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’ https://doi.org/10.3389/fsoc.2020.00067

 

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

article

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.

References

Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., et al. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. Int J Pediatr Endocrinol 2020, 8. doi:10.1186/s13633-020-00078-2.

Brik, T., Vrouenraets, L. J. J. J., de Vries, M. C., and Hannema, S. E. (2020). Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch Sex Behav. doi:10.1007/s10508-020-01660-8.

Chen, T., Yu, W., Xie, X., Ge, H., Fu, Y., Yang, D., et al. (2020). Influence of Gonadotropin Hormone Releasing Hormone Agonists on Interhemispheric Functional Connectivity in Girls With Idiopathic Central Precocious Puberty. Front Neurol 11, 17. doi:10.3389/fneur.2020.00017.

Cohen-Kettenis, P. T., Schagen, S. E. E., Steensma, T. D., de Vries, A. L. C., and Delemarre-van de Waal, H. A. (2011). Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up. Arch Sex Behav 40, 843–847. doi:10.1007/s10508-011-9758-9.

Cohen-Kettenis, P. T., and van Goozen, S. H. M. (1998). Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. European Child & Adolescent Psychiatry 7, 246–248. doi:10.1007/s007870050073.

Costa, R., Carmichael, P., and Colizzi, M. (2016). To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nat Rev Urol 13, 456–462. doi:10.1038/nrurol.2016.128.

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., and Colizzi, M. (2015). Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine 12, 2206–2214. doi:10.1111/jsm.13034.

de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., and Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 8, 2276–2283. doi:10.1111/j.1743-6109.2010.01943.x.

Delemarre-van de Waal, H. A., and Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology 155, S131–S137. doi:10.1530/eje.1.02231.

Edwards-Leeper, L., and Spack, N. P. (2012). Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center. J Homosex 59, 321–336. doi:10.1080/00918369.2012.653302.

Ferguson, G., Simm, P., O’Connell, M., and Pang, K. C. (2019). Gender dysphoria: puberty blockers and loss of bone mineral density. BMJ 367. doi:10.1136/bmj.l6471.

Fisher, A. D., Ristori, J., Bandini, E., Giordano, S., Mosconi, M., Jannini, E. A., et al. (2014). Medical treatment in gender dysphoric adolescents endorsed by SIAMS-SIE-SIEDP-ONIG. J. Endocrinol. Invest. 37, 675–687. doi:10.1007/s40618-014-0077-6.

Giordano, S. (2007). Gender Atypical Organisation in Children and Adolescents: Ethico-legal Issues and a Proposal for New Guidelines. Int J Child Rights 15, 365–390. doi:10.1163/092755607X262793.

Giordano, S. (2008). Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder? Journal of Medical Ethics 34, 580–584. doi:10.1136/jme.2007.021097.

Giordano, S., and Holm, S. (2020). Is puberty delaying treatment ‘experimental treatment’? International Journal of Transgender Health 21, 113–121. doi:10.1080/26895269.2020.1747768.

Hembree, W. C. (2011). Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child and Adolescent Psychiatric Clinics of North America 20, 725–732. doi:10.1016/j.chc.2011.08.004.

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 102, 3869–3903. doi:10.1210/jc.2017-01658.

Joseph, T., Ting, J., and Butler, G. (2019). The effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria: findings from a large national cohort. J. Pediatr. Endocrinol. Metab. 32, 1077–1081. doi:10.1515/jpem-2019-0046.

Khatchadourian, K., Amed, S., and Metzger, D. L. (2014). Clinical management of youth with gender dysphoria in Vancouver. J. Pediatr. 164, 906–911. doi:10.1016/j.jpeds.2013.10.068.

Kim, E. Y. (2015). Long-term effects of gonadotropin-releasing hormone analogs in girls with central precocious puberty. Korean J Pediatr 58, 1–7. doi:10.3345/kjp.2015.58.1.1.

Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., and Rotteveel, J. (2015). Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J. Clin. Endocrinol. Metab. 100, E270-275. doi:10.1210/jc.2014-2439.

Kreukels, B. P. C., and Cohen-Kettenis, P. T. (2011). Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol 7, 466–472. doi:10.1038/nrendo.2011.78.

Lopez, C. M., Solomon, D., Boulware, S. D., and Christison-Lagay, E. R. (2018). Trends in the use of puberty blockers among transgender children in the United States. J. Pediatr. Endocrinol. Metab. 31, 665–670. doi:10.1515/jpem-2018-0048.

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: https://www.hrc.org/resources/supporting-caring-for-transgender-children/. [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: https://researchcommons.waikato.ac.nz/handle/10289/12160 [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: https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents.pdf [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.

https://datastudio.google.com/embed/reporting/7a0a692c-6d2d-4b38-a903-56d57c8cc471/page/LgMQB

Europe2

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?

Australia Supports Trans Children

Evie-Macdonald

Following months of Australian (Murdoch) media scaremongering about trans children, and anti-trans lobbying by right wing groups, Australian politicians asked a leading  Australian medical body (RACP). to review the Australian healthcare approach to supporting transgender youth.

Today brought two important announcements, from the RACP and from AusPATH.

The RACP is the Royal College of Australian Physicians, representing 25,000 Australian medical professionals. The RACP today provided the following announcement:

The RACP has recommended against a national inquiry into gender dysphoria and made suggestions to improve care to young trans people.

In August 2019, the Federal Minister for Health Greg Hunt wrote to the College seeking advice on the treatment of gender dysphoria in children and adolescents. The RACP has now provided that advice to the Minister. The full advice is linked below.

The RACP strongly supports expert clinical care that is non-judgemental, supportive and welcoming for children, adolescents and their families experiencing gender dysphoria. Children and adolescents with gender dysphoria are a very vulnerable population, experiencing stigma and extremely high rates of depression, self-harm, attempted suicide and suicide.

Ensuring children and adolescents with gender dysphoria can access appropriate care and treatment regardless of where they live, should be a national priority. Withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people. 

The RACP notes that there are substantial dangers posed by some of the proposals that have been put forward during the recent public debate on this issue, such as holding a national inquiry into the issue. A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention.

Today, the Australian Professional Association for Trans Health released the following response:

The Australian Professional Association for Trans Health (AusPATH), established in 2009 as the Australian and New Zealand Professional Association for Transgender Health, is Australia’s peak body for professionals involved in the health, rights and wellbeing of trans people, including those who are gender diverse and non-binary (TGDNB). The AusPATH membership comprises approximately 300 experienced professionals working across Australia.

AusPATH welcomes the Royal Australasian College of Physicians (RACP) advice to Minister Greg Hunt, Federal Minister for Health, regarding the care and treatment of TGDNB children and adolescents, and seeking medical intervention. This advice is based on the available scientific evidence and the expertise of those with relevant clinical experience across sub-speciality areas of medicine and bioethics.

 AusPATH agrees with the RACP that ensuring children and adolescents who are trans, including those who are gender diverse and non-binary “can access appropriate care and treatment regardless of where they live, should be a national priority”, and that “withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people.”

As stated by the RACP, “clinical care needs to be “non-judgemental, supportive and welcoming for children, adolescents and their families”.

