society statement “combining all outcome studies to date, gender incongruence of a minority of prepubertal children appears to persist in adolescence”.

It is important to note that the Endocrine guidelines themselves provide a longer quote on this topic

“However, the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/ gender incongruent in adolescence (Source: Steensma TD, Kreukels BP, de Vries AL, Cohen-Kettenis PT. Gender identity development in adolescence. Horm Behav. 2013; 64(2):288–297.

Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). In adolescence, a significant number of these desisters identify as homosexual or bisexual. It may be that children who only showed some gender nonconforming characteristics have been included in the follow-up studies, because the DSM-IV text revision criteria for a diagnosis were rather broad. However, the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood (41, 42). With the newer, stricter criteria of the DSM-5 (Table 2), persistence rates may well be different in future studies.”

The NHS has here chosen to omit the important clarification within the Endocrine guidelines, that highlights that even back in 2017 it was recognised that the ‘desistance’ statistics rely on old definitions that focused on gender non-conforming children rather than trans children, and that newer studies focused specifically on trans children expect to find a different outcome.

The citation about collective studies showing high rates of desistance from the 2017 Endocrine society cites a 2013 study by Steensma, which in turn cites a 2011 literature review again by Steensma.

Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology and Psychiatry. 2011;16(4):499-516. doi:10.1177/1359104510378303

In this 2011 literature review, statistics are drawn from studies published in 1968, 1972, 1979, 1984, 1986, 1987, 1987, 1995, 2008, 2008. The vast majority were published last millennium, drawn from research conducted even earlier, research that focused on gender non-conforming children who were problematised lest they grow up to be gay. Several of those studies were outright conversion therapy studies for gender non-conforming children, with methods that were coercive and abusive.

Ten studies are included in the 2011 literature review and these are the ten studies upon which the NHS is basing 2022 clinical practice. Take a look at the titles of these ten studies:  

Bakwin H. (1968). Deviant gender-role behavior in children: Relation to homosexuality. Pediatrics, 41, 620–629.

Davenport C. W. (1986). A follow-up study of 10 feminine boys. Archives of Sexual Behavior, 15, 511–517.

Drummond K. D., Bradley S. J., Peterson-Badali M., Zucker K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental Psychology, 44, 34–45.

Green R. (1987). The “Sissy Boy Syndrome” and the development of homosexuality. New Haven, CT: Yale University Press.

Kosky R. J. (1987). Gender-disordered children: Does inpatient treatment help? Medical Journal of Australia, 146, 565–569.

Lebovitz P. S. (1972). Feminine behavior in boys: Aspects of its outcome. American Journal of Psychiatry, 128, 1283–1289.

Money J., Russo A. J. (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.

Wallien M. S. C., Cohen-Kettenis P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.

Zucker K. J., Bradley S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press.

Zuger B. (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.

Even from the project titles you can see these early research projects had a problem with femininity, ‘sissy-ness; ‘effeminancy’ or ‘proto-homosexuality’ in boys. These were not research projects on trans kids, but on kids who were deemed insufficiently masculine, many with explicit goals of teaching young boys to toughen up to prevent them becoming a ‘homosexual deviant’. The fact that many of these young boys grew up to be gay men rather than trans women tells us nothing about outcomes for today’s trans kids.

The authors of the above studies are also synonymous with key figures in conversion practices, especially conversion practices to try to prevent homosexual outcomes. Bryant, the child who in the 1970s was at the centre of the ‘sissy boy’ research project (Green, 1987, included above) went on to in the 2000s write his PhD on the damage of this research, how he felt rejected and coerced and was deeply harmed (see Bryant, 2005).

These abusive studies predominantly on boys who were deemed insufficiently masculine are entirely meaningless in driving clinical practice for trans kids in 2022. Why are they guiding clinical practice on trans kids and social transition in 2022? And why does the NHS cite them via a citation in a 2017 Endocrine Society endocrine guidance note that cites a 2011 literature review that cites the above texts, rather than actually owning up to based clinical practice on 50 year old conversion therapy literature?

I’ve been writing about this for over 5 years see

In the time since the publication of the Endocrine guidelines in 2017, the validity of the claim that trans children ‘desist’ in their identities has been strongly critiqued in the literature.

Even focusing just on the more recent of those studies, those published in 2008, gives serious cause for concern, with those studies widely condemned as both flawed and misinterpreted (Ehrensaft et al., 2018; Priest, 2019; Temple Newhook et al., 2018a, 2018b), critiqued for “methodological, theoretical, ethical, and interpretive concerns” (Temple Newhook et al., 2018a, p. 1). 

These older statistics on ‘desistance’ are also challenged by more modern research, with recent longitudinal studies from Australia (Tollit et al., 2021), USA (Olson et al., 2022) and Spain (De Castro et al., 2022) showing a large majority of trans and non-binary children and adolescents continuing to identify as trans or non-binary (96% across child and adolescent age groups in Australia over a ten-year period, 97.5% of children under 12 at 5 year follow up in the USA, and 97.6% of children and adolescents at 2.6 year follow up in Spain). 

[service spec page 13] “the approach will focus on careful observation of how gender dysphoria develops as puberty approaches and is reached”.

This statement that gender dysphoria needs to be observed (and the inference it is likely to change or desist) as puberty approaches is not evidenced.

Within older literature there is one study that mirror this language, which is now considered discredited as a source on this topic.

Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011;16(4):499–516.

This older 2011 paper has in the past been cited to suggest puberty is diagnostically important for determining which children will persist in their identity. This study in fact does not demonstrate this, it instead demonstrates the following:

Social divisions: 25 people aged 14-18 reminisced about their experiences at the age of about 10, a time when social divisions between boys and girls increases in the Netherlands. 14 children who were still registered with the gender identity service in adolescence recall at that time of increased social division having wanted to be grouped with the children of the opposite gender to their assigned gender and wanting to socially transition. 11 children who had left the service before the age of 12, recall having wanted to be grouped with their assigned at birth gender and having not wished to socially transition.

View of puberty: 11 children who were in the service in childhood but left the service before the age of 12 and did not apply for puberty blockers, remember not having been distressed by the idea or the reality of pubertal changes. 14 children who were still in the service in adolescence and who applied for blockers remember being distressed at pubertal changes.

Sexual attraction: In a sample of 25 people registered at the gender clinic in childhood, when interviewed in adolesence, 14 transgender people were heterosexual, 5 cisgender girls were heterosexual and 6 cisgender boys had a variety of sexual orientations.

None of the above is evidence that puberty is diagnostically important for distinguishing between children who will or who will not need medical intervention at puberty. The study mis-cites the conclusions that can be drawn from the evidence at hand, and these mis-citations cannot still be influencing policy over a decade later when they have been called out time and again as flawed and mis-used.

[service spec page 13] “family/social circumstances that may impact on a child’s gender dysphoria”

There is no evidence that family circumstances impact on gender dysphoria, whereas there is significant evidence that family rejection impacts on poor mental health in trans children who are not affirmed.

  • 2. Omission of modern & relevant evidence on trans children’s identities.

Research by Olson (2015) and Fast (2017) shows that:

“Transgender children do indeed exist and their identity is a deeply held one.”

“Three- to 5-year-old socially transitioned transgender children did not differ from controls or siblings on gender preference, behaviour, and belief measures.”

“Transgender children aged 5-12 viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender control groups.”

“These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.”

(research) “findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.”

Olson, K.; Key, A.; Eaton, N. (2015) Gender Cognition in Transgender Children Psychological Science

Fast, A & Olson, K. (2017) Gender Development in Transgender Preschool Children, Child Development

Research has shown that trans children’s may hide their identity for months or years before disclosing it to family, and hence a ‘sudden’ assertion to a parent or outsider may commonly have been long thought about by a child.

  • 3. Inclusion of outdated, mis-placed & mis-interpreted evidence on social transition

[service spec page 10] “in some cases a further consultation may be appropriate following further local assessment and intervention and or a process of watchful waiting”.

[service spec page 13] “support an exploratory approach that allows a child time and opportunity to consider different options in a flexible and non-judgemental context”.

[service spec page 14] “the clinical approach has to be mindful of the risks of an inappropriate gender transition and the difficulties that the child may experience in returning to the original gender role upon entering puberty if the gender incongruence does not persist into adolescence”

This reference to ‘difficulty returning to original gender role’ relies on one single (uncited) source which can be traced back to a letter to the editor from 2011 ((Steensma & Cohen-Kettenis, 2011) referencing the case of two Dutch children. A closer analysis reveals that neither of the two children referenced in that letter, in fact none of the children in that study, had experienced social transition according to today’s definition (Ashley, 2019a). They had non-conforming gender expression, but did not change pronoun or name, and they remained referred to as their gender assigned at birth (Steensma et al., 2011). The usage of this case, involving a small number of children who did not socially transition, to justify restrictions on supporting trans children, can be considered inappropriate, and ethically flawed (Ashley, 2019a).

Critiques of the shoddy evidence base on supposed harms of social transition are now well established and its continued use to caution against social transition is unacceptable in 2022.

This part of the NHS specification contrasts strongly with the 2017 Australian standards of care which state “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”.

[service spec page 14] “for pre-pubertal children the clinical approach… will be a watchful approach overall….with a more individualised approach where the child’s level of global functioning may be maintained or improved through a carefully observed process of exploration of social transition”

[service spec page 15] “not all adolescents will want or benefit from social transition”

This sentence conflates two very different concepts.

The part on adolescents not benefitting from social transition is completely unevidenced. It also fails to consider the harms of attempting to prevent an adolescent from social transition and the control and coercion associated with such denial of self-actualisation.

‘Watchful waiting’ as a clinical approach is not supported by evidence, and is better framed as ‘delayed transition’. Significant critique is available of the harms of preventing or delaying transition (as explored further below).

[Service spec page 15] “approaches to support social transition may be considered in cases where 1) gender dysphoria is diagnosed, consistent and persistent”

Gender dysphoria does not need to be diagnosed for a social transition. Nor does it need to be consistent or persistent. This is not evidence based.

[Service spec page 15} “AND the young person…fully understands the implications of affirming a social transition (informed consent)”

A young person, particularly a young child, should not be expected to understand or predict the implications of a social transition before being affirmed in their identity. A social transition is not a medical intervention or a medical decision and inclusion of informed consent is not appropriate here. Denying a child or adolescent’s identity is a far bigger intervention and interference, than supporting a child’s identity. This is wrong and harmful. It also fails to recognise that ‘understanding implications’ is likely to focus on the risks of being trans in a transphobic world, and is likely to scare a child into trying to conform to their assigned identity. It is inherently a conversion practice.

[service spec page 15] “AND the clinical approach is necessary for the alleviation of clinically significant distress”

Whilst social transition can certainly ameliorate clinically significant distress, trans children should not experience, or demonstrate the potential of experiencing, clinically significant distress before being supporting in their identity. There also needs to be consideration of trans joy – of maintaining the potential for trans children and adolescents to have a happy childhood. Protection of trans joy, or trans normal levels of well-being are as important as preventing clinically significant distress.

[Service spec page 15] the clinical approach will involve a focus on exploring or supporting social transition through psychological support, family work/therapy…”

This fails to recognise that supported trans children living in supportive trans positive environments do not need psychological or family therapy. This needs to be stated explicitly here.

[service spec page 15] “Young people and their families will be supported in making difficult decisions regarding the expression of a gender role that is consistent with their gender identity”

This fails to consider the harms where a child suppresses their gender expression or identity. It fails to focus on the reason why it may be difficult, which is inherently life in a world where trans identities are problematised or where prejudice exists. This needs to emphasise that in this situation the difficult decision centres around building safe environments for that child to thrive in, rather than considering options where a child’s is compelled to suppress their identity.

This whole section also very much suggests a social transition is a one time event (or a mistake) rather than a step that can be taken several times, that can be itself part of exploration and self-discovery, that can be a light-hearted journey rather than a heavy and weighty diagnosis and medicalised intervention.

[service spec page 16] “Decisions about gender expression are thoughtfully considered…(even) if a young person has changed gender role prior to being seen by the service”

Why is a medicalised gender service getting involved in children’s gender expression. It does not need to be thoughtfully considered in clinical practice.

  • 4. Omission of modern & relevant evidence on social transition

Affirmative approaches advise supporting a child in their identity, prioritizing current well-being without age based barriers on acceptance (Ehrensaft et al., 2018; Temple Newhook et al., 2018b). This approach views family acceptance as critical for child self-esteem and mental health, for those children whose identity will remain constant into adulthood, as well as for those who may have a more fluid identity, including those who may go through two or more ‘social transitions’ (Ehrensaft, 2021; Keo-Meier & Ehrensaft, 2018b; Temple Newhook et al., 2018a).

A growing body of evidence supports affirmative approaches that include support for pre-pubertal social transition (Durwood et al., 2021; Olson & Gülgöz, 2018; Rae et al., 2019). Research on socially transitioned trans children has shown positive mental health and well-being outcomes, in contrast to high levels of depression, self-harm and suicidal ideation in those denied affirmation (Durwood et al., 20172021; Olson et al., 2016; Olson & Gülgöz, 2018). Research highlights the importance of family support in trans well-being, with contrasting research demonstrating the links between family rejection and suicidality, PTSD and depression (Katz-Wise et al., 2018; Klein & Golub, 2016; Pollitt et al., 2021; Russell et al., 2018; Simons et al., 2013; R. Travers et al., 2012). 

A majority of healthcare guidance published since 2015 supports pre-pubertal social transition, recommending affirmative approaches to supporting trans children, including guidance from the American Academy of Pediatrics (Rafferty et al., 2018), the Pediatric Endocrine Society Special Interest Group of Transgender Health (Lopez et al., 2017), and from national healthcare standards in Australia (Telfer et al., 2018) and New Zealand (Oliphant et al., 2018).

A study with 73 socially transitioned trans children aged 3 to 12 years found they had high levels of mental health, with levels of depression similar to cis children (Olson et al., 2016). A follow-up study on 116 socially transitioned trans children aged 6 to 14 years found high levels of mental health and self-worth in socially transitioned trans children, concluding “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 et al., 2017, p. 1).

UK based research has highlighted the benefits of social transition

Parents within this sample also evaluated the benefits of social transition, describing it as protective for their child’s happiness and well-being. Parents rejected any suggestion that supporting a pre-pubertal social transition was risky, instead emphasizing the risks of continuing to reject their child. Parents reflected upon advice for other families, emphasizing how positive it had been for their child. Parents were unanimous in recommending other parents to follow their child’s lead, affirming them in the present, perceiving this as safeguarding their child’s well-being, happiness and self-esteem.

Horton, C. (2022). “I never wanted her to feel shame”: Parent reflections on supporting a transgender child. Journal of LGBT Youth.

Other UK research has included children’s voices and perspectives on social transition

The first major theme explored experiences pretransition, with subthemes on children correcting assumptions, becoming distressed, struggling alone, reaching crisis, or growing withdrawn and frustrated. The second major theme examined experiences posttransition, with subthemes on a weight being lifted, validation at school, and well-being. This qualitative research complements existing quantitative evidence on the importance of social transition, with childhood affirmation critical to the happiness and well-being of trans children.

Horton, C. (2022). “Euphoria”: Trans children and experiences of pre-pubertal social transition. Journal of Family Relations.

  • 5. Cisnormative, pathologising, unevidenced approach to social transition being an ‘intervention’

A ‘social transition’ need not entail an end point, and may also provide an opportunity for self-understanding through, rather than just before transition (Ashley, 2019b). Bioethicist Florence Ashley (2019b, p. 6) points out that “changing names, pronouns, and undergoing transition-related interventions is routinely used by trans people in an exploratory manner, largely to positive effect.”

Ashley highlights that the categorization of ‘social transition’ as a clinical ‘intervention’ requiring justification and evidence is itself a deeply cisnormative approach; they argue that delaying or preventing a child from having their identity respected is a more active intervention in the child’s life, requiring greater evidence to justify it, than an approach that respects a child’s self-knowledge (Ashley, 2019b).

  • 6. Omission of harms of denied transition

Critics of ‘delayed transition’ argue that any potential risk of transition needs to be weighed up against the risks or harms of denying social transition (Ashley, 2021; Ehrensaft et al., 2018).

Research has shown the harms of delayed transition, with UK based research demonstrating the challenges, frustration and trauma of trans children who have experienced rejection and delay. UK research highlights that such harmful delays occur even within families who appear to be, or who have come to be affirming, with entrenched cisnormativity impeding affirmation.

“Families within this sample were unified in their positivity about supporting and affirming their child, with the only regrets spoken about being regrets at having been too slow in supporting their child. Families in this sample had experience-based insights into the negative repercussions on their child’s well-being of delay, dismissal and rejection, with every interviewee emphatic on the harms intrinsic to ‘delayed transition”. see: Horton, C. (2022). “I was losing that sense of her being happy” – Trans children and delaying social transition. LGBT+ Family Studies.

These findings also reinforce retrospective research on the negative mental health toll of childhood rejection, drawn from research with trans adults and trans youth (Ehrensaft et al., 2018; Katz-Wise et al., 2018; Priest, 2019; Turban et al., 2020; Wallace & Russell, 2013).

Further insights into the impacts of childhood rejection can be gained from retrospective research with trans adults (Kennedy, 2022; Turban et al., 2020), 

extensive literature drawing a connection between safe and affirming homes and trans youth well-being (Hill et al., 2010; Pollitt et al., 2019; Riggs et al., 2020; Russell et al., 2018).

  • 7. Fails to condemn conversion practices

explicit attempts to convert or coerce a trans child into a cis identity are condemned by mainstream health professionals (AusPATH, 2021; British Psychological Society et al., 2017; Coleman et al., 2012). Pediatric medical institutions across a number of countries have emphasized that efforts to convert trans children to a cisgender identity are both ineffective and unethical (Telfer et al., 2018). The UN Independent Expert on Protection Against Discrimination based on Sexual Orientation and Gender Identity called conversion practices “degrading, inhuman and cruel” (UN Human Rights Council, 2020, p. 21). 

A number of studies have outlined the harmful effects of conversion therapy, with the effects most pronounced on trans people who endure conversion therapy in childhood (Turban et al., 2020). Research has shown that exposure to conversion practices before the age of ten is significantly associated with severe psychological distress and lifetime suicide attempts (Turban et al., 2020). Children exposed to such practices are known to experience a severe loss of self-esteem and a sharp increase in depression, leaving them at risk of school drop-out and substance abuse (Turban et al., 2020). 

As explicit conversion therapy has moved outside of what is deemed acceptable, or in some locations legal, there remains a significant gray area, with conversion practices continuing, including from healthcare professionals, but without explicit labeling as such (Ashley, 2022). The UN report on conversion therapy underscored the harm of therapies that aim to change a child’s gender identity from trans to cis, or that hold a child being cis as preferable to a child being trans (UN Human Rights Council, 2020). The same report also emphasized that “practices aimed at changing gender identity include preventing trans young people from transitioning” (UN Human Rights Council, 2020, p. 11).

  • 8. Pathologising & incompatible with ICD-11

[service spec page 8] “research will include” “epidemiology”

[service spec page 14] “clinicians should remain open and explore…”

There is also no examination of the cisnormative bias in clinicians needing to be open and explore trans identities, when there is no such clinical exploration of cis identities.

Being transgender is now recognized by the medical establishment as a non-pathological part of human diversity, with space for trans lives to be celebrated and normalized, as a valued and important part of our families and communities (AusPATH, 2021; World Health Organisation, 2018). A medical shift away from the problematisation and pathologisation of gender diversity, has significant implications for trans children, who until relatively recently would have been diagnosed with a ‘disordered’ identity, growing up with isolation, rejection and shame (Bryant, 20062007; Gill-Peterson, 2018). 

This service specification has not grappled with the shift from ICD-10 with gender diversity pathologised, through to today’s ICD-11 where gender diversity is celebrated as part of human diversity.

Indeed the very intention of the shift to ICD-11 is to destigmatise and improve access to healthcare with the WHO stating:
In 2020, we have a better understanding of the issues surrounding this condition, and they are not related to a mental health condition.  Treating gender incongruence in a mental health chapter was causing additional stigma for an already stigmatized condition. WHO officials added the hope that adding this condition to a sexual health chapter of the ICD codes would “help increase access to care for health interventions” and “destigmatize the condition.”,incongruence%20of%20childhood%E2%80%9D%2C%20respectively.

The harms of continued pathologisation and NHS responsibilities to drive forward active depathologisation are outlined in this research

Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

  • 9. Intrusive and inappropriate assessment

[service spec page 12] “assessment will focus on psychosexual development and any sexual experience.

Literature has evidenced the harms of such intrusive and inappropriate questioning

Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

Horton, C. (2022).“Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies. 1(1-2):47-70

  • 10. Redefining EA2010 protections to remove & medicalise rights for trans children

[Equality and health Inequalities Impact Assessment section on ‘gender reassignment’]

This section is entirely unacceptable, effectively seeking to medicalise and disenfranchise trans children and adolescents through an interpretation of the protected characteristic of ‘gender reassignment’ that does not accord with the EA2010.

It suggests trans children need a diagnosis of gender dysphoria to be protected, which is not true.

It states that medical intervention is necessary to be protected, which is not true.

It even goes so far as to suggest that adolescents accessing HRT privately may not be protected under the EA2010 characteristic of gender reassignment.

Having an NHS gender service, that should be advocating for trans children and adolescent rights, instead actively seek to confuse or undermine existing rights and legal protections, is extraordinary and a dire indictment of the prejudice and poor judgement underpinning this whole service specification.

  • 11. Misapplication of ‘safeguarding’ to threaten access to life-saving healthcare

[Service spec page 12] “assessments will focus on… risk including safeguarding… including impact of any unregulated medications”

[service spec page 16]

The service needs to understand that families and adolescents looking outside of the NHS do so where the NHS has failed in its duty of care for trans youth. In my opinion, the NHS at present, and even more so in this specification, is actively harmful for trans youth. Taking steps to access essential healthcare whilst protecting trans children from the harms within the NHS model of care, is entirely appropriate. Whilst the NHS fails to provide timely depathologised healthcare, families and adolescents need to be able to access private healthcare, whilst keeping their GPs up dated.

Families with trans children, and trans adolescents already have serious trust issues with parts of the NHS. Guidance that further breaks down trust with GPs, and guidance that makes families or adolescents fear that conversations with GPs will lead to safeguarding interventions, only increases the chances of families and adolescents distancing themselves from the NHS, with consequences for wider healthcare needs.

[service spec page 18] “nor will it enter into shared care arrangements”

A blanket ban on the NHS supporting any part of healthcare sourced privately, including routine blood tests or drug administration, makes access to essential healthcare through private providers even more inaccessible, especially for families on low income. It directly prejudices against trans youth who do not have wealthy families, who will be able to access care abroad or through private provision regardless of the in-availability of shared care.  

[Equality and health Inequalities Impact Assessment section on ‘families on low income’]

Fails to consider how low income families are disproportionately impacted by failures in NHS care.

[service spec page 18] “where a young person has been prescribed hormones outside of the eligibility and readiness criteria…the service will not accept clinical responsibility…”

This means that any young person who is forced into accessing private healthcare (due to failures in NHS delivery and accessibility) will be kept out of NHS services until the age of 18. This can leave families needing to pay private healthcare costs for many years. Where family circumstances change and a family cannot continue to afford private healthcare, or where an adolescent can no longer rely on family funding, it leaves adolescents completely without access to essential medication, with no consideration of the physical and mental health risks where care is discontinued.

  • 12. Ignorant of flaws in dysphoria definitions

[service spec page 21] “appendix a diagnosis of gender dysphoria”.

The specification does not at all engage with the known deficiencies in the DSM-V diagnosis criteria.

Australia national healthcare guidance in contrast critiques the known flaws in the DSM diagnosis and makes allowances for how to provide non-stereotyped care for trans youth.

[service spec 23] “options for children who have degrees of gender incongruence but do not meet the diagnostic criteria for gender dysphoria”

Particularly the diagnosis for children is very based in stereotype, meaning that trans children who do not adhere to regressive gender stereotypes can be found sub-threshold for diagnosis, despite being trans, being socially transitioned and potentially needing access to medical intervention at puberty.

The specification notes that the DSM diagnosis will shift to the ICD-11 diagnosis, but again fails to engage with the relevance of that change in diagnostic category.  

  • 13. Ignorant of potential for harm in adding extra GP layer into referral

[service spec page 9] “referral to the service will require a consultation meeting attended by the relevant local secondary health care team and or GP”

This introduces a screening process where the child and their needs are represented by the GP. It fails to consider a huge range of problems with this model. There is significant evidence that GPs can be prejudiced, uneducated, ill-informed in this area. The small percentage of people who are at present not referred to GIDS by their GP often correspond to those who have a transphobic GP who refuses to refer to the service out of transphobic prejudice.

[service spec page 9] “outcomes following the screening process include discharge with psychoeducation”.

[service spec page 10] “in some cases a further consultation may be appropriate following further local assessment and intervention and or a process of watchful waiting”.

Giving such GPs power to represent the child’s interests in the screening discussion leaves significant room for the child to be failed in a context where GPs have no education or support on trans children. It also leaves open to yet another round of intrusive questioning of trans children – if the GP needs to represent the child in the screening process the GP will themselves need to get to know the child’s experiences, a task that many GPs are underqualified for, and a process that can be harmful to a child’s well-being and wider confidence and trust in healthcare professionals.

[service spec [page 9] “If after professional consultation between a referrer and the service a child is considered suitable for assessment, the referrer will be advised to proceed with the referral via a standardised referral form”.

This additional layer adds yet another delay in a process that is already very heavily delay-ridden. How is this in any way centring child healthcare needs or making the system more efficient and effective.

  • 14. Ignorant of harms of denial of healthcare

[service spec page 13] “implications of medical treatment (and non-treatment)”.

The second part of this statement should not be in brackets and the specification needs to much more significantly present the evidence of the harms of denial of medical treatment.

The Endocrine society, in its recommendation in support of puberty blockers, states the following:
These recommendations place a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm from early pubertal suppression.”

  • 15. No centring of child rights to healthcare

[service spec page 8] “an individual’s route will be determined by… family and social context”

This leaves it open to trans children and adolescent’s path to healthcare being blocked by family or social context – it fails to consider child rights or how the service will centre the child and their wellbeing through the care pathway.

[service spec page 12] “the hopes and expectations of their family members/carers”

This section needs to distinguish between the need for family member support and education to help them support their child’s needs, and the potential for family members to cause harm by impeding access to healthcare.

[service spec page 14] “Medical interventions will not be considered until at least puberty…”

This feels inappropriate phrasing – a better phrasing would be to state that medical interventions are not needed in this cohort until puberty.

[service spec page 15] factors that could influence the complexity and length of the intervention include…”

Here a long list of factors that can extend assessments and delay healthcare are provided, with no consideration of child rights to care, including rights for those with mental health problems, safeguarding issues, unsupportive families, or difficulties providing consent. A child-centred approach may need to devote additional resources or effort to support children will more complex situations, but this also needs to prioritise ensuring such children are not kept in extended assessment or denied access to time-sensitive healthcare.

[Equality and health Inequalities Impact Assessment section on ‘looked after children’]

Fails to actively consider how to ensure looked after children, and those without parental advocates, are not discriminated against in healthcare access.

The specification fails to outline the necessity of trans healthcare. The Endocrine society states:
““These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary”

  • 16. No centring of healthcare accountability or mechanisms to empower service users

Existing evidence has highlighted the potential for abuse of power and child powerlessness in clinical care

Horton, C. (2022).“Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies. 1(1-2):47-70

While other research has demonstrated the flawed mechanisms for accountability in the GIDS system.

Accountability and avoidance of areas of unlimited clinician control is critical especially in an area affected by potential for clinician prejudice.

  • 17. Presentation of psychoeducation as treatment for dysphoria

[Service spec page 2] “The primary intervention…. Is psychosocial (including psychoeducation) and psychological support and intervention, the main objective is to alleviate distress associated with gender dysphoria”.

This is entirely unevidenced, can be interpreted as a form of conversion therapy, and suggests psychological support is a means of alleviating gender dysphoria. There is no emphasis here on psychological support to cope with the challenges of living in a trans hostile world, or psychological support to deal with gender minority stress, bullying, abuse or family rejection. This seems to support psychosocial support itself will change a person’s experience of gender incongruence or dysphoria and is entirely unevidenced, goes against modern healthcare best practices, and will cause direct harm to trans children and adolescents.

[service spec page 8] “research will include” “outcomes of psychological treatments to reduce distress”

There is no consideration of the place for talk therapy in helping youth deal with transphobia or gender minority stress. The phrasing is left open for conversion therapy.

[service spec [age 9] “outcomes following the screening process include discharge with psychoeducation”.

This needs to justify why a child or adolescent who has wanted and needed referral to the service would be discharged with psychoeducation. It fails to consider who the psychoeducation is for, what its purpose is. It strongly leaves the specification open to an interpretation that the screening can identify who is ‘really trans’ and who can be assigned psychoeducation to reconcile with their assigned gender. It leaves space for conversion practices that are unacceptable in modern healthcare.  

[service spec page 14] “psychological support will focus on alleviating emotional problems” “The overall aim is to reduce distress in the individual”

This approach leaves open the interpretation that psychological support is an effective treatment for gender dysphoria, rather than psychological support to deal with gender minority stress.

In contrast, the endocrine society states that the purpose of counselling linked to social transition is to help manage other people’s reactions:

“During social transitioning, the person’s feelings about the social transformation (including coping with the responses of others) is a major focus of the counseling.”

  • 18. No emphasis on psycho education to raise trans positivity

[service spec page 13] “psychoeducation”

The section on psychoeducation focuses on gender identity development, not on the very important topic of raising trans positivity.

Other literature has highlighted the importance of education on trans identities and trans positivity, especially for cis parents.

Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

  • 19. No centring disability & neurodiversity rights

[service spec page 8] “an individual’s route will be determined by… the presence and impact of other clinical needs”

This leaves it open to trans children and adolescent’s path to healthcare being blocked or disadvantaged if they are disabled or neurodivergent – it fails to consider disability and neurodiversity rights or how the service will centre the child and their wellbeing through the care pathway, making sure disabled youth are not discriminated against.

[service spec page 12] “assessments will focus on …neurodevelopmental needs and their relationship with gender incongruence”

Neurodivergent trans children should not need to explain or define the relationship between neurodiversity and gender incongruence.

[service spec page 15] “more intensive clinical interventions may be needed…to address other clinical diagnoses”

The service is not committing to upholding the rights of disabled trans youth, including disabled or mentally ill trans youth.

[Equality and health Inequalities Impact Assessment section on ‘disability’]

Fails to consider the reality that disabled children are likely to be discriminated against with greater barriers to timely healthcare. Fails to put in place strategies to ensure those with disabilities, co-existing mental health conditions and neurodiversity are not discriminated against in access to timely healthcare.