AusPATH also supports the RACP recommendation that the Australian Government provide funding for research, especially in relation to the long-term health and wellbeing outcomes for trans, including gender diverse and non-binary young people. Increased investment in research and expansion of the knowledge base, for young people and adults, will be vital in improving the current and disturbing high rates of depression, anxiety, suicide attempts and suicide amongst this cohort.

Improving outcomes can only be achieved by reducing the stigma, discrimination, bullying and harassment that trans people, including those who are gender diverse and non-binary, are subjected to on a daily basis. Negative, hateful media campaigns aimed at invalidating the experiences and strength of this community, and those who provide care for them, is reprehensible, harmful and must stop.

There is much work for us to do to improve the lives of all trans people in Australia. AusPATH looks forward to assisting the clinicians, researchers, educators and advocates across Australia to continue the provision of high quality, patient-centred, human rights-focused and comprehensive gender affirming care and treatment.

Best Practice

The Australian guidelines for healthcare for trans youth represent world best practice. These guidelines are summarised in this blog here

https://growinguptransgender.com/2017/10/01/australian-gold-standard-of-care-for-trans-children/

I want to highlight a couple of things about the approach that the overall Australian health service has taken to the transphobic pressure it has come under.

  1. The Australian healthcare service overall has centred the needs, rights and wellbeing of transgender children, both in their healthcare, in their engagements with the media, and in their response to political and media pressure.
  2. They have emphasised the importance of patient centred, human rights focused and comprehensive gender affirming care.
  3. They clearly and unambiguously state “withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people.” This clarity in messaging is vitally important in a context of media misinformation and transphobic scaremongering.
  4. They acknowledge, highlight and condemn the negative impact that media and societal transphobia has on the wellbeing of trans children.
  5. The RACP “strongly supports expert clinical care that is non-judgemental, supportive and welcoming”. This strong support, combined with positive and non-pathologising language is really important in this media communication.
  6. The RACP takes a clear public position, backing up the needs and wellbeing of vulnerable trans children and their families. They state “the RACP notes that there are substantial dangers posed by some of the proposals that have been put forward during the recent public debate on this issue, such as holding a national inquiry into the issue. A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention”.

I want highlight the absurd contrast between the way the health service in Australia has tackled this and the current UK NHS approach.

The UK NHS service for transgender children (GIDS) is hugely behind global best practices for transgender youth healthcare – see here for a comparison between the GIDS approach and the Australian approach

https://growinguptransgender.com/2017/09/30/australian-standards-of-care-part-2/

The UK is out of touch with gender affirmative best practices as endorsed by Auspath, the Endocrine Society, the American Academy of Pediatrics – and is behind healthcare practices across the US, Canada, Spain, New Zealand, Australia. New global guidelines from the World Professional Association for Transgender Health (WPATH) are due out this year, and are expected to endorse an affirmative approach to support for transgender children. The UK GIDS service, with its pathologising approaches, three year wait for first appointments, psychoanalytic approach (without one single paediatrician) and refusal to embrace evidence based gender affirmative healthcare, is a disgrace.

When faced by the same media and right wing funded transphobic pressure that doctors in the US and Australia have faced, the UK NHS has responded very differently.

Here in the UK we have a court case to investigate whether trans teens are somehow uniquely unable to give informed consent to safe and reversible puberty blocker treatment that has been studied in trans youth for 32 years.

There is a NICE evidence review into puberty blockers and hormones (despite the Endocrine Society having released global guidance in 2016 on this, despite no evidence of harm and much evidence of benefits, and despite WPATH global standards of care producing new global guidelines on this that are due out this year (Standards of Care Version 8). The ToR for this review will be critical, as recent reviews by the BMJ and the evidence review informing the GIDS 2016 service specification were both heavily flawed, bringing ideological biases to the evidence review, and omitting key evidence. The team involved in the heavily flawed 2016 service specification review completely ignored submissions from those advocating for the rights and wellbeing of transgender children – how do we ensure this doesn’t happen this time round? There is very little community faith that this NICE review will be effective – we know there is a lack of the type of RCT evidence NICE normally prioritises, the question is, what do we do based on the level of evidence currently in existence. In Australia and the US (and elsewhere) healthcare providers are very clear that affirmative care is the only way to support trans youth. Parents such as myself are very clear on this. Trans adults are very clear on this. Trans youth are very clear on this – but is NICE interested in these perspectives? We know and experience the harm of inadequate care – we see it daily in our families.

There is also an NHS panel being formed to review the NICE evidence and provide NHS recommendations on trans youth healthcare. Will important questions like the NHS’ failure to offer timely non-pathologising affirmative care led by paediatricians rather than psychoanalysts even be on the agenda? Who is shaping the agenda for these reviews and investigations – they certainly don’t match with the issues that matter to those of us supporting transgender children – they seem to match the agenda of those wishing to ban healthcare for transgender children. Why is there no acknowledgement, that publicity about these reviews, in a context of minority stress and transphobia, adds to the harm, adds to discrimination, makes life worse for transgender children and families?

Who on this panel will be speaking up for the rights of transgender children? Families of trans children, trans healthcare experts and trans communities have little faith in this process centring the rights and wellbeing of trans children. A very significant concern is the question of who will be on that panel. There will be no voice representing trans children on that panel. No voice representing trans adults. No voice representing supportive parents of trans children.

We know there are strong transphobic voices in the UK, including in the NHS, who deny the existence of transgender children like my daughter. Voices who, like in Australia and the US, are actively campaigning to withdraw healthcare for transgender children. Some of these voices are clear in their transphobia – others are subtler in crouching their views in descriptions of ‘concern’ and ‘lack of RCTs’. Many of these opponents advocate stopping all trans youth healthcare, increasing the access barriers, and taking us back to reparative and talk therapy based approaches of rejection and stigma. Approaches that are known to cause harm.

If anyone who has publicly condemned healthcare for transgender children, including those who argue against healthcare until the age of 24 (!) is on the panel, this panel will lack all credibility with families of transgender children. There would be no place for anti-vaccine voices on a review of vaccine safety – there would be no place for anti-climate change fringe voices on a review of climate change policy – there absolutely is no place for anyone who has spoken out against the rights and wellbeing of transgender children in a NHS panel reviewing this healthcare.

The biggest concern – There will likely not be one single paediatrician with experience supporting trans children on that NHS review panel. In other countries like Australia, trans youth healthcare is led by paediatricians. Here in the UK there is not one single paediatrician with this experience and specialism. Our NHS service is led by psychoanalysts who are not medically qualified. This is a huge knowledge gap for this NHS review panel. The panel absolutely has to have on it a paediatrician with experience in leading the care of transgender children. If there is not one such experienced and qualified paediatrician in the UK (which there is not), the panel needs to fill this knowledge gap by inviting experienced paediatricians from the US or Australia to join this panel. Someone like Michelle Tefler, the paediatrician in charge of the Australian trans youth healthcare system would be ideal.

And as we wait, families and transgender children are already being harmed by the UK NHS approach – by the media messaging about reviewing the evidence base on puberty blockers. Already children are experiencing additional trauma, scrutiny and disbelief from NHS health professionals like GPs, from school teachers, from social services, from family members, as a direct result of this inquiry. Direct harm due to the NHS’s chosen approach.