  • 20. Failure to recognise gender minority stress as key driver of mental health differentials

[Service spec page 2] “experience co-existing mental health… and or family or social complexities in their lives”.

[service spec page 11] “increased prevalence of mental health needs such as depression anxiety risk-taking behaviours”

This section entirely fails to deal with the significant body of evidence that demonstrates that mental health issues, or family and social issues are highly likely to not be co-existing, but directly caused by societal prejudice and gender minority stress. The stress of living in a trans hostile society places a significant burden on trans children and this service specification needs to recognise that in many cases mental health differentials and family/social difficulties are not caused by gender incongruence, but by societal, community, peer and family responses to that gender incongruence. It is absolutely vital to recognise that the ‘problem’ is not internal to the child, but one of the reaction to the child. This places a very significant emphasis on the need to undertake responses at family, community and society level, not at the level of the child.

These references to co-existing conditions also fail to recognise that denial of essential healthcare is a known driver of such mental health difficulties.

[service spec page 12] “assessments will focus on… impact of gender incongruence on educational attainment, bullying or harassment”.

This needs to clearly distinguish that it is not gender incongruence that has this impact, but societal prejudice.

[service spec page 14] “The overall aim is to reduce distress in the individual”

Fails to understand that solutions to tackle GMS should not focus on the individual but on the surrounding environment.

Trans children and adolescents are known to be at risk of poor mental health, with a wide variety of studies noting high levels of depression, anxiety or suicidal ideation (Srivastava et al., 2020; Strauss et al., 2020; Veale et al., 2017). A growing body of research has also shown that poor mental health is not intrinsic to being trans, with evidence demonstrating a wide range of external factors that correlate with good mental health, including family support (Katz-Wise et al., 2018; Klein & Golub, 2016; Pullen Sansfaçon et al., 2019; Simons et al., 2013; Travers et al., 2012), social affirmation (Durwood et al., 2017; Olson et al., 2016; Whyatt-Sames, 2017), and safe and welcoming trans-inclusive primary and secondary education (Horton, 2020; McGuire et al., 2010).

Trans children’s experiences of Gender Minority Stress in education in the UK are evidenced here:

Horton, C. (2022). Reducing Gender Minority Stress – Support for trans pupils in our schools. International Journal of Transgender Health.

  • 21. Suggests intrusive search for causation

[Service spec page 2} “the relationship between these aspects (mental health, neuro-developmental and or family or social complexities) and gender incongruence may not be readily apparent and will often require careful exploration”.

This phrasing leaves itself open to the interpretation that gender incongruence may be ‘caused’ by family disfunction, mental health issues or neurodiversity, suggesting that such causes ‘often’ need to be ‘carefully explored’. This is an outdated approach that has been tried for many decades and found to be harmful and abusive. Existing research shows that trans children and families find such ‘exploration’ intrusive, harmful and irrelevant.

[Service spec page 5] “build and document the history and nature of gender incongruence”.

It is striking that despite citing the Endocrine society elsewhere in this specification, it does not mention a key conclusion of the Endocrine society that gender identity has a “durable biological underpinning”

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” Journal of Clinical Endocrinology & Metabolism (JCEM), Nov 2011.

The Endocrine society position paper states:

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.

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder.

[service spec page 8] “a care plan should be tailored…following careful therapeutic exploration”.

The fact a care plan can only come after careful therapeutic exploration suggests this is mandatory, and that it is therefore neither therapeutic nor exploratory. Therapeutic exploration is client driven not clinician driven. Mandatory exploration is something quite different, and instead is an intrusive and abusive exercise in clinician power over a trans youth. This approach fails to consider the power wielded by clinicians (some of whom hold transphobic prejudices), and the need to centre trans children’s right to not engage in forced exploration before having access to a care plan. It is a one-size fits all approach that fails to recognise that many trans children have no need of, and will be harmed more than helped by therapeutic exploration, and that mandated exploration is neither therapeutic nor exploratory. To the contrary, there is evidence that mandated exploration can put trans youth into a position of defending their identity, reducing space for genuine exploration, and leading to worse outcomes.

Furthermore, work by Ashley has demonstrated that self-guided reflection and exploration is a process that should take place through the process of wider healthcare, not as a step before access to a care plan.   

  • 22. Leaves space for gender exploratory therapy

[service spec page 14] “clinicians should remain open and explore…”

Gender exploratory therapy is a rebranded label for conversion therapy, and the service specification, with numerous references to exploration retains space for this harmful practice.

  • 23. Uses dated and unscientific language for ideological purposes to illegitimise and disenfranchise

[service spec page 3] “biological sex”.

In this section the NHS has redefined the diagnosis of gender incongruence to include the inaccurate term of “biological sex”

The WHO ICD-11 instead defines gender incongruence thus:

“Gender incongruence is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex”.

The NHS has rewritten the WHO’s definition to include inaccurate and transphobic language of ‘biological sex’ rather than ‘assigned sex’ with this change likely to delegitimise and disenfranchise.

[Service spec page 6] “biological sex”

In this section the NHS propose the whole system’s outcome monitoring system records by ‘biological sex’, with this inaccurate and harmful categorisation likely to other, delegitimise, insult and harm trans children and young people. Such monitoring is also likely to lead to service users refusing to participate in data gathering – services need to maintain service user trust and confidence for any effective collaboration including in basic data gathering. Having a monitoring system that is designed to monitor by “biological sex” is cisnormative and harmful – every monitoring report will misgender and harm its service users. This is unacceptable.

The Endocrine society (who are the only citation in this specification) specifically advise against use of the phrase “biological sex”. They state that “the terms biological sex and biological male or female are imprecise and should be avoided.”

The phrase biological sex rather than sex assigned at birth is an ideological inclusion in this document, with potential to illegitimse and disenfranchise trans people, especially given existing political discourse around ‘sex’ and ‘single-sex spaces’. This phrase should be nowhere near a document purporting to serve and support trans children and young people. It is a direct microaggression, serving to signify to readers that the service is not designed in their interests.

[Equality and health Inequalities Impact Assessment section on ‘sex’]

This section misgenders and delegitimises trans children and adolescents, ascribing them as ‘natal males’ and ‘natal females’. This is unacceptable language in a specification supposed to help trans children.

  • 24. Emphasis on MDT

[Service spec page 8] “the provider will deliver the Service through an integrated MDT”

There is no consensus on what an MDT for trans youth healthcare looks like, and within the Helen Webberley GMC proceedings, expert witnesses (leading clinicians from the US) gave extensive testimony on the inappropriateness of an MDT for trans youth healthcare. The NHS needs to take this expert testimony on MDTs into account here.

  • 25. Failure to centre endocrine care pathways

Being trans is not a medical condition. This is clearly established under ICD-11. Trans children and adolescents mainly need to have specialist healthcare support when they require endocrine interventions. Having a specialist gender care pathway that barely engages with a focus on endocrine care, is deeply regressive and fails to recognise that for many trans children, endocrine care is the sole reason for engaging in trans healthcare. Support with gender minority stress could be found outside of tertiary trans healthcare care, support for families can be found through more informal structures, and support for social transition often does not require and would even be harmed by incorporation into specialist healthcare.

  • 26. Failure to engage with trans expertise

The draft specification is unbelievably bad. This is what happens when healthcare is ideologically influenced, and when trans expertise is explicitly excluded. The NHS needs to do so much better. Trans kids deserve evidence-based trans-positive healthcare.

27. Under-planning for given population

I noticed in the spec that they mention lower referrals for 2020-1 without contextualising the referral numbers were artificially low because of the pandemic.

I also noticed that in their consideration of referral numbers they entirely fail to consider the trans youth who have not bothered to get an NHS referral recently because they know the wait list is 4+ years – those who have had to go private or who have waited for adult services (knowing GIDS won’t help them before adulthood anyway) are entirely unconsidered in the specification’s analysis of the size of the population the new service will cover.

Steph’s place did some further important analysis of the under-planning for the population in their blog:

Additional important critique of the service spec is in this blog

Evidence-based medicine: What do we mean by ‘low quality’ evidence in Trans Healthcare?

In 2021 the NHS (NICE) reviewed the evidence for the use of puberty blockers within trans adolescent healthcare. They concluded that the evidence was of “very low certainty”, a finding that was then repeated across national media, with the headline “Evidence for puberty blockers use very low, says NICE”. This unsurprisingly prompted increased demands, including from politicians, for withdrawal of trans adolescent healthcare.

Several people have written about the flaws in the NICE review, including this excellent article by AJ Eckert. I’ve examined parents of trans children’s concerns with the NICE approach to evidence in a recent peer reviewed article in which parents of trans children described puberty blocker Randomised Control Trials as “conversion therapy” or akin to “eugenics”.

A recent expert report from the US indirectly challenges the NICE approach, and merits further reading.


In 2022 the Florida Agency for Health Care Administration published a biased and ideologically driven report claiming that medical care for gender dysphoria does not meet generally accepted medical standards. A group of experts linked to Yale University responded with an analysis and critique of the poor science underpinning Florida’s report. Their full report is here.

Evidence Quality

One section of the Expert report from Yale University focuses on evidence quality. Their analysis has relevance for conversations on trans adolescent healthcare happening in the UK (including the Cass review), so this blog will shine a spotlight onto this section of the report.

*Note: In the below quoted sections, BPW refers to sources cited in the original (and misleading) Florida report. The June 2 report refers to the original, and flawed Florida report.

The following italicised text is taken directly from the Yale report. Please take time to read this section through:

…the BPW analysis reaches the conclusion that there is little or no evidence for the benefits of medical care for gender dysphoria.

The BPW analysis is highly deceptive, because it dismisses nearly all existing studies of medical treatment for gender dysphoria as “low quality,” without explaining that this is a highly technical term and not a natural-language condemnation of the studies. By contrast, the GRADE system, which the authors purport to use, is quite clear about its quality rating systems and its limitations.

In general, only randomized controlled trials (RCTs) are coded as “high” quality evidence in the GRADE system. A randomized controlled trial is a study that divides patients randomly into a control group (no treatment) and a treatment group. In contrast, an observational study records information about patients in a real-world setting that is more reliably generalizable, e.g., a cohort of patients seen at a clinic. Under the GRADE guidelines, observational studies are coded as “low” in quality.

The key point is that “low quality” in this context is a technical term and not a condemnation of the evidence, because “low quality” studies regularly guide important aspects of clinical practice. Indeed, the GRADE system, which the BPW document claims to use, specifically notes that GRADE should not be used to dismiss observational studies or to give absolute priority to RCTs: Although higher quality evidence is more likely to be associated with strong recommendations than lower quality evidence, a particular level of quality does not imply a particular strength of recommendation. Sometimes, low or very low quality evidence can lead to a strong recommendation.

The methodology adopted by the BPW document will thus, predictably, conclude that any body of scientific literature that does not contain RCTs is “low” in quality. Had BPW begun, as they should have, with a literature review of the evidence on puberty blockers and hormones, they would have seen that the evidence consists primarily of observational studies (for the good reasons discussed below). Thus, the 30 pages that it takes the authors to lay out their methodology is misleading: a knowledgeable reader would know that if there are few or no RCTs in the literature, then the BPW technical conclusion is foregone and, as importantly, is not a sound guide for clinical recommendations.

Put in simpler terms, if we coded apples as “high quality fruit” and bananas as “low quality fruit,” then any fruit bowl that has only bananas would predictably be technically coded as “low quality.” But that technical conclusion conveys very little information without context. For example, if no apples exist, then bananas may be a nutritious choice.

The drafters of the GRADE system emphasize that technically “low quality” evidence can support a strong clinical treatment recommendation. For example, pediatricians now agree that children should not be given aspirin for fevers. This recommendation is based on observational studies that showed an association between aspirin treatment during viral illnesses and the development of Reyes syndrome (a rapid and progressive disease of neurological dysfunction that can be fatal). Based on those studies, it would be unethical to conduct an RCT giving some children aspirin, and so the strong, consensus treatment recommendation is based entirely on “low quality” studies.

The critical fact is that RCTs are not, and cannot be, the gold standard for medical research on gender dysphoria. In the context of treatments for gender dysphoria, randomized controlled trials would often be inappropriate for ethical reasons. Medical care has long been shown, by reliable scientific methods, to address gender dysphoria and improve mental health: as we have repeatedly noted, these treatments have been recommended by rigorous clinical practice guidelines issued by WPATH and the Endocrine Society and endorsed by every major medical organization. Given this medical consensus, which is based on solid scientific evidence, it would be unethical to conduct an RCT that involved denying standard medical care to a control group of individuals.

Similar ethical issues, along with practical barriers, leave many areas of consensus medicine supported by observational studies and not RCTs. Many surgical procedures, for example, are not supported by RCTs. Nor are standard protocols for lowering cholesterol using statins, one of the most widely-prescribed drugs in the United States.

It is thus simply a mistake – and a mischaracterization of medical research across fields of medicine – to conclude that the absence of RCTs means that there is “no evidence” for the efficacy of medical treatment for gender dysphoria. Medical research requires, instead, that researchers evaluate the design and conduct of specific observational studies and do so with an awareness of clinical context.

In sharp contrast to BPW, this is precisely what the authors of the Endocrine Society did in their 2017 clinical guidelines, which use the GRADE system but, in addition, carefully discuss the characteristics of the studies supporting each treatment guideline. The Endocrine Society discloses the GRADE rankings for each treatment recommendation in order to be transparent about the evidence base for each of its recommendations. Then, following National Academy of Medicine (formerly, Institute of Medicine) standards for clinical practice guidelines, they proceed to a qualitative review of the evidence, place the evidence in clinical context, and discuss openly the values at stake in making a clinical practice recommendation.

The June 2 Report repeatedly and erroneously dismisses solid studies as “low quality.” If Florida’s Medicaid program applied the June 2 Report’s approach to all medical procedures equally, it would have to deny coverage for widely-used medications like statins (cholesterol-lowering drugs taken by millions of older Americans) and common medical procedures like mammograms and routine surgeries.

In its opening words, the June 2 Report makes an error that is repeated throughout the document: “Studies presenting the benefits to mental health, including those claiming that the services prevent suicide, are either low or very low quality and rely on unreliable methods such as surveys and retrospective analyses, both of which are cross-sectional and highly biased.” As we document in Section II.B., above, it is an outright mistake to conclude that a study in the technical category of “low quality” is unreliable or poor evidence for clinical practice. Thus, it is frank error for the June 2 Report to dismiss well-done, scientifically important studies because they rank as “low quality” using specialized, technical terms.

Like the BPW document, the June 2 Report thus relies on a deceptive use of technical terminology that is at odds with the standards used in medical research. It simply is not – and cannot be – the case that all clinical recommendations must be based on RCTs. Many areas of medicine do not lend themselves to ethical and practical RCTs. It is unethical to conduct an RCT when randomizing a patient to a control group would cause harm by denying treatments of known efficacy. For example, it would be unethical to conduct an RCT on the treatment of juvenile diabetes by randomizing some participants to receive insulin and others to receive no treatment.

It is quite common for the medical community to adopt important, consensus clinical practices supported by observational studies alone. For example, observational studies, notably the famous Framingham Heart Study, provided the framework for clinical practice guidelines in prevention and treatment of cardiovascular disease. In 2013, the American College of Cardiology and the American Heart Association issued updated clinical practice guidelines on the treatment of cholesterol to reduce heart disease risk in adults (the “Cholesterol Guidelines”). These authoritative guidelines have been widely used in clinical practice but are based not only on RCTs but on a great deal of observational evidence, including studies technically ranked as “low quality.” Concretely, many of the original treatment recommendations regarding statins are based on observational studies, not RCTs. The authors of the Cholesterol Guidelines, very much like the Endocrine Society authors, are quite careful to grade their evidence. But they do not rest their treatment guidelines on a mechanical assessment of technical quality. Instead, they (like the Endocrine Society) carefully explain why particular bodies of evidence should be given weight in clinical decision-making.

The cholesterol example shows that the June 2 Report rests on a fundamental misunderstanding of medical research and clinical practice. If the Florida Medicaid program actually adopted the standard of evidence urged by the June 2 report, the program would not cover statins (drugs to lower cholesterol) for many patients, which are prescribed to 28% of adults over the age of 40 and are one of the most effective ways to prevent cardiovascular death. Other common practices that would have to be reconsidered under this logic include: post-menopausal hormone replacement therapy (which reduces lifetime risk of heart attacks and stroke) and mammography screening for breast cancer.

The same point is true of the technically “low quality” evidence base for many surgical procedures, including minimally invasive gall bladder surgery, which have long since had a foundational grounding in observational studies. We think it unlikely that Florida’s Medicaid program will begin to refuse to pay for statins, mammograms, and routine surgeries. If not, then the June 2 Report reflects an untenable and discriminatory double standard.

(I’ll emphasise in case of confusion – all the above text in italics is not my work, but a direct quote from the Yale report – the authors of which are listed here)

Relevance for the NHS

The text above prompts several important questions for the NHS:

  1. Does the NHS (NICE report and Cass review) reflect a similar “discriminatory double standard” in its characterisation of the evidence base as ‘low quality’? Does NICE use the same approach across other areas of healthcare (including e.g. abortion)?
  2. Should the NHS (NICE and the Cass review) be more careful when using technical terms like “low quality evidence” in an already polarised and politicised area of healthcare, knowing how such terms are reported in the media and knowing how such terms inflame and undermine support for healthcare?
  3. Why has the NHS (NICE and the Cass review) failed to grapple with the very well established reasons why “high quality evidence” like RCTs are infeasible and unethical? Given the known ethical and practical impossibility of RCTs, why on earth did the NICE review recommend collection of such “high quality evidence”?

I’m also left with some bigger questions for the UK:

4. The above intervention from an esteemed team of establishment professors across different disciplines is likely to hold some weight in challenging and holding to account poor healthcare sector practices. Here in the UK we do not have paediatricians, law professors, experts in effective approaches to experience-informed healthcare speaking up on the clear flaws in the NHS approach to trans adolescent healthcare. Why not?

5. Are there lessons we can learn from experts in other areas of healthcare who have challenged commitment a narrow definition of ‘evidence’ within healthcare policy?

(post-script: I’d normally include a link to the NICE report, but it appears to have disappeared from the NICE website – if someone has a functioning link please let me know so I can update it).

Ten Easy Tips for Trans Inclusive Education on Puberty and Bodies

Schools have a duty of care to trans pupils, with a requirement to provide LGBTQI+ inclusive PSHE. However, many schools still struggle to provide trans inclusive primary and early secondary school education on puberty and bodies, with schools often drawing upon outdated and exclusionary curricula.

Research has shown that trans children can experience exclusionary curricula, especially on bodies and puberty, as upsetting, delegitimising and harmful. Schools providing trans exclusionary education are associated with high levels of minority stress for trans pupils, with minority stress leading to poor levels of mental health and increased chances of trans pupils dropping out from education.

The good news is that trans inclusive education should not be difficult, once educators become confident in a slightly different and more inclusive way of approaching the subject.

In this blog I will share 10 recommendations for trans-inclusive puberty education, with quotes from educational resources that are trans inclusive. Importantly, this blog and the content highlighted herein focuses on how to ensure mainstream education on puberty and bodies is trans inclusive (it is aimed at ensuring the education every child receives is trans-inclusive, rather than aiming to specifically cater to trans children’s unique needs). (I’d also be interested in any additional advice on ensuring trans inclusive materials like these are intersex inclusive as well as disability inclusive).

This blog will primarily focus on a new educational resource called You-ology. It is produced by the American Academy of Pediatrics (the world’s biggest organisation of paediatricians), and aims to provide puberty education tailored for EVERY body. It is available in e-book form for £8.

You-ology: A puberty guide for EVERY body

This book does a couple of important things well:

1. It acknowledges, and frames puberty according to, the important role played by hormones.

On hormones:

“During puberty there are hormones that tell your body to grow faster, hormones that tell your breasts or testes (also known as testicles or balls) to start growing, hormones that tell your hair to sprout in new places, and hormones that cause new smells to creep out of your armpits”.

Growing bigger:

“Growing is one of the first signs of puberty. A hormone called growth hormone increases a ton during puberty to make you grow fast. Your hands and feet start to grow! So when you find yourself outgrowing your trainers faster than normal, you can smile to yourself and know puberty is starting!”

Testosterone and oestrogen:

“There are hormones called oestrogen and testosterone that cause most of the changes. A tiny, pea-sized gland in the brain, called the pituitary gland, sends a chemical messenger (yep, another hormones) to the testes or ovaries to tell them to start making hormones. Testes make a lot of testosterone. Ovaries make a lot of oestrogen and a little testosterone. Throughout this book, we will tell you more about what each of these hormones does.”

2. It considers the changes that happen to a majority of bodies. It emphasises shared experiences in puberty, rather than suggesting humans have two completely distinct and separate puberties. Rather than presenting ‘girl puberty’ in one lesson and ‘boy puberty’ in another, it instead divides up pubertal changes into the different types of changes. It provides one chapter on hair changes, one chapter on body odour changes, one on emotions. The similarities are emphasised as well as the differences, emphasising within the section on hair that in puberty most bodies develop increased hair on the legs and under the arms, while some bodies, especially bodies with a lot of testosterone, also develop hair in other places. Below is a quote from the You-ology chapter on hair.

On hair:

“where you sprout hair depends on – you guessed it – hormones. EVERY body begins to make the hormone testosterone early in puberty. Testicles make a lot. Ovaries make a little. Even a little testosterone will cause EVERY body to grow darker, thicker hair on their legs, in their armpits, around their private parts; around their nipples or on their face. The amount of testosterone you have determines how much and where the hair shows up. If you have a lot of testosterone, you will grow more hair on your face. You might also (later in puberty) grow hair on your chest, abdomen (belly) and back”.

3. Where changes are significantly gendered, with most girls having a different experience to most boys, it divides the content according to the specific type of change, rather than dividing into girls vs boys. It provides one chapter on breasts and chests, one chapter on periods, one on testosterone driven changes. It manages to talk about these changes without excluding, shaming or delegitimising trans children.

On vaginas:

“If you have a vagina. So let’s get back to body parts and start with outside private parts that most girls, and some nonbinary and trans kids have. If you have these parts, you know some of the names for them. If you don’t have these parts, it’s a great time to learn more about them!

On penises:

“Let’s shift to talking about the genitals that most boys and some trans and non-binary kids have. If you were born with a penis, you’ve been looking at and touching it since you were a baby, right? And at some point (hopefully a long time ago!), you learned to hold your penis to aim it into the toilet when you pee. So if you’re like most kids with a penis, you have been pretty familiar with your genitals for a long time, and you know the names too, but let’s go through them just to be sure. If you don’t have a penis, it’s still important to learn about these parts to understand how EVERY body works!”

On uterus and ovaries:

“Most girls and some trans/non-binary kids have some pretty cool inside parts that work together. First, remember how we talked about the opening of the vagina? The vagina is actually a soft tunnel that starts at the vulva and goes inside the body to connect the inside parts to the outside world…”

On sperm & testes:

“Most boys and some trans/non-binary kids have bodies that can make sperm, and the penis is involved. Do you wonder how? We already mentioned that urine travels in the urethra as it passes through the penis and out of the body. But guess what also comes out through the uretha? Sperm. The cool thing is that urine and sperm comes from very different places inside the body. Urine is made by the kidneys and then sent into the bladder to be stored. Sperm …etc ”

On breasts:

“If you are like most girls, or some nonbinary or transgender kids, you have ovaries, which also help puberty start by making oestrogen. The very first thing oestrogen usually does is telling the breasts that it’s time to start growing”.

Where diagrams are used to show specific body parts, there is no reductive label provided of ‘boy’ or ‘girl’ bodies. This kind of title is not needed and alienates and invalidates trans pupils in front of their peers. Below is an example of a diagram of body part that does not need to have a ‘girl’ or ‘boy’ heading.

4. It recognises and is not afraid of acknowledging diversity, explicitly recognising the existence of trans people, intersex people, and the reality that not every person experiences puberty in the same way. Key to this inclusive approach is bringing in the word ‘Most’. When talking about gendered changes, this resource talks about, for example, periods being something that happens during puberty for ‘most girls, and some trans and non-binary kids’. Addition of the word ‘most’ is really important for trans, non-binary and intersex kids, making space for the reality that all bodies are different. Addition of the word ‘most’ is also important for cis girls who may not have periods for a variety of reasons.

5. I also like the way that this resource talks about puberty as inherently about moving from a child’s body towards having an adult’s body, in comparison to other puberty resources that describe puberty as building bodies ready for reproduction. De-centring fertility and reproduction during education on puberty is helpful, especially for individuals who are likely to have a non-traditional route to building (chosen) families, a category that is likely to include a significant proportion of LGBT youth.

6. Hormone driven changes. The resource is clear that the changes of puberty are driven by hormones. It finds a way to talk about hormones explicitly, talking about the changes that are caused by oestrogen, and the changes caused by testosterone. It talks about breast development being a pubertal changes that occurs in bodies with a large amount of oestrogen. It acknowledges that a majority of all bodies have some testosterone. It talks about the types of changes that are typical for bodies that have a large amount of testosterone.

7. Clear and upfront on body parts. Where body parts are integral to a particular pubertal change, this resource again is clear and upfront. When talking about periods, it talks about the changes that happen to people with a uterus, which includes most girls. Most girls, and anyone else with a uterus, when they have a large amount of oestrogen during puberty, are likely to start having periods.

8. It avoiding ruse of the reductive term ‘biological sex’. Within any trans inclusive puberty education it is important to avoid simplistic and reductive definitions of sex or ‘biological sex’. Where biological characteristics are relevant, it is important to refer to them in the plural, as ‘biological sex characteristics’. The Endocrine Society (global experts on hormones or endocrinology) advises against using the term biological sex noting that “the terms ‘biological sex’ and ‘biological male’ or ‘biological female’ are imprecise and should be avoided”. There are multiple sex characteristics (chromosomes, gonads, hormone levels etc), and humans do not fall into only two binary divisions in terms of sex characteristics. This recognition is critical to including trans and intersex people, as well as to including people who may not have a specific sex characteristic for a variety of reasons (eg cis women who have had a hysterectomy).

9. Likewise, it is important to avoid using gendered language like ‘male’ or ‘female’ to define body parts. Within this specific You-ology resource, there are a couple of references to ‘male bodies’. This type of reductive language goes against the ethos of the wider book and is rather frustrating. Let’s be clear here – using the word male to describe bodily features is just as exclusionary and harmful as talking about a ‘boy’s body’. There is no way to respectfully (or even accurately) describe a trans girl as having a ‘male body’. This type of language is delegitimising, inaccurate and disrespectful. If we care for the well-being of trans pupils, non-binary pupils or intersex pupils, we need to evolve away from inaccurate and binary language that excludes, delegitimises and stigmatises. (the image below comes from work by Sophie Labelle)

10. Being up front about the diversity amongst humans is easy to do, it simply requires educators who are themselves educated, and unafraid of talking about diversity. In the UK however, we have a generation of teachers who have themselves grown up under section 28, who have not have the opportunity to themselves receive diversity informed education. This is why inclusive educational resources like this one are so very important.

Further resources

I’ll include here a few other recommended resource, but please send me other ideas to add in.

What makes a Baby by Cory Silverberg and Fiona Smyth provides visually appealing information on babies, reproduction, fertility and families, suitable for any age. It is designed to be trans inclusive, and inclusive of all ways of building a family, including IVF, adoption, chosen families.

A guide for adults to help children engage with the book is also available here

A new resource (You know, sex) by the same team aims at a slightly older audience, covering bodies, puberty, and sex ed. with the same visually engaging and inclusive style.

The above resources are all paid-for US resources, not included in the curricula of major UK providers of PHSE education. The limited UK PHSE materials that I have seen have had woeful trans inclusivity, and would require adaptation by individual teachers to avoid harming trans pupils. This is obviously poor, and more is needed to pull up the standard of generic and off-the shelf PSHE materials, especially from PSHE specialist providers.

A downside of these resources shared above is that they do not include practical class materials or worksheets. (Mainstream UK puberty worksheets can often be trans-exclusionary and harmful, requiring individual adaptation by any teachers who care for their trans pupils). If any educators have produced free to access class worksheets or other materials that are trans inclusive, please email me ( with links to any trans inclusive educational materials or worksheets.

Trans inclusive education is not difficult to do. It is time to make sure education is fit for every pupil.

Update: Someone has also recommended this book (that I’ve not yet read) The Every Body Book: The LGBTQ+ Inclusive Guide for Kids about Sex, Gender, Bodies, and Families by Rachel Simon and Noah Grigni

The Failure of the Cass Review

This morning people who care about trans kids were reacting in utter dismay to hearing the Secretary of State for Health use the Cass interim review to justify the need to exclude trans people from a ban on conversion therapy.

I’ll link the lovely Olly Alexander linking to a clip of our Health Secretary using Cass to call for conversion therapy for trans kids – see here

Despite evidence that conversion therapy on trans children is particularly harmful, with research showing “For transgender adults who recalled gender identity conversion efforts before age 10 years, exposure was significantly associated with an increase in the lifetime odds of suicide attempts”.

For days now, MPs and commentators have cited the Cass review, in justification of the need for conversion therapy specifically for trans kids.

Of course they do not say conversion therapy for trans kids. They talk of ‘children suffering from gender confusion or gender distress’, they talk of ‘exploratory therapy. They talk of ‘unintended consequences, by which some clearly mean, they fear the law would stop them conducting conversion therapy on trans kids.

Those who want to conduct conversion therapy on trans kids hide behind a new favourite term of ‘exploratory therapy’. It is a friendly sounding rebrand of conversion therapy. It is focused on probing, delaying, questioning and at its heart, problematising trans identities. There is nothing wrong with being trans. Some kids are trans – get over it.

The same people who actually want conversion therapy for trans kids, are trying to create confusion on the meaning of affirmative therapy. They are trying to paint affirmation as a bad thing, as something forced. They are wrong and they know it. Affirmation is about meeting a person where they are, about listening to what they need. It has space for as much talk therapy on identity as a person wants. Without coercion. Without compulsion. Without considering trans or cis as a bad outcome.

Parents of trans kids are today VERY upset. People had put their faith in Cass to help our kids.

Personally, I feel something else other than upset. I feel cross at myself for not speaking up earlier.

Back when the Cass review was first announced, I had serious concerns. Concerns that have continued to mount.

There was Cass’ personal twitter following of a load of highly transphobic groups & no trans people.

There was the Cass review’s initial refusal to even say the word trans kids, in a review aimed primarily at helping trans kids.

There was the lack of any trans people on the Cass team, and the fact that the Cass team explicitly asked for people with no knowledge or experience of trans-ness, as though that was a preferable.

The fact there was no oversight group consisting of respected trans health experts and trans community leaders.