Again, I will compare this to the Australian RACP approach which stated today:
“the RACP notes that there are substantial dangers posed by some of the proposals that have been put forward during the recent public debate on this issue, such as holding a national inquiry into the issue. A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention”.

Why does the NHS continue to fail transgender children so badly, in so many different ways?

Why can’t we learn from the Australian healthcare system?

Who is speaking up for trans children’s rights and wellbeing within the decision making circles of the NHS?

 

 

PhD starts here

download

Throughout the past years of trying to secure the rights of my child, I’ve been frustrated at the substantial barriers trans children face.

The many ways in which their rights are infringed.

The systemic obstacles they need to jump over, hoping for equality of opportunity.

Their very existence is challenged.

Lack of data is part of the problem – time and again trans kids are left out of surveys or research – they aren’t even considered.

With these challenges in mind, I’ve applied for, and been accepted onto a PhD at Goldsmiths Education department.

My topic: Cisnormativity and the rights, equality and well-being of socially transitioned transgender children under the age of 12. I’ll be supervised by Dr Anna Carlile.

I’ll have a focus on trans children in education, as well as considering families, healthcare and wider rights.

I’m doing it part-time, and aim to publish as I go. Watch this space.

I’m very interested in connecting with trans positive researchers, as well as with researchers specialising in child rights / child participation.

I can be reached on twitter @fiercemum

Wish me luck!

Watchful Waiting – A Parent’s View

penguin

Some more UK commentators, and even the Royal College of General Practitioners, have recommended a ‘watchful waiting’ approach for trans children.

I’ve written previously that this UK guidance is out of synch with the medical recommendations in the US, Canada, Spain, New Zealand, Australia. How it is out of synch with experts in other countries who consider watchful waiting, which they more accurately describe as ‘delayed transition’, to be harmful to trans kids.

Here I want to share my own experience, and the experience of other parents, on how watchful waiting plays out in practice. For me watchful waiting is a misleading term – it sounds very benign and sensible. While the term used to describe this elsewhere, ‘delayed transition’, is a more accurate description, the reality for those living through it is that ‘prolonged rejection’ is a better description of what ‘watchful waiting’ means in practice.

From as soon as my child could properly speak, they asserted ‘I am a girl’. For some initial time, in total ignorance about gender diversity, I opted for active rejection: ‘No, you are not a girl you are a boy’.

Months and months of daily (multiple times a day) active rejection followed. My child would insist their gender several times a day. Active rejection was not leading to any change in my child’s insistence (just an increase in my child’s distress and depression). I researched and came across the UK guidance for ‘watchful waiting’, whereby they recommend a supposedly neutral approach where a child is not actively rejected (ie stopping saying ‘no you are not a girl’) but without any active affirmation (without saying, ‘ok we will call you a girl’).

We really tried that watchful waiting approach with our child. This is how it played out in practice with an insistent, consistent, persistent and increasingly distressed trans child (and these are the children who we are talking about, who most obviously benefit from affirmation).

Every single day my child would cry and say ‘I’m a girl’. During watchful waiting we would tell them I loved them and we didn’t need to talk about gender – They were left thinking their mum and dad did not understand or did not care about this thing that was so important to them.

Every day they would cry themselves to sleep saying ‘But I’m a girl’. I would hug them and tell them I loved them, whilst ignoring the thing that was causing their distress. – They were left thinking that one part of them was broken – un-loveable – unacceptable. How shame inducing? How pathologizing?

Every day I would try to actively break down gender stereotypes, try to break down gender roles or restrictions around gender expression without supporting my child’s identity. This only made my child sadder as their mum was missing the point entirely. In one conversation that sticks in my mind:

Child: ‘But mummy I am a girl’

Me: ‘Boys and girls can do all the same things. Would you like a doll?’

Child: ‘I don’t like dolls, I am a girl…. can I have a spiderman’

In another one:

Child: ‘I’m a girl’

Me: (Desperately thinking about what my child might associate as typically ‘girl activities)… Would you like to try out ballet classes?’

Child: ‘I don’t like dancing’

Me: ‘What do you like?’

Child: ‘Climbing trees. Girls can like climbing trees’.

I was not listening to my child. I was rejecting her.

Every day they spent sad, rejected, and fixated on the topic of gender. They were losing out on the carefree fun childhood of their peers. Every day spent sad and depressed and rejected is a lost day of childhood. Every day spent feeling that who they are is unacceptable to their mum, is a day piling on shame, self-hate, low self-esteem.

I watched them get lower, get less happy, get less curious about the world, get less excited about life get sadder, get more isolated and alone. This is what I was watching. What was I waiting for? My child had told me in very consistent, persistent and insistent terms what she needed. She needed to be loved and accepted as a girl. It was the only thing that mattered to her and she felt deeply rejected, deeply broken, deeply unacceptable. Was I waiting for her mental health to crash? Was I waiting for her to snap out of it? Was I waiting for her to reach an arbitrary age? Was I waiting for her to turn 10?

What would waiting until age 8 or age 10 until I stopped passively rejecting her mean for my child? What would be the benefit to her, of keeping her in a state of continued rejection, depression and sadness until age 8 or 10 as the NHS advises?

What are the risks of waiting until age 8 or age 10 until I stop rejecting her?

What is at stake?

For me the biggest stake is her childhood, her happiness, her self-esteem, her self-worth, her curiosity, her interest, her learning, her education. I care about her happiness right here and now.

During our phase of watchful waiting, my child was on pause, she was stuck, she was unable to thrive.

As soon as we moved to affirmation, everything changed.

Affirmation was a much easier thing to do in practice.

She said:

‘I’m a girl’

And we said: ‘ok we will call you a girl’.

We switched pronouns. As far as our family life was concerned, that was a very quick and easy switch. We switched pronouns and our daughter thrived. She has never once cried herself to sleep since that day. She no longer wanted to talk about gender every time we were alone. She started to talk about animals, and space, and nature, and how things work. She started to explore. She started to have a childhood. She became lighter and carefree. A huge burden lifted from her shoulders (and noticeably shifted to ours as we sought to get the wider world to respect her identity).

The price of watchful waiting was very high for my family. The price was very high for my daughter.

Watchful waiting robbed my daughter of a period of her childhood. A period when she could have been happy and loved and accepted and carefree. When instead she was left feeling rejected and broken. For a child like mine, watchful waiting causes harm.

I am thankful that we had access to other sources of information (my next blog will be on the evidence base for affirmation versus watchful waiting).

I am thankful that the period of rejection was not so long, and that the damage to her self-esteem was not deep.

I am thankful that since the day we stopped rejecting her, the simple change of pronoun, she has flourished in every way.

She laughs, she can dream, she can learn, she can play. She is having a carefree happy childhood. This was literally not possible under prolonged rejection (ie watchful waiting).

Many other parents tell the same story. Of trying watchful waiting for months or years and watching their child sink.

People with no experience of living daily with trans kids need to start listening to the impact ‘watchful waiting’ has in practice. They need to start listening and understand that it is neither neutral, nor benign, nor easy. It is hard to passively reject your child daily. It is hard to watch them sink. It is an approach that fundamentally misunderstands insistent, consistent, persistent trans children. It is an approach that fundamentally undervalues the right of a trans child to a happy childhood.

Trans kids only get one childhood. They need to know they are loved as who they are. They need to know their parents and carers have their backs, will listen to them, will accept them, will stand up for them.

Stop rejecting trans kids. Passive rejection can hurt as much as active rejection. Quiet rejection, rejection through silence and omission can hurt as much as loud rejection.

Listen to your trans kids. Love your trans kids.

 

New Zealand Healthcare Guidelines Affirm & Support Trans Children

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New Zealand has produced guidance for trans healthcare: Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand

Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018.

This follows similar guidelines produced in the US (by the world’s largest paediatric medical organisation the American Academy of Pediatics), Australian affirmative healthcare guidance for transgender children and adolescents, and similar practices in place for trans children and adolescents across Canada, Spain, Germany

New Zealand’s gender affirmative healthcare guidelines for transgender children, yet again shows the UK GIDS is stuck in the dark ages, the UK NHS is failing transgender children.

Here’s a ten point summary (written by me) for those disinclined to read further:

  1. New Zealand endorses gender affirmative healthcare for trans children and adolescents.
  2. New Zealand acknowledges that some children are trans at a young age, that some adolescents come to understand their gender identity at or after puberty, and that all are valid and in need of affirmation and support.
  3. New Zealand uses modern, trans positive language and does not problematise trans children, being clear that trans children who are supported should be able to thrive and should be able to be as happy as any other child.
  4. New Zealand supports social transition for trans children, emphasising the important benefits and protective aspects for their well-being.
  5. New Zealand recognises the importance of supportive families, and prioritises educating parents/carers to accept and affirm their trans children, providing clear and reassuring guidance to listen to their child.
  6. New Zealand is clear that gender affirmative healthcare is medically necessary, considering a range of aspects of health including support in dealing with minority stress.
  7. New Zealand supports access puberty blockers, which it emphasises are reversible. It emphasises that withholding timely access to blockers causes harm, and emphasises that not using blockers can lead to irreversible unwanted physical changes.
  8. New Zealand supports individualised access to hormone therapy, acknowledging the compelling reasons why access prior to age 16 is appropriate for some individuals. It provides clear information on the changes that are reversible, partially reversible, not reversible and the time on HRT for these changes to emerge.
  9. New Zealand acknowledges the harm caused by the pathologisation of gender diversity, and commits to depathologisation within the health service. New Zealand acknowledges being gender diverse is not a mental health condition and commits to mental health support being optional and not a mandatory part of accessing affirmative healthcare.
  10. New Zealand acknowledges the negative health impacts of discrimination, and acknowledges the importance of health service providers advocating for trans people, advocating for social and public policy change to reduce the negative effects of minority stress.

This blog summarises the main areas of the New Zealand guidance that are relevant for trans children and adolescents, highlighting areas where New Zealand’s healthcare guidance for trans children is ahead of the UK NHS (I use the word ahead rather than different, as there is a clear trajectory for trans children’s healthcare globally – I have no doubt the UK will eventually make a change in this direction – as have already done Australia, much of USA and Canada, Spain, Germany etc – It just remains to be seen how many years the UK will cling on to outdated practices, and how many children will be harmed in the meantime.

 The New Zealand Guidelines: An Overview

*Note: The guide is written with many references to Maori terms and indigenous approaches. This heavily abridged version aimed at a UK and global readership just includes English terms – the guidance is worth reading in full.

Commits to gender affirming healthcare (UK GIDS does not offer this)

Gender affirming healthcare (definition): “Healthcare that is respectful and affirming of a person’s unique sense of gender and provides support to identify and facilitate gender healthcare goals. These goals may include supporting exploration of gender expression, support around social transition, hormone and/or surgical interventions. This may also involve providing support to family, caregivers or other significant supporting people”.

“Children and young people: For the purposes of this guideline: those aged up to 11 years are considered children; those aged from 12 to 24 years are considered to be young people”

Normalises gender diversity, normalises rise in referrals (UK GIDS describes the rise as ‘unexpected’ & speculates negative reasons for the rise)

“Internationally and within New Zealand there has been a substantial increase in the demand for gender affirming healthcare over the past decade. The Youth secondary school survey, estimated that approximately 1.2% of adolescents in New Zealand identify as transgender. It is likely that this level of referrals to health services will continue in the foreseeable future.”

Prioritises autonomy and avoidance of pathologisation (UK GIDS does not)

“Autonomy: Autonomy in the context of transgender healthcare involves transgender people being able to able to make informed choices for themselves regarding gender affirming care and being free from experiencing harmful pathologisation and other barriers to accessing this care.”

Acknowledges the importance of partnering with trans communities (UK GIDS does not)

“To successfully enhance the health and wellbeing of transgender people, providers need to partner with transgender communities to shape these services.”

Acknowledges that gender affirming healthcare is medically necessary (UK GIDS does not)

“The medical necessity of gender affirming healthcare has been acknowledged by WPATH, the Australian and New Zealand Professional Association for Transgender Health (ANZPATH) and many other international organisations.

The Yogyakarta Principles pull together existing international human rights legal standards which state that transgender people have the right to access the highest attainable standard of gender affirming care.

Acknowledges the impact of social stigmatisation including in the healthcare system (UK GIDS does not)

“Social stigmatisation and discrimination, including within the healthcare system, present additional barriers to accessing health services and contributes to adverse health outcomes”.

Prioritises community leadership (UK GIDS does not)

“Community leadership: This guiding principle informs us that for health promotion to be effective it needs to be led by relevant communities. Health professionals have important roles to play but cannot replace the leadership which exists in communities. An example of this is the partnership between transgender communities and the Northern Region health board from 2014 to present. Transgender people have been involved in the steering of the project, including development of services and these guidelines. The importance of trans community leadership in the development of trans healthcare services is paramount.”

Recognises the importance of different areas of health: (UK GIDS does not)

“Transgender health recognises the equal importance of spiritual health, family health, mental health and physical health.”

Acknowledges legacy of pathologisation of gender diversity and clarifies it is not a mental health illness, acknowledging the importance of avoiding stigmatisation (UK GIDS does not)

“Historically transgender healthcare has suffered from the pathologising of gender diversity and the inappropriate labelling of gender/cultural identity and expression as a diagnosed mental health illness. The resulting legacy of this pathologisation is a tension in health services between the need to avoid further stigmatisation while simultaneously acknowledging the importance of the wider concept of mental health as part of holistic healthcare delivery.”

Prioritises informed consent and self determination (UK GIDS does not)

“The practice of informed consent in relation to gender affirming healthcare is important because it reaffirms the self-determination of the transgender person and their knowledge of their needs, identities, and self. Informed consent enables the health provider to work alongside the transgender person in a flexible and responsive way”.

Recommends involving trans people in development and provision of services. (UK GIDS does not)

“Health services enable the involvement of trans and gender diverse people, including Māori trans people, in decisions that affect them with regard to the development and provision of services.”