Back at the start I felt deep in my gut that this would go badly and would not serve the needs of trans kids. I seriously considered trying to get parents of trans kids together to stage a boycott until there was some proper trans representation. I didn’t for four major reasons. For one, the biggest reason, I was so tired & out of time and energy. For two, I wanted to give optimism a go – just cos everything else always fails trans kids in the UK, why couldn’t this be different – here we had a paediatrician reviewing trans kids healthcare, something I’d been asking for for years, maybe this time would be different. For three, I hoped having formal peer reviewed publications to feed into the process would make a difference (spoiler – it didn’t – the Cass team had my peer reviewed research article on the UK service from the highly respected international journal International Trans Health and didn’t even bother citing it). For four, I didn’t think things could really get much worse for trans kids in the UK, so I didn’t see how much real harm it could do.

Obviously I was very wrong. I noted my initial reaction to the pathologisation embedded in the Cass report.

The Cass interim report is now being cited everywhere to justify the need for conversion therapy for trans kids. It is being cited to deny inclusion of trans people of any age from a ban on conversion therapy.

The red flags about the Cass process meanwhile continue to grow.

I’ve been interviewed, found Cass on the face of it an empathetic listener who keeps her cards close to her chest.

Other parents of trans kids have been interviewed, again felt Cass had listened with kindness.

Many are deeply upset about the Cass interim report and the way it has encouraged further bigotry.

The Cass interim report couldn’t even take a decision on whether being trans is pathological. It couldn’t even take a decision on whether trans kids are better off being loved and supported or put through conversion torture. It is not acceptable.

I won’t dig into the details of the Cass report itself, but the references and evidence base are deeply biased and flawed. It is yet another total failure for trans kids in the UK.

There are still no trans experts involved in a senior role in the Cass review. There is no trans power at all.

The Cass process seem to think the exclusion of trans people is acceptable, because they have told themselves they are not dealing with trans people at all. They have told themselves they are dealing with healthcare for ‘children suffering from gender distress’. This phrasing has become standard.

Worryingly there are also trans-antagonistic people involved in the research for Cass.

This week, the world respected paediatrician with over a decade of practical hands on experience HELPING trans kids in Australia published a response to the Cass review in the British Medical Journal. That response is not open access to the public, but this is of incredible important to those who are directly affected (and now even threatened) by the Cass outputs, so I will put its text here:

Gender identity services for children and young people in England

Landmark review should interrogate existing international evidence and consensus

Ken C Pang, 1, 3 Jeremy Wiggins, 2 Michelle M Telfer1, 3

1 Royal Children’s Hospital; 2 Transcend Australia; 3 Murdoch Children’s Research Institute

The long awaited interim report of the Cass review was finally published in March this year.1 Commissioned in September 2020, the independent review led by paediatrician Hillary Cass examined NHS gender identity services for children and young people in England. These services are currently provided by a single specialist clinic known as the Gender Identity Development Service. After consulting people with gender diversity, health professionals, and support and advocacy groups, Cass expressed various concerns within her interim report, such as increasingly long waiting lists, the “unsustainable workload” being carried by the service, and the “considerable risk” this presented to children and young people.

Recognising that “one service is not going to be able to respond to the growing demand in a timely way,” Cass used her interim report to recommend creation of a “fundamentally different service model.” Under this model, the care of gender diverse children and young people becomes “everyone’s business” by expanding the number of providers to create a series of regional centres that have strong links to local services and a remit to provide training for clinicians at all levels.1 Although it remains to be seen how and when this key recommendation will be implemented, the proposal will be largely welcomed by gender diverse children and adolescents and their families in England. The shift away from centralised, tertiary, and quaternary centres is already occurring internationally, including in Australia,2 where local services are being enhanced to meet growing demand and provide more equitable and timely care.

Hormonal treatment
In what was likely a disappointment to many, the interim report did not provide definitive advice on the use of puberty blockers and feminising or masculinising hormones. Instead, Cass advised that recommendations will be developed as the review’s research programme progresses. In particular, the report expresses the need for more long term data to assuage safety concerns regarding these hormonal interventions. Although additional data in this area are undoubtedly needed, the decision to delay recommendations pending more information on potential unknown side effects is problematic for several reasons.

Firstly, it ignores more than two decades of clinical experience in this area as well as existing evidence showing the benefits of these hormonal interventions on the mental health and quality of life of gender diverse young people.3 -9 Secondly, it will take many years to obtain these long term data. Finally, Cass acknowledges that when there is no realistic prospect of filling evidence gaps in a timely way, professional consensus should be developed on the correct way to proceed.” Such consensus already exists outside the UK. The American Academy of Pediatrics, the Endocrine Society, and the World rofessional Association for Transgender Health have all endorsed the use of these hormonal treatments in gender diverse young people,10 -12 but curiously these consensus based clinical guidelines and position statements receive little or no mention in the interim report.

Indeed, there is no evidence, as yet, that the Cass review has consulted beyond the UK. This inward looking focus may be a reflection of how England’s gender identity service has come to chart its own path in this field. For example, its current use of puberty blockers diverges considerably from international best practice. In particular, NHS England mandates that any gender diverse person under the age of 18 years who wishes to access oestrogen or testosterone must first receive at least 12 months of puberty suppression.13 However, many young people in this situation will already be in late puberty or have finished their pubertal development, by which time the main potential benefits of puberty suppression have been lost.11 Moreover, using puberty blockers in such individuals is more likely to induce unwanted menopausal symptoms such as fatigue and disturbed mood.14 For these reasons, puberty suppression outside the UK is typically reserved for gender diverse young people who are in early or middle puberty, when there is a physiological reason for prescribing blockers.

Another possible reason exists for the Cass review appearing to have neglected international consensus around hormone prescribing. While the interim report often mentions the need to “build consensus,” Cass seems keen to find a way forward that ensures “conceptual agreement” and “shared understanding” across all interested parties, including those who view gender diversity as inherently pathological. Compromise can be productive in many situations, but the assumption that the middle ground serves the best interests of gender diverse children and young people is a fallacy. Where polarised opinions exist in medicine—as is true in this case—it can be harmful to give equal credence to all viewpoints, particularly the more extreme or outlying views on either side. Hopefully Cass will keep this in mind when preparing her final report.

The above is available on the BMJ here

(Back to me typing) The authors of the above include some of the most respected paediatricians with decade long expertise in working with trans kids in Australia. The Cass team should have been queuing up to learn from Australian experts. The fact they have totally ignored expertise from outside of the UK and its partner system in the Netherlands, strikes as amazing arrogance. The fact the Australian experts felt the need to write a submission to the BMJ to raise their concerns with the Cass report is again astonishing, and in another less transphobic country would set off alarm bells.

I don’t know where we go from here.

I do know the cards are now on the table. I have zero faith in the Cass process. It has already done more harm than good.

My number one hope for Cass was it would take significant strides in depathologising approaches to trans kids. It has done the exact opposite. 18 months in and they won’t even say the word trans.

I had hoped Cass would educate the public that being trans is not a problem or a pathology. It has done the opposite, and legitimised some incredibly problematising media pieces this week alone.

I had hoped it would move us from psychoanalysis to modern healthcare – instead people are using Cass to justify the need for exploratory therapy, conversion therapy by a different name.

I had hoped it would move trans kids’ healthcare away from a monopoly mental health trust to modern secondary or primary care. Instead, the focus appears to be on talk therapy to problematise trans-ness, without tackling the hostile climate that makes life so hard for trans kids, and perhaps with even less route to medical intervention where needed.

Cass has done nothing to highlight the biggest problem for many trans kids. The climate of societal transphobia. Just this week we have had headlines stating trans people can be humiliated and segregated as the UK tries to bring in a bathroom bill by the back door. Trans kids and adolescents have been in crisis again this week, many are really struggling with mental health. Not because there’s something inherently wrong with being trans, but because the UK is a hostile terrifying place to be trans as our rights are continually debated or taken away. Cass has done absolutely nothing to highlight the crisis in mental health caused by the terrible way our country treats trans people.

Cass has failed us on every level.

The whole process is cis-supremacism in full dominance.

Why do a bunch of cis people continue to debate and dictate whether or not trans kids should be put under conversion therapy.

Why do cis people continue to have all the power, and continue to use it to harm trans kids.

Trans liberation now. Trans kids deserve so much better than this.

“We just think of her as one of the girls” – Applying a Trans Inclusion Staged-Model to trans children’s experiences in UK primary and secondary schools.

 Horton, C. and Carlile, A.

NB. This is the accepted manuscript of an article published in a special issue of the Teacher’s College Record. The final published version (not open access) is available here.


Background/Context: Throughout the past decade, increasing numbers of trans children are being supported in childhood, with schools in countries across the world tasked with educating a generation of (known) trans pupils. Schools can adopt diverse approaches to inclusion or exclusion of trans pupils, with consequences for trans children’s well-being and safety at school. The literature includes extensive critique of the limitations of common approaches to trans inclusion, highlighting negative impacts on trans pupils.

Purpose: This article aims to reframe and bring nuance to conversations on trans inclusion in education, drawing upon primary research in the UK to make explicit different approaches to trans inclusion, their ideological underpinnings and their implications for how trans children are welcomed in our schools.

Setting: The research took place in the UK, with interviews conducted at a time of escalation of anti-trans discourse in UK courts and media.

Population: This article draws on data from two qualitative research projects focusing on the experiences of trans and non-binary children and their parents in the UK: one focusing on trans children aged 3 to 12, and the other on trans young people aged 12 to 18.

Research Design: Semi-structured interviews explored trans children’s experiences in education in the UK, with a focus on trans inclusive approaches to school culture, restrooms, and team sports. Data were analysed against the Trans-Inclusion Staged Model (TISM), a framework for distinguishing between different approaches to trans inclusion.

Findings: Within the TISM we differentiate between trans oppressive, assimilationist, accommodative and emancipatory approaches to educational inclusion. Interviews highlighted the harms and injustices in non-emancipatory approaches, revealing the role of cis-supremacy in forcing trans pupils into positions of vulnerability.

Conclusion/Recommendations: The TISM emphasizes the structural and systemic nature of trans oppression, illuminating the power imbalances embedded in non-emancipatory approaches and acknowledging the need for fundamental reform. We recommend analysis and recognition of areas of school practices that are trans oppressive, assimilationist, accommodative or emancipatory. We call for increased recognition of cis-supremacy within education, and commitment to emancipatory approaches to trans inclusion, enabling progress towards equity and gender justice in our schools.

Key Words: Transgender; children; education; schools; inclusion


Throughout the past decade, increasing numbers of trans children are being supported in childhood, with schools in countries across the world tasked with educating a generation of (known) trans pupils (Pullen Sansfaçon et al., 2015; Roche, 2020). Schools can adopt diverse approaches to inclusion or exclusion of trans pupils, with the literature detailing a wide range of challenges faced by trans children in education (Neary & Cross, 2018; Riggs & Bartholomaeus, 2018). This article aims to reframe and bring nuance to conversations on trans inclusion in education, drawing upon primary research in the UK to make explicit different approaches to trans inclusion, their ideological underpinnings and their implications for how trans children are welcomed in our schools.

In the first part of this article, we provide context for trans inclusion in UK schools, and summarise relevant global and national literature on trans inclusion in education. In the second part of this article, we introduce the Trans-Inclusion Staged-Model (TISM), distinguishing between trans oppressive, assimilationist, accommodative and emancipatory approaches. In the third part of this article the TISM is applied to primary data on trans children’s experiences in education in the UK, with a focus on trans inclusive approaches to school culture, restrooms, and team sports. We evaluate the limitations of different approaches to trans inclusion, discussing the implications for trans and non-binary pupils. We end with recommendations on emancipatory approaches to trans inclusion, striving towards a future of equity and gender justice in our schools.


Trans children’s rights in England, Scotland and Wales are protected under the Equality Act 2010, with “gender reassignment” one of nine protected characteristics (Wadham et al., 2016). The protected characteristic of gender reassignment applies to trans children, encompassing anyone who “is proposing to undergo, is undergoing, or has undergone a process (or part of a process) of…changing physiological or other attributes of sex”, the latter including, for example, pronoun change (Wadham et al., 2016, p.20). Department of Education advice on the application of the Equality Act in schools makes explicit that transgender pupils are protected from discrimination noting that it is “unlawful for schools to treat pupils less favourably because of their gender reassignment” (Department of Education, 2014, p.17). The same guidance states that where education is gender segregated, “pupils undergoing gender reassignment should be allowed to attend the single sex class that accords with the gender role in which they identify” (Department of Education, 2014, p.20). The use of the Equality Act 2010 to protect the right to “reasonable adjustment” in schools has not yet been tested in court for the characteristic of “gender reassignment”, though it has been tested and proven with regard to other protected characteristics, for example disability (C & C v The Governing Body of a School, The Secretary of State for Education (First Interested Party) and The National Autistic Society (Second Interested Party) (SEN) 2018).

Across the UK a wide range of school guidance materials or policies have been developed to support inclusion of trans children and young people in education (Horton, 2020), but without adequate clear UK-wide national guidance. The UK government’s 2018 “LGBT Action Plan” (Government Equalities Office, 2018) committed to funding an extension of research started in 2014 into homophobic, biphobic and transphobic bullying at school. This work was, contrary to other research (Greytak et. al.,2013), inclusive of the ‘T’ in ‘LGBT’, but its focus on bullying meant that this work did not attempt to address systemic areas of policy and curriculum, and guidance drawn from the research was never disseminated to schools (Carlile and Paechter 2018).

Across the UK a wide range of school guidance materials or policies have been developed to support inclusion of trans children and young people in education (Horton, 2020), but without adequate clear UK-wide national guidance. The UK government’s 2018 “LGBT Action Plan” (Government Equalities Office, 2018) committed to funding an extension of research started in 2014 into homophobic, biphobic and transphobic bullying at school. This work was, contrary to other research (Greytak et. al.,2013), inclusive of the ‘T’ in ‘LGBT’, but its focus on bullying meant that this work did not attempt to address systemic areas of policy and curriculum, and guidance drawn from the research was never disseminated to schools (Carlile and Paechter 2018).

The most significant recent change in UK educational policy relating to trans children could be argued to reside in the 2020 Relationships, Sex and Health Education guidance which requires secondary schools in England (for ages 11 to 16) to deliver LGBT inclusive curriculum, and strongly advises primary schools (for ages 4 to 11) to do so. Partly because of the Covid pandemic, the impact of this new policy remains to be seen (Epps, 2021). However, it is limited to a particular curricular area, so does not necessarily have the potential for widespread policy change or the usualisation of LGBT people and trans children in particular across the curriculum, school policies and practice (Carlile and Paechter 2018).

Review of relevant literature 

Existing global literature on trans children’s experiences in education raises areas of significant concern, with evidence of bullying and harassment, of school drop-out, and of encounters with discrimination and prejudice (Horton, 2020; Bower-Brown et al., 2021; McBride, 2020). Schools and individual teachers may feel underprepared for trans inclusion, with research highlighting the “panic” that can be experienced when a school is first faced with (knowingly) including a trans pupil (Payne & Smith, 2014). The picture for trans pupils in the UK remains poor, with the 2017 Stonewall school report finding 45% of 500 surveyed secondary school trans pupils had attempted to take their own life, and 84% reported self-harm (Bradlow et al., 2017). Qualitative research on secondary school age trans pupils has highlighted a wide range of challenges and areas of educational injustice across the UK (Bower-Brown et al., 2021, Carlile, Butteriss, and Pullen Sansfaçon 2021). Research on primary school trans pupils found evidence of trauma in schools poorly prepared for trans inclusion (Anonymised 2).