Commits to improving based on feedback (UK GIDS does not)

“Health services have a process for receiving feedback and evaluating people’s experience that report on outcomes and commit to acting on the feedback/data received to improve services.”

Recognises impact of colonisation in persecuting gender minorities who were accepted and valued in pre-colonial society (UK GIDS does not)

“It is increasingly apparent that, in Aotearoa pre-colonial Māori society, people of diverse genders and sexualities were both accepted and valued within extended families. The colonisation in the 1800s by the British had a huge impact on Māori culture and society. Any expression of gender or sexual fluidity was strongly discouraged by the missionaries. Recorded histories overlooked or erased stories of takatāpui.

Likewise, Pacific cultures also accepted gender diversity as part of the normal range of human expression. The impact of colonisation of many of the Pacific Island nations through faith-based missions and colonial government administrations has had a negative impact on the acceptance of gender diverse people.”

Recognises the minority stress intrinsic to living in a transphobic society (UK GIDs does not)

“Tangata takatāpui moved from a social and cultural situation where minority stress was simply not a factor in the pre-colonial world of Māori, to one where it has become a key force in the negative health outcomes they experience”.

“Minority stress: Minority stress theory suggests that trans and gender diverse people experience stressors as a result of sociocultural sanctions about being transgender and/or gender nonconforming. These include prejudice, discrimination and violence which negatively impact on physical, social, spiritual, and psychological wellbeing. It is important to note that minority stress results from a multitude of everyday events that trans people experience. Daily stressors for trans people can include not being affirmed by health providers, being asked invasive questions in inappropriate settings, or not having access to a safe public bathroom. Minority stress here includes the economic stressors that many trans and gender diverse people also negotiate.”

Recognises that supporting wellbeing of trans people must include addressing these barriers to health (UK GIDS does not)

“Supporting the wellbeing of transgender people includes recognising that barriers to health, housing and employment will have negative health impacts. Improving health services is part of creating health, education, housing, and employment environments that are accessible, respectful, and inclusive of trans and gender diverse people”.

Recognises the importance of trans positive health services (UK GIDS does not)

“Trans positive health services: Primary and secondary health services that are respectful and affirming of people’s gender identities can have a positive impact on trans people’s well-being. There are many important nonmedical supports that can be useful for health services to be aware of when supporting people who are socially transitioning.”

Supports social transition (UK GIDS does not)

“Social transition: Social transition consists of the steps many transgender people choose to take to alter their presentation in the world to better align with their gender identity. Transition looks different for every individual and it is important to note that neither social or medical transition is required in order to be recognised as a trans or gender diverse person.

Transgender people should be supported through these steps of social transition to allow them to have positive experiences in the world as a truer representation of themselves. Social transition can also start out part-time in known safe environments, such as home or school.”

*Note there is nothing negative here about the psychological impact of social transition (GIDS latest scare story). There is no age-based barrier to support. No references to the discredited and harmful ‘watchful waiting approach’ that UK GIDS still clings to. Watchful waiting sounds benign. It depends what you are watching whilst you wait. For many trans kids, rejection causes immense harm. For many trans kids, affirmation and fully love and support allows our children to breathe, allows them to thrive, allows them to enjoy their childhoods. Why should trans children in New Zealand, Australia, USA, Canada, Spain (including Canary Islands) have happy childhoods whilst UK trans children are left depressed, rejected, ashamed.

Recognises family health (UK GIDS does not)

“Family Health: There are many forms of family support; a parent looking out for their trans child, an adult supporting their trans partner or parent through transition, a family advocating for respectful care of their trans relative in a resthome. In reality it is not just one person who ‘transitions’ but the whole family”.

Highlights that family support is a HIGHLY protective factor (UK GIDS does not)

“Family and young people: Family support is a highly protective factor for trans young people. Research shows that trans young people reporting strong family connectedness have a greatly reduced likelihood of poor mental health, even when experiencing stigma and discrimination elsewhere. Family support provides a place from which takatāpui rangatahi can draw strength and resilience to help deal with the challenges they face outside the family.”

Prioritises helping parents gain support to understand their loved one (UK GIDS does not)

“Parents report a range of emotions following disclosure from their child that they are transgender, including confusion, the need to have time to process, the need to grieve for the loss of a son/ daughter, fear for the future and acceptance of their child. While the young person is likely to have spent considerable time developing an understanding of who they are, families may perceive the change as being sudden and require time to adjust. Families report that they need information and time to understand their loved one’s journey. It is an important part of the role of health services to support this process. Some families find joining parent support groups helpful.”

Recommends primary and secondary health services provide clear, unambiguous affirmative advice to parents/carers (UK GIDS does not)

“Practice points: Primary and secondary health services need to provide education, promote connection to family and to support family to be able to support gender diverse children and young people through simple advice:

  • Assure your child/young person that they have your unconditional love and support, or at least that you will commit to their journey with them.
  • Encourage exploration of how they express themselves. It is important that young people have spaces in which they feel safe enough to explore their gender.
  • Use the child/young persons preferred gender pronouns (he/him, she/her, they/them etc) and preferred name when they are ready to do so. Support family and friends to do the same, providing it is safe to do so.
  • Provide written/online information for family.”

Is confident and non-pathologising on topic of transgender children (UK GIDS is not)

“Gender diverse children: Many children explore different ways of expressing their gender though play. Most of these children are comfortable with the sex they were assigned at birth, although some are not. Some children will assert themselves as a gender different from the sex assigned at birth. These transgender children are usually insistent, consistent and persistent in their gender identity and may exhibit distress or discomfort with their physical body. Some transgender children are aware of their gender identity from a very early age, while others may take some time to figure it out or find a safe way to express it. Children can be very aware of the disapproval of those around them and may try to hide their feelings about their gender. For gender expansive children, including those who may identify as transgender, no medical intervention is needed pre-puberty.”

*Note the way the language is affirming and reassuring about young trans children as well as affirming and reassuring about children who are aware of their identity later. The UK uses language that is unsupportive and un-reassuring about both.

Is clearly supportive of a gender affirmative approach for trans children, including unambiguous support for social transition (UK GIDS is not)

“Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach which involves assisting children to create an environment where their gender can be affirmed. This might require providing education and support for families and schools to be able to support the gender diverse child to navigate a social transition and helping children to develop the coping skills to address any negative reactions that they might experience for being gender diverse. Family may want support from their primary care health team, a paediatrician, child and adolescent mental health service or parent support group to work out how best to support their child. This is particularly important if there is associated distress related to gender identity.

*note no fear mongering on social transition, no words of concern and caution, no words about regret or desistance, nothing on need to delay, deny or diagnose.

*note the emphasis on providing assistance externally, to make the world a better place for a trans child. The UK focuses their effort internally, onto the trans child themselves, focusing on psychoanalysis of that child, making their gender diversity the problem.

Non-pathologising about trans adolescents who are aware of their identity at puberty (UK GIDS is not)

“Young people: Trans young people may present to a range of health providers requesting support with their gender identity, so all health teams need to be able to provide an inclusive environment where young people will feel safe talking about their gender. Some young people present with longstanding diverse gender identities since childhood, while others find that adolescence was a crucial time for the development of their gender identity. Identity may emerge during or after the onset of the physical changes brought on by puberty and the changing social and romantic interactions with peers.