            Phipps and Blackall (2021) draw attention to the ways in which cisnormative gender regimes are embedded in school culture. Cisnormativity is the assumption that everyone is, or should be, cis (i.e. not trans) (Keo-Meier & Ehrensaft, 2018). Research has examined the ways in which school cisnormativity disadvantages and harms trans pupils (Bartholomaeus & Riggs, 2017; Cumming-Potvin & Martino, 2018; McBride & Neary, 2021). Miller (2016, p. 3) describes how school cisnormativity privileges cis pupils, reinforcing a culture of educational injustice, where minoritized students are “forced to focus on simple survival rather than success or fulfilment”. Trans pupils are placed under significant stress when educators and policy makers try to fit them into cisnormative schools that were not designed to meet the needs of trans children (Smith & Payne, 2016).

            Recognizing the challenges faced by trans children in education, efforts have increasingly shifted towards building understanding of and commitment to trans inclusion in our schools (Horton, 2020). Payne and Smith (2014) review school approaches to trans inclusion, noting willingness to take minor actions to enable inclusion, whilst avoiding examination of more systemic aspects of school culture. Martino et al. (2020, p. 1) highlight a tendency for some trans inclusion approaches, especially in primary schools, to focus purely on gender stereotypes, noting how this side-steps issues of genuine trans inclusion, and “eschews the necessity of addressing cisgender privilege and cisnormativity in the education system”. Neary (2021) discusses the limits of individualizing and conditional methods of inclusion, where trans children are forced to bend themselves to fit into cisnormative systems.  Literature has highlighted the insufficiency of some efforts towards trans inclusion (Pullen Sansfaçon et al., 2021). Even when schools do try to accommodate trans students, it is often attempted through reactive accommodation that lacks integration and fails resolve more systemic issues (Martino et al., 2020). Smith and Payne (2016, p. 34) point to a lack of commitment to institutional and systemic change, noting that “failure to make structural changes is indicative of narrow interpretations of gender-inclusive schooling”. Smidt and Freyd (2018) question the ambition of approaches to trans inclusion that fail to recognize cisnormativity or address areas of institutional oppression.

Conceptualizing Trans Inclusion as a Staged Model

This article builds from the critiques of narrow approaches to trans inclusion summarised above, challenging us to raise our ambition for trans inclusion, centring a commitment to equity and justice in education. We recognize that under the heading of ‘trans-inclusive’ education there are a multiplicity of intentions, aspirations and assumptions. We suggest that conflation of different approaches under one heading of trans-inclusive education impedes understanding, analysis and action towards trans-equality. Here we propose a staged-model for trans inclusion, the Trans Inclusion Staged-Model (TISM). This staged-model aims to more clearly distinguish and differentiate between different approaches to trans inclusion in schools, illustrating four discrete approaches. We see value in utilising this staged-model as a conceptual framework for clarifying distinctions between diverse approaches to trans inclusion, drawing attention to their ideological assumptions, priorities and limitations.

Staged-models or maturity models are widely used across diverse spheres and sectors to benchmark and improve practices (McLeod et al., 2020; Tarhan et al., 2016). Such models have been critiqued as a static assessment tool, when used to place snapshot judgements on processes, institutions or practices that are complex and dynamic. Here this staged-model is not presented as a rigid evaluation tool, but instead intended to provide us with the language and conceptual clarity to have more meaningful discussions on different approaches to trans inclusion. With this article we hope to prompt readers to reflect upon the ideological and ethical underpinnings of each proposed level, and to question where current trans-inclusive practices lie. Benchmarking against a staged-model can be a helpful way of understanding the strengths and weaknesses of current practice, and can provide a stepping stone from which to prioritize actions for improved practice. This model defines four staged levels, ranging from trans-oppressive, to trans-assimilationist, to trans-accommodative, through to trans-emancipatory (see next section for details).

Whilst it can be used to assess established practice, the TISM is intended to be future looking, for shaping strategies and action plans. It is recognized that the benchmarking of practice is subjective and dynamic. For example, what aspirations for trans emancipatory practice look like from a point of trans oppressive practice may differ significantly depending on the aspirations we hold as we move closer to a position of gender justice. This is proposed as a strength of the TISM, with expectations, ambitions and priorities not set in advance, rather providing a framework to enable self-driven evaluation and progress. The TISM can help those who are committed to equity and justice to make progress towards trans-emancipatory education.

The TISM is also designed to ensure approaches to trans inclusion benefit all pupils, including those with least privilege. We particularly see value in our proposed staged-model for drawing attention to those who are ill-served by current practice, illuminating why some trans-inclusive practices can fail to benefit all trans pupils. We recognize (and explore herein) the limitations of non-emancipatory approaches to trans inclusion. Such approaches are hypothesised as more likely to benefit a certain type of trans pupil: those with parental support and social capital, those who are binary-oriented, non-disclosing, who do not challenge cis-dominant institutional hierarchies, often those who are white, and who have access to healthcare. We see value in this staged-model in drawing attention to those who are at risk of being left behind in non-emancipatory approaches to trans inclusion.

A note on language

In this article the term “trans children” will be used. Trans children includes transgender and or non-binary children, also described as “gender diverse children” (Keo-Meier & Ehrensaft, 2018). “Cis” is a term for non-trans or cisgender people. This article uses the term cisnormativity, in preference2 to related and overlapping terms including cisgenderism and cissexism. Where all ages under 18 are included (including the youngest pre-primary and primary school children) the term “children” will be used. Where necessary this will be divided into trans children and trans adolescents, and where appropriate the term “trans young people” or “trans youth” will be used, with the term “youth” excluding younger children and including young adults (UNDESA, 2013).


This article draws upon two datasets. Carlile collected one dataset as part of an international project looking at the experiences of trans children and their parents in Canada, Switzerland, Australia, the US and the UK (Pullen Sansfaçon et al 2021) and focusing on separately interviewing twelve parent-child dyadic pairs.  Participants were families who lived in England and who were contacted via a support group. They mostly identified as “white British” or “English” and all the parents interviewed were cisgender women. The children were aged between 5 and 20, with the mean age being 15. Eight of the children identified as boys, two as girls, and three as non-binary. Data was collected in line with Vincent’s (2018) guidelines on conducting research with trans people. It was therefore important to take a robust approach to confidentiality (Adams et al., 2017); to work with a trans researcher who interviewed most of the trans child and youth participants and sense-checked the analysis; to invite participants to choose the location of the interview and to pause and restart where necessary; and to ask the questions in an open format as far as was possible, notwithstanding the need to adhere to the established question schedule in order to allow for an international comparison. 

Horton collected a second dataset as part of a PhD on the experiences of trans children who socially transition under the age of 11 and their families. 30 parents and 10 trans children from across England, Scotland and Wales were interviewed. The 30 parents shared experiences supporting their trans children (current average age 11; range 6-16) who socially transitioned at average age 7 (range at transition 3-10 years old). Interviewed parents were 100% cis, 93% female, 90% white and were contacted via 6 UK support groups for parents with trans children. Horton brings experience as a non-binary parent of a young trans child and is themselves a member of four of those parent support groups, enabling privileged access to a hard-to-reach cohort of parents with young trans children. The 10 interviewed children, who opted in to participation after their parent was interviewed, were on average age 12 (range 9-16). Semi-structured interviews, covering broad topics including healthcare, education and families, lasted 1-3 hours (average 2 hours) for parents, and 20-50 minutes for children (average 25 minutes). Interviews utilised broad open-ended questions, allowing interviewees to talk openly and at length around each topic. Interviews were conducted remotely on Microsoft Teams. The interview methodology with trans children was flexible, adapting to individual child preference, with some interviews conducted one-to-one, some conducted with their parent present, one with their parent asking pre-determined questions and recording the interview, and one child preferring to provide written responses to questions that they selected from a longer list of potential questions.

Both Carlile’s and Horton’s data collection methodologies adhered to British Educational Research Association guidelines and were ratified by the authors’ university. These included information sheets and consent forms which were provided in a range of versions appropriate to each age group and explained verbally where necessary.

Methods of Analysis  

Data collected by Carlile was transcribed by a third-party transcription company and then coded in NVivo using a thematic analysis approach which went through three coding stages in collaboration between the initial data collection team members. Coding grouped together themes of the experience of clinical settings, children’s identities, extra-curricular activities and friendships, as well as the school experiences which are the focus of this paper. Data collected by Horton was transcribed by the author, the transcripts compared against the recordings for accuracy, and stored on an encrypted platform. Anonymised transcripts were then coded in Nvivo applying reflective thematic analysis (Braun & Clarke, 2006). This paper examines a subset of the wider data corpus, focusing on experiences in education. Data from two datasets were brought into the analysis, both to see how the proposed model could be applied to different datasets, and to enrich the analysis with data on a wider cohort and age range of trans pupils. We were confident in the compatibility and complementarity of the two datasets and methodological approaches, with Carlile acting as supervisor for Horton’s PhD, and having experience of prior collaboration on a range of research partnerships.  

Trans-Inclusion Staged-Model

We propose a staged-model of trans inclusion, from trans oppressive to trans emancipatory (see Table 1). This section provides an overview of the four proposed levels of trans inclusion, grounded in existing literature. The following section applies this model to our own data, drawn from primary research in the UK.

Table 1: Staged- model: from trans oppressive to trans emancipatory

ApproachTrans- OppressiveTrans- AssimilationistTrans- AccommodativeTrans- Emancipatory
Locus of changeNo changeIndividual child allowed to changeClass or year groupWhole school
Time-scale for changeNo changeOne discrete momentWhile specific child is presentSustained forever
Power structureCis-supremacy in full dominanceCis-supremacy with exceptionalismBenevolent cis-supremacyGender justice and trans liberation
Significance of changeStatus quoBrief glitch in the matrix then reset / recategorization then business as usualTemporary accommodation / accommodation within discrete parametersGenuine power shift to cis trans equality

This staged-model for trans inclusion contrasts four levels or approaches to trans inclusion in schools ranging from trans oppressive, through to trans emancipatory.

At the first level of the framework, schools, policies or areas of educational practice are considered trans-oppressive. In this approach, trans identities are actively persecuted and disenfranchised, with trans pupils forced to present and align with their incorrectly assigned gender. A trans-oppressive approach assumes trans pupils are illegitimate, inferior or unworthy of rights, making no space for trans well-being. Across global literature there are numerous examples of schools adopting a trans-oppressive approach, with significant consequences for trans children in schools that are hostile and discriminatory (Ferfolja & Ullman, 2017; Ingrey, 2018; Luecke, 2018; Meyer & Keenan, 2018; Miller et al., 2018; Omercajic & Martino, 2020).

The second level in the framework aspires for trans-assimilation. In this approach, a trans pupil can be re-categorized, shifting from one binary box to the other, and is then expected to disappear into a cisnormative system without wider implications for a school. A trans-assimilationist approach assumes a trans pupil is exactly the same as a cis pupil, but mis-categorized. It assumes a binary-oriented trans pupil, who can change their category, and then disappear un-noticed within a school that immediately regains its appearance of uniform cis-ness. A trans-assimilationist approach can suit or appeal to some trans pupils, especially those who are gender-conforming, who “pass”, who are non-disclosing, and who are binary-oriented. Martino and Cumming-Potvin (2017) provide an example of a teacher adopting a trans assimilationist approach, accepting a trans child as though cis, without consideration of anything further being needed. Frohard-Dourlent (2016) similarly highlights how a teacher discourse of “open-mindedness” can contribute to trans-assimilationist approaches, where a pupil’s transitude is dismissed, without any recognition of the ways in which assimilationist approaches can perpetuate systems of inequality. Frohard-Dourlent (2016) draws a comparison to white people who describe “not seeing race” and the way this discourse can reinforce and avoid scrutiny of the racism embedded in institutions and cultures.

Martino and Cumming-Potvin (2017) describe how a swift transition of a trans child from one category to another can be accomplished within a school without disrupting cis-supremacy, and without considering any need for action beyond that very moment of transition. Davy and Cordova (2019) note that such schools can readily re-categorize binary oriented trans pupils, yet struggle to effectively absorb non-binary pupils. McBride (2020) references literature on visibility, noting that invisible minorities can be side-lined and ignored. Martino et al. (2020, p. 2) reference the “erasure of trans personhood within school communities”, where trans pupils are absorbed into a cis-mainstream without any effort towards active trans inclusion.

At level three of the framework schools prioritize trans accommodation, where adaptations or disruptions to the cis-dominant status quo are negotiated or permitted on an individualized basis. This accommodative approach is often driven by a single pupil or their family, with a visible trans pupil providing the catalyst for adaptations catering to that specific child. A trans accommodative approach recognizes that trans pupils can have different needs to cis pupils. However, it still assumes a trans pupil is a one-off, a diversion from the norm, with everything in the school reverting to business as usual once that pupil has passed through that class or year group or left the school. When taking an accommodative approach, there may be an assumption that changes are being made just for that one pupil, and there is often a significant burden on individual pupils to ask for, educate on, or advocate for the adaptations that they need.

Martino and Cumming-Potvin (2017) talk of the impact of an “out” trans student disrupting the familiar and taken for granted cisnormative binary. Several authors have written about the immense burden placed on trans children, or their families, when expected to advocate for their own inclusion in cisnormative institutions that were not designed with trans pupils in mind (Davy & Cordoba, 2019; Neary & Cross, 2018; Riggs & Bartholomaeus, 2018). The same authors emphasize the inequalities inherent in accommodative approaches, in systems where pupils and parents draw on their existing social capital, connections, power and privilege to demand accommodation. They recognize the likelihood of inferior outcomes where pupils or parents lack the knowledge, capacity, authority or power to assert their rights. In an accommodative approach, the power structure of cis-supremacy remains in place; accommodation has to be requested, and may be denied. While cis-supremacy is in place, trans pupils are by default put into a position of having to make themselves “coherent and intelligible to adults who have the power to (dis)allow” their inclusion (Frohard-Dourlent, 2018, p. 11).

A trans-accommodative approach often regards accommodations as a short-term aberration, with institutions reverting to the earlier status quo once a known trans pupil has left. Meyer and Keenan (2018, p. 749) emphasize the deficiencies in an approach that is “primarily focused on the management of individual people and cases, rather than institutional change”. Schools in this approach risk perpetually burdening trans pupils, placing them in a position of precarity where they need to negotiate their own inclusion. McBride and Neary (2021, p. 2) describe how trans adolescents disrupt institutional cisnormativity through “individual and collective acts of resistance”.  Trans adolescents may be effective in challenging discriminatory policy or practice, though this does not deny the emotional toll of putting adolescents in such a position (Meyer et al., 2016). In order to resist and challenge cisnormativity trans youth have to assert and stand up for their own rights, a position where they “risk becoming identifiable and targetable” (McBride & Neary, 2021, p. 4). Such pupils are forced into a position as a visible minority, with the potential of being singled out as a troublemaker. Frohard-Dourlent (2018, p. 2) notes how schools that we could describe as assimilationist or accommodative “mark trans students as troublesome because they, (intentionally or otherwise) highlight the limits of the gendered assumptions that underlie many school practices”. 

Across the literature there are examples of schools more easily assimilating a certain type of trans pupil; one that is gender conforming, binary-oriented, non-disclosing, who can be easily absorbed into a cis-dominant system with barely any disruption (Horton, forthcoming; Frohard-Dourlent, 2018). Schools find it simpler to accommodate “binary trans students, because their genders are more culturally intelligible” (Frohard-Dourlent, 2018, p. 2). Binary-oriented trans pupils are easier to assimilate or accommodate without significantly changing the gendered assumptions on which schools are run. Non-binary pupils “are more threatening to the dominant paradigm” (Frohard-Dourlent, 2018, p. 9) presenting challenges to (cis-supremacist) schools.