*note no scaremongering about social contagion. No scaremongering about adolescents confusing gender for sexuality. No scaremongering about social media and the influence of the internet. No undermining of the validity of trans teens who become aware of their identity at or after puberty (all of these have been talked about in the media by UK GIDS).

Non-pathologising understanding of gender fluidity (UK GIDS is not)

“Similarly, some previously gender expansive children may shift along the gender spectrum to find their gender identity more aligned with the sex assigned at birth. In all of these situations, these young people and their families will benefit from supportive healthcare providers who pay attention to how the young person is expressing their gender.”

*Note the guidance sees no trade-off or tension between supporting trans kids and supporting kids who shift gender modality. It argues that both benefit from supportive healthcare. UK GIDS likes to argue that their known harm to trans kids somehow benefits kids who might shift gender modality (despite no evidence of this).

Focuses on co-existing concerns without using co-existing concerns as a pretext for denying identity or delaying affirmation (UK GIDS does not)

“Trans young people need to be assessed routinely for risks around abuse, bullying, drug and alcohol use, nutrition and unhealthy eating behaviours, sexual health and any mental health concerns“

*It would not be surprising to me if youth with co-existing issues are better able to address other co-existing issues, once their gender is affirmed. In the UK adolescents with co-existing concerns are denied affirmation of their gender, on the pretext that their gender issues may be symptoms of a misguided coping strategy for dealing with other issues. There is no evidence for this approach which is rejected elsewhere and causes harm to some of the most vulnerable youth (eg descriptions of children and teens in UK GIDS having their identity invalidated and being forced to discuss trauma as a potential cause of gender ‘confusion’ if they have suffered abuse or bereavement).

Prioritises peer support (UK GIDS does not adequately encourage peer support and some media engagement has encouraged scaremongering on ‘social contagion’, discouraging wary parents from helping their child connect to peer support)

“Trans young people often benefit from being linked into supportive peer groups, including online groups.”

Understands trans kids may find puberty difficult (UK GIDs recent media engagement seemed to suggest that trans kids were finding puberty difficult because of being too supported and affirmed in their childhood – they suggested childhood rejection was the best way to avoid trans kids worrying about puberty)

“Anticipation of and/or experiencing pubertal body changes can be very distressing.”

Is clear and unambiguous on evidence of benefits of puberty blockers and gender affirming care (UK GIDS is not)

“There is good evidence that puberty blocking and gender affirming care for trans young people significantly improves mental health and wellbeing outcomes.”

When parents are unsupportive, unequivocally prioritises the need of trans adolescents, even under age 16 (GIDS does not)

“Decisions regarding medical interventions are ideally made collaboratively between the trans young person, their family and the health team. However, it is not always possible to involve family. Lack of family support does not preclude trans young people from accessing care. While young people aged 16 years and older are considered to be able to make decisions about their medical care younger people are not prohibited from consenting to medical interventions if the young person is deemed to be competent to make an informed choice. To assist this informed consent process, we recommend that gender affirming healthcare for young people is provided within a multi-disciplinary team”.

Prioritises the importance of trans students being in school (UK GIDS does not. In UK, the number of trans children out of school (often due to mental health problems linked to continued rejection, minority stress, violence, bullying) should be a national scandal)

“Schools: Feeling connected to school is also a significant protective factor for trans young people. Schools have an obligation to provide safe environment for their students. The Youth New Zealand school survey found that while 74% of trans young people thought that school was okay, 54% were afraid that someone at school would hurt or bother them. There are a range of support materials available for schools.”

Clearly is on the side of trans students and unambiguously supports the need for records to correctly reflect gender identity (UK GIDS does not)

“However, many students have reported to us that they still experience barriers to updating school records to correctly reflect their gender identity and experience gender-based exclusion from activities such as joining sports teams, choirs and groups”.

Recommends schools provide information on gender affirming healthcare (UK GIDS does not)

“Practice points for school health teams • Have information on gender affirming healthcare services readily available and on display. • Provide training on working with transgender students for the whole student health team”.

*UK language from GIDS to schools can be the opposite of affirming, referring to complex cases, pathologizing and stigmatising gender diversity and discouraging schools from full support.

Is interested in the general wellbeing of trans students (UK GIDS focuses on gender identity, is not proactive on discrimination)

“School health teams should: “• Have information and support available for transgender students who experience discrimination from students or teachers. • Be connected to local health and social services in your area that specialise in working with transgender young people. • Enable students to establish a diversity group or other support for transgender students (if they desire to do so).”

Provides clear affirmative guidance for family members: (UK GIDS does not)

“• Listen first and foremost. Be available to listen to your family member’s experiences. Make an active effort to listen without judgment. Remember that advice isn’t always necessary; sometimes all they need is a kind ear. • Respect trans people’s pronouns  Trust that they are making the right decisions for themselves. • Educate yourself and others”.

Recommends family members listen to and learn from trans people (UK GIDS does not)

“Read and listen to the stories of transgender people. This will give you a better understanding of their experiences and enable you to interact in a positive way with your family member.”

Encourages peer support (UK GIDS does not)

“provide easily accessible information and access to peer support services for trans people of all ages and their family”.

Recommends children receive gender affirming healthcare (UK GIDS does not)

“That gender affirming healthcare services for children and young people are provided by clinicians with expertise in child and youth development.”

*note there is no requirement for psychoanalysis, the foundation of the UK GIDS service.

Non-pathologising approach to mental health of trans people (UK GIDS does not)

“Mental health: Trans and gender diverse people have the same inherent potential to flourish and thrive as other people, but currently experience increased risk of harm because of discrimination, social exclusion, bullying and assault, as well as institutional barriers such as difficulties accessing healthcare, bathrooms, and appropriate legal identification. Trans people from ethnic minority or refugee backgrounds are likely to be at even greater risk of experiencing harm.”

*GIDS does not acknowledge that trans kids have the same inherent potential to flourish and thrive. It does not acknowledge that the mental distress trans kids face is in large part due to cisnormativity and transphobia, including in (and encouraged by) NHS health services.

Acknowledges wider determinants of health (UK GIDS does not)

“It is becoming increasingly accepted that it is the additive effects of minority stress that results in mental health difficulties. It is important that health services acknowledge these wider determinants of health and the potential role they play in leading positive societal change to improve health outcomes”.

*The best things NHS GIDS could do for trans children is to give clear unambiguous affirmative trans positive statements about trans children to schools, to parents, to the UK media. Instead they do the exact opposite, making life so much harder – literally making minority stress and wider determinants of health worse. Where is the commitment to Do No Harm when it comes to the NHS and trans children?

Explicit on benefits of affirmative care on mental health and wellbeing (UK GIDS does not)

Being transgender is often but not always accompanied by gender dysphoria, a person’s discomfort or distress with their body or gender roles associated with their sex assigned at birth. Constant reminders can be experienced when showering or dressing. However, increasing evidence demonstrates that supportive, gender affirming care for trans people significantly improves gender dysphoria and mental health and wellbeing outcomes. International studies consistently show high rates of mental health issues such as anxiety and depression for trans people. In New Zealand the Youth’12 secondary school survey highlighted the mental health disparities experienced by transgender young people compared to their cis gender peers with 41% vs 12% experiencing significant depressive symptoms and 20% vs 4% reporting an attempted suicide, respectively, in the past 12 months. Because of the high prevalence of mental health problems among trans people, health services that are multidisciplinary and include mental health professionals will be more responsive to the on-going needs of trans people accessing gender affirming health care.

Psychotherapy is not mandatory (psychoanalysis is integral to UK GIDS)

The role of mental health professionals: Trans people may seek support from mental health professionals for a range of reasons, including support related to their gender or concerns with their mental health. Mental health professionals should be aware that mental health problems may be related to the effects of minority stress for being transgender or may be due to other causes. While many trans people access psychotherapy for support with living in their affirmed gender, psychotherapy is not a requirement of accessing gender affirming care. Mental health professionals with the appropriate skills and knowledge can assist with the informed consent process for readiness for gender affirming hormones. The WPATH SOC state that it is important for mental health professionals to have open dialogue with prescribing practitioners, and other providers of a trans person’s care and to access regular peer consultation and feedback. These mental health professionals should have the knowledge to provide information to trans people regarding gender affirming care treatment options and community support availability”.

Recognises the duty of health service providers to be an advocate for trans people (UK GIDS absolutely does not)

Finally, an important component of ethical health care provision is for providers to be advocates for the trans people who use their services. This could include educating or working with family members, schools, workplaces, healthcare settings, and other parts of the community on being inclusive and affirming of trans people. Recognising stigma, discrimination, and violence as the source of many issues that trans people face in Aotearoa, New Zealand, all health professionals should work collaboratively with trans people to advocate for social and public policy change to reduce the negative effects of minority stress”.

Mental health issues are not a barrier to gender affirmative care (In UK GIDS they are)

“Practice points • Include mental health issues as part of a holistic psychosocial assessment, for example discussion of anxiety, depression, risk of self-harm, while being clear that having mental health issues is not a barrier to accessing gender affirming services. • With the involvement and consent of the transgender person, plan for provision of on-going support for any mental health issues identified. • Respect the self-determination of each person as being the expert on their experience. This is often referred to as the “informed consent model” of gender affirming healthcare because it counteracts pathologisation and repositions the transgender person as being at the centre of their own life. • Recognise the impact of hostile environments on trans and gender diverse people, (i.e. minority stress) and validate the experiences that people have navigating those environments. • Ensure access to gender affirming health services alongside secondary mental health services: provide clear information about what to expect from secondary mental health services if referrals are appropriate, and work alongside secondary mental health services if they are involved”.

Recognises that trans children/young people may want support with challenges that are not related to gender (UK GIDS forces a prolonged focus on gender as the problem)

“When discussing stressors, follow the transgender person’s lead as to whether their current challenges and health needs are focused on their gender or on something else in their life. • Listen to each transgender person about ways that they would appreciate you advocating for them, which may be on an immediate interpersonal level (for example with family members or other health providers) or on a broader level in relation to other settings such as schools and workplaces”.

Embeds guidance for trans children in guidance for trans people of all ages (UK GIDS keeps trans children separate – using this to maintain a greater degree of pathologisation than would be accepted in adult care). Eg this section on pronouns is written the same for adults or children. Children are not treated worse just because they are young.

“Listen and reflect back the language each person uses about themselves, including gender identity terms, preferred names (even if not legally changed) and correct pronouns”.

Recognises neurodiverse people can also be trans (UK GIDS raises extra barrier to care for neurodiverse children and young people. In the media and to parents UK GIDS emphasises neurodiverse children and young people may be confused about gender identity)

“Neurodiversity and gender diversity It has been increasingly recognised that neurodiversity (autism spectrum) is common among the transgender community. Involving clinicians with the relevant diagnostic skills can be helpful for some people, as being able to identify as being on the autism spectrum can be helpful to understand behaviour and learn strategies to manage any difficulties. It is important to acknowledge that the person presenting is the expert on their own experience. Although some neurodiverse people may have difficulty in articulating their gender identity, this should not create an unnecessary barrier to access any relevant gender affirming services. Some people may express their gender identity non-verbally. The presence of neurodiversity can add complexity and extra time and support may potentially be required to help navigate all stages of the gender health journey including gender exploration, social, medical and surgical transition. Family may need support to understand more about the co-existence of neurodiversity and gender diversity, so that they understand that it is a common overlap and that being on the autism spectrum does not invalidate being transgender or seeking health services as part of transitioning.”

*See how reassuring the language is above. We never hear this from UK GIDS, who encourage allistic parents to reject neurodiverse children’s gender identity (for insistent trans children, the euphemisms that UK GIDS uses to avoid accusations of conversion therapy ie ‘delay’ ‘caution’ ‘watchful waiting’ equals rejection in practice).

“It is recommended that clinicians consider two key questions when working with people on the autism spectrum: • Is the gender identity clear, urgent, pervasive, and persistent over time? • Does the gender dysphoria increase or decrease with interventions?”

Physical Health is dealt with alongside wider health dimensions (UK GIDS focuses on psychoanalysis to test/validate gender identity followed by physical interventions)

“The physical dimension is just one aspect of health and well-being and cannot be separated from the aspect of mind, spirit and family. These guidelines are based on the principle of trans people’s autonomy of their own bodies, represented by healthcare provision based on informed consent.”

Prioritises informed consent (UK GIDS does not)

“Medical treatments such as hormone therapies and surgical interventions may also be an important part of a person’s transition and physical health. While many trans people will benefit from hormone therapies and surgical interventions, some may choose only one of these options and others may decide to have neither. For those who are seeking medical support, access to competent care through an informed consent model is of paramount importance.

In regards to transition goals, it is important to recognize that each person will articulate these differently. It is not helpful to assume that everyone wants to conform to binary gender norms and clinicians need to be aware not to impose a binary view of gender.

The importance of discussing individual transition goals and individualising treatment options is especially true for non-binary people but also applies to those with a more binary gender”.

States unambiguously that withholding gender affirming treatment is not a neutral option (UK GIDS does not)

“Withholding gender affirming treatment is not considered a neutral option.

Avoiding harm is a fundamental ethical consideration for health professionals when considering healthcare. Withholding gender affirming treatment is not considered a neutral option, as this may cause or exacerbate any gender dysphoria or mental health problems. Conversely, access to gender affirming care may reduce the mental health pressures a trans or gender diverse person is experiencing. This does not discount that clinical decisions can be complex, particularly where there is family opposition for young people, the person is neurodiverse or has complex mental health needs. It is best practice that gender affirming healthcare is provided by well-resourced multidisciplinary teams that include mental health professionals and have good links with peer support groups.

Practice points: Acknowledge that withholding gender affirming healthcare is not considered a neutral option”.

Being trans and wanted to socially transition is not a mental health condition, mental health support should be optional not mandatory (in UK GIDS it is mandatory and indeed at the heart of their approach)

“Social transition can be a stressful time for some people who may benefit from extra mental health support, but it is important to ensure that they consent to having this support and it is not enforced as a requirement for accessing gender affirming care.”