Level four: trans-emancipatory education, describes schools where trans pupils are understood as genuine equals to their cis classmates. This entails a genuine power shift to a position of gender justice and trans liberation, where trans pupils are genuine equals to their cis classmates. Existing literature provides limited insights into trans emancipatory education. Frohard-Dourlent (2018, p. 1) “argues for more systemic changes that do not require the presence of trans bodies, and instead offer possibilities for educational spaces in which all students would experience fewer pressures of gender”. Neary (2019) highlights how parents advocating for trans children do not want individualized accommodation of their particular child, but rather aspire towards schools where gender is less rigidly policed for all children.

Across the four levels we note the varying influence of cis supremacy. Cis supremacy is here understood as a situation where cis people hold power over or are privileged over trans people, with trans people systemically disadvantaged. Sharrow writes about how institutions are a “site for advancing, enshrining, and normalizing cis-supremacist gender orders” (2021, p.1). Schools that ignore cis-supremacist hierarchies are complicit in perpetuating, legitimising and enabling discrimination (Ferfolja & Ullman, 2021). Frohard Dourlent (2016, p. 68) emphasizes how approaches that fall short of emancipation avoid “a systemic analysis of how power functions to constitute both students and educators within systems of gender conformity”. Here we make this consideration of power explicit, focusing on cis-supremacy, and acknowledging the ways in which non-emancipatory approaches to trans inclusion may aim to assimilate or accommodate a trans pupil, whilst leaving underpinning structures, processes and systems of cis-supremacy unchallenged.

A note on non-disclosure versus assimilation

Disclosure is a term to describe how and when an individual decides to share with others information about their being trans. Across any of these levels of the TISM, an important distinction is made between a school imposing their own agenda onto a trans child’s approach to disclosure (pushing a trans child into being out as trans, or pushing a child to being non-disclosing), and a child being enabled to make their own decisions on disclosure. It is important to note that trans children may assert their right to non-disclosure across all approaches (including in trans-emancipatory or trans-oppressive schools). The description of assimilation in level 2, therefore, is not a description of an individual child’s preference to assimilate and be presumed cis, but where a school implicitly or explicitly encourages or demands assimilation. Horton (forthcoming) describes a school explicitly restricting a child from using the word “trans” to describe themselves, an example of enforced assimilation.

The TISM in practice: Application to three common scenarios

In this section we consider three scenarios in which schools commonly take distinct approaches to trans inclusion or exclusion: a school’s capacity to build a trans-positive culture (including meaningful inclusion in the community and responses to bullying and misgendering); PE and sport; and toilet facilities. These common elements of school infrastructure are illuminating foci for the application of the Trans Inclusion Staged-Model (TISM) described above. They have been selected as they are frequently invoked by the parents, children and young people both authors interviewed as visceral exemplifications of a sense of inclusion or exclusion. As one participant explained: “…it would be nice if the school could have had like just … found a way to like make everyone have PE and not feel uncomfortable about how they look. Or like feel about their gender or themselves. Or where they pee or do their business or take care of themselves” (boy, 15).

Building trans-positive school cultures

Trans children are known to be at risk of isolation, bullying and a lack of belonging in school with implications for their well-being, educational attainment, and ability to complete their education (Horton, 2020; McBride, 2020). We consider a trans-positive school culture to be one which implements meaningful trans inclusion in the school community, and effective, confident institutional responses to bullying and misgendering. The examples below highlight the ways in which many schools are not consistently committed to implementing systemic changes to create trans-positive cultures that are safe and welcoming for trans pupils (Smith and Payne 2016).

Trans-oppressive schools fail to ensure school safety, with pupils left unsupported against bullying or social exclusion, being physically or emotionally unsafe at school. One of our participants described how they had been bullied by other students: “… some of the boys in class … started to just call me … “it” because they were like, “oh it’s a thing” instead of a person” (non-binary young person, 15).

Trans-assimilationist schools are likely to take a reactive response to overt manifestations of bullying, punishing pupils for abusive language or correcting pupils who misgender, without tackling the underlying attitudes or ignorance that drives delegitimization and exclusion of trans children. The children and young people we interviewed who were pupils in such schools were likely to talk about exclusion from friendship groups, feeling misunderstood and unwelcome, even while schools reacted to individual incidents of abuse. Several of the trans-assimilationist schools described by our interviewees did not appear to be tackling systemic and wide-spread transphobic bullying. The data suggested that these schools addressed a pupil’s transition as a simple gender category change, considering a child’s transition to be a one-off event, and failing to recognize the need for broader action to create a trans-positive school environment. A parent of a primary aged child (under 11) described this experience: “… they just sort of tried to carry on as if everything was fine but this child just had a different name and pronouns”.

One parent we interviewed reported a teacher saying to her: “We just think of her as one of the girls, we just never would have thought that anything might be an issue”. Interviewees reported that pupils in such schools were likely to experience periodic incidents of bullying or abuse, with the onus on an individual pupil or parent to report and seek action on each incident. Where bullying was widespread or comprised an ongoing series of individually minor incidents from multiple individuals, trans pupils were at risk of being labelled over-sensitive or demanding, with schools losing patience in responding to each incident. Where trans pupils responded themselves to recurrent bullying incidents, they were at risk of being labelled a trouble-maker. 

In contrast, the schools described by our interviewees which we would characterise as trans-accommodative appeared to recognize that a lack of trans-representation or trans-positivity could underpin the bullying or isolation of trans pupils. Such schools were reported to prioritize tackling underlying attitudes or lack of knowledge and understanding of transitude. One child described the contrast between a school with a reactive trans-assimilationist approach, and a new school they moved to that they considered more proactive in raising awareness and understanding. The new school provided proactive education, including showing a TV series with trans-positive depiction of a young trans girl navigating a new school  (Kalceff, 2020), in sessions attended by both staff and students. The young person (girl, 11) felt that this made “…an extremely big difference – in the school where they didn’t show the video I would get picked on a lot by people because they don’t understand it very well. When in the other school where they did show the video, you understand why it’s difficult and why it’s hard”.  Whilst we cannot be sure that positive representation was instrumental in changing culture, for this young person, a proactive effort to educate classmates (an approach we could characterise as trans accommodative) contributed to a trans-positive school culture.

In trans-accommodative schools, proactive trans positive education was often prompted by the presence of a particular trans child. Our participants explained that trans-positive education was not provided ahead of the arrival of a specific known trans child, and often only took place after advocacy from a child or parent, or after schools noted persistent or wide-spread bullying, recognizing the negative repercussions of a reactive anti-bullying approach. It seems from the data we collected that in trans-accommodative schools trans-positive education is prompted by a specific trans pupil disrupting the cisnormative status quo, with that trans pupil enduring ignorance and hostility while a school moves on a learning curve towards trans-positivity. As one frustrated parent stated ”I don’t have the time for people to learn. I need them to be able to keep my child safe straight away”. Schools with what could be considered trans-emancipatory cultures prioritized trans-positive education with high expectations for trans inclusion before a trans pupil’s arrival or transition. Where pupils joined or transitioned in a school with a pre-existing commitment to trans-equality, they did not need to request or advocate for trans-positive adaptations: trans positivity was already expected. This did not mean a total absence of transphobic bullying incidents, but such trans-emancipatory schools were well equipped to tackle both overt bullying, and the awareness and attitudes that legitimise transphobia. Trans-emancipatory schools are ones with a robust response to bullying underpinned, crucially, with proactive education of all students and staff, raising awareness, acceptance and trans-positivity.

The different approaches to ensuring a trans-positive culture found within our data highlight the limitations and opportunities of different approaches to trans inclusion. These findings build upon existing literature that critiques the shortcomings of trans inclusive approaches primarily grounded in an anti-bullying agenda, noting that such approaches can be pathologising rather than educational and celebratory, and tend to individualize transphobia, erasing and distracting from wider systemic and institutionally-perpetuated roots of trans inequality in education (Ferfolja & Ullman, 2021; Formby, 2015; Ullman, 2018). At the same time, we note that anti-bullying approaches can provide the foundation for a shift towards improved practice, with schools generally being comfortable with the notion of being against bullying (Carlile 2020). A trans-emancipatory approach goes beyond anti-bullying, “usualising” trans people across the curriculum and school environment in a systemic way. This movement beyond the narrow boundaries of anti-bullying practice  is closer to the responsibilities embedded in the public sector Equality Act 2010 duty to actively enhance knowledge and understanding of marginalised groups (Carlile 2020).

PE and sport

Physical education (PE) spaces are often noted to be explicitly binary (Jones et al., 2017; Muchicko et al., 2014). Bullying, heteronormative notions of masculinity, and institutional structures such as uniforms, teams and changing rooms can exclude trans children and young people (Human Rights Council, 2020; Greenspan et al., 2019; Kulick et al., 2019). Analysis of a secondary school trans pupil’s experience in PE emphasized how inclusion of trans pupils in binary PE systems fails to challenge wider cisnormativity (Phipps & Blackall, 2021). Neary and McBride (2021) draw attention to the compromises trans youth must make to participate in sport.

In a trans-oppressive school, trans pupils might be forced to use facilities or compete in sport as their incorrectly assigned gender. Across our dataset, there were several examples of trans pupils being expected to play sport with pupils of their assigned gender. In other schools, a lack of clear policy led to confusion and debate on where trans pupils should play, with trans children left feeling unwelcome in sport. A large number of trans children in both samples were disengaged from school sports, even at primary school level, finding cisnormative and gender segregated spaces unwelcoming. Several parents described trans children who had disengaged from PE. One explained that her child “… loves sports but he’s not participating in PE. Why? Why, why is a child who loves rugby, football, swimming, hockey, basketball, dancing, why is he not participating in sport?”

Other schools recognized the rights of trans pupils to play sport in their gender. In a trans-assimilationist scenario, trans pupils are recategorized, and following formal request and discussion, are allowed to play and compete in their affirmed gender. This assimilation occurs without any changes to the originally available options or categories, and for some trans pupils, an assimilationist approach enabled them to participate and enjoy PE and sport. Assimilation into gendered groupings is however, less likely to meet the needs of non-binary pupils. Whilst trans-assimilationist schools can enable binary-oriented trans pupils to play in their affirmed gender, the best option such schools are able to offer non-binary pupils is to pick which of two binary teams to play on. According to our interviewees, this approach did not meet pupil need, creating uncomfortable environments. One non-binary young person explained their changing-room experience:

…PE was the hardest thing …in the changing rooms everyone would just be like “[name] is staring at me” when really, I wasn’t staring at them… they were just judgemental. 

The trans-assimilationist schools described in our data appeared not to recognize or challenge the cisnormative nature of physical education spaces, and failed to create an environment in which trans pupils felt welcome and wanted. One parent reported that their primary-aged non-binary child asked them: “why do they have a girl’s race and a boy’s race … which race would I run in? And if there was a “both” race, would I be the only one running it?” Another parent described how her child had completely dropped out of doing sports altogether: “… because if they were going to compete, they could only do it in a binary gender, they had to pick one. So that really sort of took the joy of it out of it for them”.

Across our datasets, PE was a space where notably there were no examples of trans-accommodative or trans-emancipatory approaches. Adapting PE to cater for the needs of a minority of trans pupils was beyond the scope of ad-hoc and responsive reactions to a specific pupil. And whilst schools continue to treat each trans pupil as a one-off, the schools we heard about did not seem to be developing practices where all trans and non-binary children and young people can easily be welcomed in sport and physical education.

Toilet facilities

School toilets (“restrooms” or “bathrooms” in the US and Canada) are another example of explicitly gendered infrastructure (Kjaran, 2019). Toilets can function as spaces of exclusion, fear and discomfort, posing specific dilemmas for non-binary children (Bower-Brown et al., 2021; Paechter, Toft and Carlile 2021). Several of our interviewees described trans-oppressive approaches to school bathrooms, where they were denied access to appropriate facilities with material consequences for their mental and physical health. Many participants across both datasets simply opted out of using the toilet at school at all. One child who described being unable to use school facilities said: “I would hold it in until like literally school ended”.

Many binary-oriented young people described encountering trans-assimilationist approaches, where, often following formal request, negotiation and permission, they were allowed to use facilities matching their gender. This approach to the use of toilets viscerally exemplifies the way in which a trans-assimilationist approach can allow some trans pupils to be re-categorized within a school, without changing anything else in the school system. For some binary-oriented trans pupils, this approach met their needs. As Ingrey (2018, p.787) explains: “one must submit oneself to scrutiny of a public who can choose to accommodate or not” which only serves to “reinforce the binary of the gendered norm and the gendered other”.

Whilst a trans-assimilationist approach can meet the toilet needs of some binary-oriented trans pupils, it is less likely to meet the needs of non-binary pupils. Several non-binary children described needing to choose between girls’ or boys’ facilities, with neither meeting their need. Schools without toilet provision for non-binary children could be described as falling within the trans-oppressive paradigm, leading to repeated experiences of bullying and exclusion. One non-binary participant explained:

The girls were like, “you can’t come in here you’re a boy, this is the girls’ toilets”. And then they went out, they told me to go to the boys’ so I walked to the boys’. And then the boys all stared at me and they were like, “you can’t come here, you don’t look like you’re meant to be in here. Are you a girl or something or are you a [transphobic slur]”? And then like I used to get tripped up like down the hallway going to the toilets or whatever.

For a number of the young people we interviewed, the school’s original toilet options did not meet their needs. For some this was because of safety issues and bullying experiences such as that described above; for others because the schools lacked gender neutral facilities. In a trans-accommodative scenario, bespoke additional options are sometimes developed, for example in a specific location or for a specific year group, to accommodate the needs of specific pupils. This accommodation typically is developed following request, discussion or negotiation by or on behalf of a specific pupil. It is not typically sustained or accessible to other trans pupils.

Importantly, we draw a critical distinction between a trans-accommodative approach, where additional options are made available to better meet a child’s need, and trans-oppressive approaches, where trans pupils are forced to accept a bespoke or segregated option (for example, told to use a staff toilet, when they might prefer to use the general boys’ toilet). Within our data, accommodative examples included a school enabling access to a staff toilet/changing room, for a child who wanted additional privacy.  The parent felt this adaptation met their child’s need for additional privacy, but acknowledged that this approach was inadequate for the future needs of trans students: “…well, I mean, if you’ve got ten trans kids in your school, they can’t all have individual toilets so, that feels like an interim measure”. This could be understood to fall into the trans-accommodative paradigm, characterised in the model described above as “benevolent cis-supremacy”. In a trans-emancipatory approach, trans-inclusive options would be sustained and open to all pupils, without requiring permission, negotiation or request.

Conclusion and recommendations

This study introduced the Trans Inclusion Staged-Model (TISM) as a framework for understanding and distinguishing between different approaches to trans inclusion. This staged-model is intended as a tool to enable reflection, self-assessment and discussion, with particular consideration of the limitations or implications of trans-inclusive approaches that are not trans-emancipatory. The TISM does not aspire to be a rigid objective evaluation tool, and we draw attention to the fact that the same school can adopt different approaches to trans inclusion in different spheres, for example being trans oppressive in approach to sport whilst being trans emancipatory in uniform practices. We are interested in working with trans children to identify how they would rate their school in terms of trans inclusion across different domains, and identifying the domains where they would most want to see change, though that falls beyond the scope of this present article.