Emphasises that much can be done in primary health care (UK GIDS continually communicates how specialist and complex everything linked to trans children and young people is)

“Accessible gender affirming care involves people being able to access this care as close to home as possible. There are limited numbers of teams that are specialised in gender affirming care in New Zealand and these are receiving increasing demand. Primary health providers should be aware of the barriers and potential harms with requiring people to travel or wait to access care and might consider assessment and provision of gender affirming hormones within the primary care setting.”

Emphasises clearly and confidently the positive impact of puberty blockers on wellbeing (UK GIDS does not talk in the below terms about puberty blockers)

“Puberty suppression using GnRH agonists: Health teams need to be aware of the positive impact of puberty blockers (GnRH agonists) on future well-being. Be mindful of the need to refer promptly and be aware of referral pathways. Puberty blockers can be prescribed from Tanner stage 2 to suppress the development of secondary sex characteristics, although are still beneficial when prescribed later in puberty to prevent ongoing masculinisation/feminisation. Puberty blockers are considered to be fully reversible and allow the adolescent time prior to making a decision on starting hormone therapy. They do not stop growth or weight gain, and monitoring of height is recommended as adult height may potentially be increased if prolonged puberty suppression delays epiphyseal fusing. A bone age may be helpful to assess whether epiphyseal closure has occurred when considering what rate of hormonal induction to use as this may potentially impact on final height. Puberty blockers halt the continuing development of secondary sexual characteristics, such as breast growth or voice deepening, and relieve distress associated with these bodily changes for trans young people. For trans women and transfeminine people, they will prevent further masculinisation of the face and body that typically occurs into early adulthood.

*Note how confidently New Zealand health guidance talks about puberty blockers. GIDS does not talk in such reassuring ways about puberty blockers. GIDS instead speculate on an unevidenced theory about blockers potentially affecting brain development in mysterious and unstated ways. Brain development! This sounds really scary! But actually it is fully unscientific and vague – the kind of speculation you get from psychoanalysis who are not medically qualified. Do you think paediatricians go around speculating (with zero evidence) to parents about the irreversible impact on brain development of a drug that they have just prescribed to a cis 12 year old? They say ‘we don’t fully know the impact of them on adolescent brain development’. They also say things like ‘they are not reversible, as if you have taken them, you won’t know what it is like to have never taken them’. Well no shit sherlock but that isn’t what we are talking about when we talk about whether or not drugs are reversible. They also basically say to parents ‘there’s no evidence’ and ‘we give these blockers out but we don’t know what we are doing or if maybe it is the wrong thing to do’. Some anti-trans clinicians are known to tell parents that they believe blockers are harmful.  Goodness me – no wonder there is so much hysteria in the UK on trans children’s healthcare when the NHS is telling parents and media that it is prescribing drugs it does not have confidence in. The way in which UK GIDS communicates about puberty blockers is an indication of the systemic transphobia in UK GIDS – it causes real harm and negative health outcomes for trans children and families.

Access to gender affirming hormones on an individualised basis (not possible in UK GIDS)

“Gender affirming hormone treatment. In New Zealand young people aged 16 years and older are considered to be able to consent to medical care (Care of Children Act 2004), however it is increasingly recognised that there may be compelling reasons to initiate hormones prior to the age of 16 years for some individuals, although there is as yet little published evidence to support this. Consideration should be given to the individual circumstances including family support, length of time on blockers, concerns around final height, risks of delaying hormones and most importantly the ability to consent”.

Having mental health concerns is not a barrier to affirming care (It is in UK GIDS – being out of education (eg due to schools being able to tackle transphobic bullying, being depressed etc is a barrier to accessing HRT in UK GIDS)

“The WPATH standards emphasise that the having medical or mental health concerns does not mean gender affirming care cannot be commenced, rather that these need to be responded to alongside gender affirming care.  According to the standards, this readiness can be assessed by a prescribing provider or mental health professional who is experienced and competent at working with trans people.”

*Who gets to decide the definition of ‘competent at working with trans people? Would anyone in UK GIDS pass? I have heard of maybe three clinicians out of 60+ who people have regularly positive feedback on.

Clear, reassuring, easy to understand communication on the effects of masculinising hormones or feminising (GIDS does not provide it so clearly for public understanding)

table 5b

table 6a (2)

Fertility

I’ve not much considered the sections on fertility in this blog as a bit off my main focus. But two bits stood out. There is an Annex B on fertility information. I wasn’t clear whether this leaflet is accurate for those who have had blockers at Tanner stage 2 and never progressed beyond Tanner 2 of the puberty associated with their assigned gender?

Consent for form blocking testosterone is very clear, confident and reassuring, and also includes information on the harms of NOT blocking testosterone

“Annex C: A consent form for blocking ‘male’ hormones”.

Includes clear language on common side effects

“• Hot flushes • Mood swings – mostly in the first few weeks of starting • Possible fatigue. Most side effects should settle within a few days to weeks of starting the medications. Allergic reactions can happen but are rare. Please tell your health team if you have any problems. Potential risks of blockers • Increased height (unlikely if already through puberty) • Decrease future bone density”

Also includes:

Risks of withholding blockers: Withholding the use of blockers may cause additional distress leading to anxiety and depression. Not using blockers can also lead to irreversible unwanted physical changes”.

Interesting mention of need for contraception whilst on blocker, is this included in UK guidance?

Consent for form blocking oestrogen is very clear, confident and reassuring, and also includes information on the harms of NOT blocking oestrogen

“Annex D; A consent form for blocking ‘female’ hormone”.

“Blockers are a reversible medication used to stop the physical changes of puberty. It can be started in early puberty (Tanner stage 2–3). If started then blockers will usually stop significant breast development and further pubertal changes such as starting periods and widening of the hips. Blockers can also be started later in puberty where it may cause breast tissue to soften but not usually to reduce significantly in size. Blockers will stop periods but may take up to 3–6 months to do so

Starting a blocker often improves psychological distress associated with having the unwanted female hormone and allows time to think about whether starting testosterone is right for you.

Common side effects

  • Hot flushes • Mood swings – mostly in the first few weeks of starting • Possible fatigue. Most side effects should settle within a few days to weeks of starting the medications. Allergic reactions can happen but are rare. Please tell your health team if you have any problems. Potential risks of blockers • Increased height (unlikely if already through puberty) • Decrease future bone density”.

Also mentions:

Risks of withholding blockers: Withholding the use of blockers may cause additional distress leading to anxiety and depression. Not using blockers can also lead to irreversible unwanted physical changes”.

Trans Rights are Human Rights – Interview with Ed Miliband

In November 2017,  (@DadTrans) was interviewed by Ed Miliband and Geoff Lloyd for their Reasons to be Cheerful Podcast.

The episode went on to jointly win broadcast of the year at the 2018 Pink News Awards

Receiving the award, ex-Labour leader Miliband joked: “This makes up for the general election in 2015.”

He then made an emotional tribute to “Joe” (@DadTrans). Miliband said that “the podcast worked because of Joe’s testimony,  “I learned a lot by listening to him”.

Take a listen here:

Episode 9. TRANSGENDER RIGHTS ARE HUMAN RIGHTS