This study applied the TISM to three scenarios (culture, PE, toilets), illuminating different approaches to trans inclusion, and considering their implications for trans pupils. The experiences shared by interviewees primarily focus on critiques of the limitations or inadequacies of non-emancipatory approaches, and the struggle to protect trans children from trans-oppressive approaches. Our data emphasized how parental advocacy can be pivotal in a school’s shift from a trans-oppressive to a trans assimilationist or trans-accommodative approach, dependant on an individual parent’s ability and opportunity to advocate for their child’s rights. Against a background of a lack of UK-wide educational guidelines, and varying education authority guidelines, trans children’s rights to equal access to education appear to often be determined by the attitudes and knowledge of individual school leaders, or reliant upon the advocacy and knowledge of parents of trans children. This leaves a subset of trans pupils potentially more vulnerable to trans-oppressive environments.

Our data reveal examples of schools adopting trans assimilationist approaches, where binary-oriented trans pupils are slotted into cisnormative school systems without shifting or even acknowledging the underlying cis-supremacy. Our data also highlights a distinction between the trans pupils that seem to be easily assimilated, especially those who are conforming, binary-oriented, and non-disclosing, and trans pupils for whom simple assimilation is not feasible, including pupils who are “out and proud”, who have expectations of genuine equality, who do not or cannot “pass”, or who are non-conforming or non-binary. Schools which adopt a trans-assimilationist approach with one trans pupil, who do not recognize the limitations of such an approach, can too easily frame a less easily assimilated pupil as overly demanding, or troublesome.

Our data highlighted a number of examples of accommodative approaches, with trans children or parents negotiating adaptations to better integrate trans pupils. Parents within our sample reported frustration at trans-positive adaptations being considered a one-off, not being sustained within a school, and not being extended to other pupils. These examples highlight the limitations of accommodative approaches that do not prioritize genuine transformative change that can benefit all trans pupils.

Trans emancipatory approaches ensure all trans pupils are genuinely able to access education on an equal footing to their cis peers. Across our own data, and the existing literature, there are limited examples of what a trans-emancipatory approach looks like, with limited examples of inclusion pre-dating a child’s arrival or transition, and few examples of inclusion being embedded into a school’s culture and practices, without requiring individual advocacy. This present article does not attempt to predict or prescribe what trans-emancipatory education should look like, instead providing a conceptual vision to be built upon. Further research, in collaboration with trans pupils, could delve further into trans-emancipatory ambitions in education.

The TISM emphasizes the structural and systemic nature of trans oppression, illuminating the power imbalances embedded in non-emancipatory approaches and acknowledging the need for fundamental reform of the “institutionalised mechanisms of power that disadvantage trans people” (Spade, 2007 p.20). The TISM acknowledges how institutions like schools codify and perpetuate norms of social control that dictate which children are accepted and acceptable in school (Spade, 2015).  Spade (2015, p.5) notes how norms uphold systems of domination that “produce security for some populations and vulnerability for others”, calling for a action to tackle the population-level conditions that instil vulnerability. Serano (2016) has written on how forces like cisnormativity and cis-supremacy function in part through their invisibility as the unmarked status quo. The TISM recognizes how systems of oppression like cis-supremacy work in the background, as presumed ‘neutral’ features, un-noticed by cis people, until they are brought to our attention by their clash with, and impact on, trans children (Spade, 2015). Building on Kumashiro (2004, p.46) we note that “challenging oppression requires more than simply becoming aware of oppression…because people are often invested in the status quo.      

The TISM also emphasizes the vital importance of prioritizing solutions that will benefit the most vulnerable, recognizing who is left out in assimilationist or accommodative approaches. Echoing work by Namaste (2011) it challenges us to prioritize solutions that will benefit all trans children, rather than actions or accommodations that will elevate only a subset of less marginalised individuals. An important acknowledged limitation of the TISM is its one-dimensional focus on trans-inclusion. It is certainly critical to understand intersectionality, gendered racialisation and the interplay between cis-supremacy and for example, white-supremacy and ableism (Spade, 2015; Gill-Peterson, 2018). Trans emancipatory education cannot be meaningfully achieved whilst ignoring other areas of systemic injustice (Gill-Peterson, 2018). This recognition feeds into the proposed application of the TISM. It is proposed as a tool and framework for driving forward conversations, priorities and action upholding an aspiration and commitment to trans emancipatory education, alongside wider commitments to intersectional equity and justice. It is not proposed as a rigid pass or fail assessment or evaluation tool, and its limitations in drawing attention to the experiences of Black, disabled, neurodiverse trans pupils are noted. We do anticipate it providing a framework for further youth-led conversations on what trans emancipatory education looks like for pupils who are, for example, trans and Black, trans and an immigrant, or trans and in the care system.

We conclude our article not with a reductive list of actions to achieve trans-emancipatory education. Instead, we add our voices to Nicolazzo (2016, p.138), who asks readers to “wade through the murkiness of systemic trans oppression with us”. As educators we need to commit to asking ourselves “hard questions about how we may still be complicit in furthering trans oppression in our policies and practices even when we take positive steps” (Nicolazzo, 2016, p.142). We recognize that being trans-emancipatory requires a dynamic and ongoing commitment, rather than being viewed as a static singular achievement, prompting us to continue to push the boundary in pursuit of trans emancipation, equity and justice in education.  

We consider three opportunities for ensuring continued progress towards trans-emancipatory education. Firstly, we invite researchers analysing trans inclusion in education to identify and articulate areas of school practice that are trans-oppressive, trans-assimilationist, trans-accommodative or trans-emancipatory. Secondly, we recommend the development of tools to help benchmark school performance across the different domains of this trans inclusion staged-model. We see particular utility in a school assessment matrix  geared towards trans children and adolescents, enabling trans children, or their families to evaluate their educational experience in terms of trans inclusion. Finally, we join trans scholars in asking “for educators to imagine new possibilities” (Nicolazzo, 2016, p.140). We call for greater acknowledgement of cis-supremacy within efforts labelled as trans inclusive, recognizing cis-supremacy as incompatible with an aspiration for gender justice and genuine equality.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


Horton declares no funding associated with this research. This study was conducted as part of the author’s PhD. The PhD was self-funded, with a Goldsmiths University of London Department of Education bursary covered half of the PhD fees.

Carlile declares no funding associated with this research.


1 Primary schools in the UK include pupils aged 4-11, encompassing both primary and elementary school children.

2 The term cisnormativity is used for consistency and accessibility, drawing attention to areas of systemic oppression experienced and directed at trans and non-binary people. Cisnormativity is preferred as a term that echoes the semantic use of terminology such as transnormativity and heteronormativity, whereas cissexism carries echoes of older and less used terminology like cissexual, whilst cisgenderism, for us, carries associations with problematic and dated terminology like transgenderism. Terminology is recognized as evolving and dynamic.


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Spanish translation

I’m getting my infographic on trans inclusive education translated. Please let me know if any changes are needed to the Spanish here before I finalise (I’ll credit the awesome volunteers who translated once it is finalised) 

                                                APOYO A NIÑES TRANS EN LAS ESCUELAS

Recomendaciones de un artículo de Frontiers of Sociology (2020) sobre educación inclusiva a la comunidad LGBTTTIQA+

¿Prosperando o existiendo? Elevando el estándar para la experiencia primaria y secundaria plena de la infancia trans

  1. Les estudiantes trans frecuentemente se enfrentan al estigma, discriminación y acoso en el ambiente escolar.
  • Lenguaje afirmativo, respeto y una actitud trans-positiva son fundamentales.
  • Les estudiantes trans experimentan estrés persistente debido a que el sistema los deslegitimiza y excluye. Un acercamiento anti-bullying disminuye el impacto emocional y psicológico que la cisnormatividad tiene en elles.
  • Las escuelas deben buscar mejorar las prácticas y actividades cisnormativas que resultan una amenaza para les estudiantes transgénero.
  • Las escuelas son reacias a aceptar cambiar sus prácticas por casos aislados o individuales, lo que hace más pesada la carga para les alumnes que deben negociar su propia inclusión.
  • Las escuelas deben de cambiar su acercamiento individualizado a la adaptación proactiva y sostenida.
  • Hay una cultura de silencio que rodea las vidas trans en la escuela. La representación trans, aunque sea mínima, puede ser percibida como excesiva. Así que las escuelas no lo hacen y les alumnes se ven obligados a educar a sus compañeres.
  • La representación y visibilidad trans debe de volverse común para darles a les alumnes un sentido de pertenencia que les permita desarrollarse sanamente.

Cisnormatividad: cuando los sistemas, las políticas y las personas asumen que todo el mundo es (o debería ser) cis (no trans). Las escuelas cisnormativas colocan a les alumnes trans en desventaja, exigiéndoles que naveguen por sistemas diseñados para excluirlos.

  • Les alumnes trans pueden experimentar ignorancia y hostilidad del personal docente, lo que les causa un daño importante, incluso une profesore que les apoye y en el que confíen puede tener un profundo impacto positivo y aumentar su autoestima considerablemente.
  1. La escuela debe reconocer y abordar el impacto que tienen las acciones del personal docente y administrativo. Es esencial un liderazgo claro que puede ser impulsado por la dirección de la escuela.
  1. Las escuelas carecen de planes para les alumnes trans, no cuentan con protección contra el acoso y el abuso. Les alumnes trans necesitan igualdad de oportunidades en la escuela donde pueden sobresalir y prosperar.
  1. Les alumnes trans deben ser bienvenidos, reafirmados, representados, validados, apreciados y respetados como todos los demás.
  1. La educación y la formación del profesorado y personal administrativo deben ir más allá de solo hablar de bullying. Debe haber una sensibilización constante para ayudar al personal a entender las formas en que la cisnormatividad privilegia a los individuos cisgénero y hace la vida más difícil para las personas trans.
  1. Les alumnes trans necesitan al menos un adulto de confianza que les defienda, les ayude a entender sus derechos y a desenvolverse en las culturas cisnormativas. Les profesores aliados deben entender y desafiar los sistemas y enfoques que deslegitiman y marginan a los alumnos trans.
  1. Les alumnes tienen derecho a una experiencia académica segura, inclusiva y reafirmante.
  1. Las escuelas deben escuchar a les alumnes trans y centrarse en los derechos de les niñes, también deben considerar sus responsabilidades institucionales, asegurándose de que cumplen con su deber de atención a les alumnes trans.

Trans: El término trans se utiliza para incluir a las personas transgénero, no binarias y/o con diversidad de género.

German translation

I’m translating my infographic on trans inclusive education into German (and will credit the volunteer translator when it’s finalised). Please let me know if you have any suggested changes to the translation below.

Erkenntnisse und Empfehlungen sind entnommen aus dem folgenden Artikel in “Frontiers of Sociology” 2020 (open acess) zum Thema LGBT+ – inklusive Bildung: “Thriving or surviving? Raising our ambition for trans children in primary and secondary schools” Cal Horton, Goldsmiths, University of London

trans Schüler_innen erfahren Stigmatisierung und Entwertung in der Schule, oftmals begleitet von Diskriminierung und Belästigung

Affirmativer Sprachgebrauch, Respekt und transpositives Verhalten sind entscheidend

Trans Schüler_innen sind anhaltendem Stress ausgesetzt, während sie sich in Systemen bewegen, die sie delegitimisieren und ausschließen. Ein reiner Anti-Mobbing-Ansatz unterschätzt möglicherweise, welche emontionalen und psychologischen Auswirkungen Cisnormativität(1) auf trans Schüler_innen hat.

Schulen müssen sich mit den cisnormativen Gewohnheiten, die sich negativ auf des Wohlergehen und die Psyche von trans Schüler_innen auswirken, auseinandersetzen.

Schulen reagieren meist auf fallbezogene Anfragen. Hierdurch wird trans Schüler_innen die Bürde auferlegt, ihre eigene Inklusion verhandeln zu müssen.

Schulen müssen von einer fallbezogenen Lösungsfindung hin zu einer proaktiven und nachhaltigen Einbindung der Schüler_innen.

Es herrscht eine Kultur des Schweigens im Hinblick auf trans in Schulen – minimale Repräsentation von trans Personen kann bereits als exessiv wahrgenommen werden. Trans Schüler_innen, denen angemessene Repräsentation an der Schule verwehrt wird, erfahren Gefühle von Scham und niedrigem Selbstwertgefühl. Sie sind beispielsweise häufig dazu gezwungen, ihre Mitschüler_innen selbt über transbezogene Themen zu informieren.

Die Repräsentation und Sichtbarkeit von trans Personen muss normal und unspektakulär werden, so dass trans Schüler_innen mit einem Gefühl von Zugehörigkeit und Selbstwert aufwachsen können.

Trans Schüler_innen erfahren durch pädagogische Fachkräfte oft Ingnoranz und Feindseligkeit, was zu großem Schaden führt. Schon eine einzige unterstützende und vertraute pädagogische Fachkraft kann wesentlichen Einfluss auf die schulischen Erfahrungen von trans Schüler_innen haben. Eine transpositve Einstellung des Kollegiums korreliert signifikant mit dem Wohlergehen der betroffenen Schüler_innen.

Schulen müssen den Druck und die vorhandenen Barrieren anerkennen und sich damit auseinandersetzen. Eine klare Positionierung ist hier ausschlaggebend. Diese kann von Ministerien, Schulämtern, Schulleitungen sowie einzelnen Lehrkräften oder anderen pädagogischen Fachkräften ausgehen.

Schulen mangelt es an Ambitionen, trans Schüler_innen zu helfen. Es wird lediglich das Mindestmaß geleistet, um Schikanierung und Misbrauch zu verhindern. Trans Schüler_innen benötigen Chancengleichheit, so dass sie schulischen Anforderungen erfolgreich gerecht werden und ausgezeichete Leistungen erbringen können.

Trans Schüler_innen sollten sich in Schulen willkommen und bestätigt fühlen. Sie sollten sich selbst in dem sie umgebenden System wiederfinden und als gleichwertig respektiert werden.

Die Qualifizierung der pädagogischen Fachkräfte muss über Basisinformationen zu transfeindlichem Mobbing hinausgehen. Pädagogische Fachkräfte müssen ein Verständnis dafür entwickeln, wie ein cisnormatives Umfeld cis Personen privilegiert den Alltag von trans Schüler_innen erschwert.

Trans Schüler_innen brauchen mindestens einen Erwachsenen, der sich für sie einsetzt, ihnen hilft, ihre Rechte zu verstehen und sie bei der Navigation in einer cisnormativen Kultur unterstützt. Verbündete pädagogische Fachkräfte müssen die Systeme und Ansätze, die trans Schüler_innen delegitimisieren und marginalisieren, verstehen und hinterfragen.

Trans Kinder haben das Recht auf eine sichere, bejahende und sie einbeziehende Bildungserfahrung.

Schulen sollten trans Schüler_innen zuhören und Kinderrechte in den Mittelpunkt stellen. Ebenso müssen die Einrichtungen ihren institutionellen Verpflichtungen nachkommen und sicherstellen, dass sie ihre Fürsorgepflicht gegenüber trans Schüler_innen erfüllen.

(1) Cisnormativität: wenn Systeme, Richtlinien und Menschen annehmen, dass jede_r cis (nicht trans) ist (oder sein sollte) Cisnormative Schulen benachteiligen trans Schüler_innen, indem sie sie zwingen, sich in einem System zu bewegen, das sie ausschließt
trans: der Begriff trans bezeichnet hier Menschen die transgender, nicht binär und/oder genderdivers sind.