The UK’s specialist Children’s Gender Identity Service, GIDS Tavistock, launched a new website this week. A website that has the potential to become the first source of guidance for people interested in issues relating to gender identity in children. A website that can help dispel the many inaccuracies and distortions about transgender children that appear in the media. A website that can be the first port of call for parents of gender questioning and transgender children.

I was very excited to see the updated website, as the old one did not provide the information and support that parents like myself so badly need, particularly in the early days when it was so hard to sort through confusing and contradictory information to find out how best to support our child.

Instead I found myself disappointed.

I’m hoping however, that the people at GIDS Tavistock have good intentions, and in the process of quickly rolling out their new site, simply overlooked the stage of consulting with parents and interested parties on what content would best support transgender children and their families.

I saw on the main Tavistock and Portman site the statement that:

issues around gender is changing all the time. If you see anything on the new site that you think is either incorrect or out of date, we’d love to hear from you. Please contact us via gids@tavi-port.nhs.uk

So I thought it would be helpful to feed back my comments on the site’s content and add a few thoughts of easily implemented changes that can be included to update the site. It is pretty long so I’ve added some scores for each of the key sections.

First up: The ‘Parents’ section:

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http://gids.nhs.uk/parents

Why does my child feel this way?

The parents section starts by presenting different opinions on why children might end up transgender. It does this in a very biased way. When summarising the view that there is a physiological causation to gender identity it presents this as “Some people think”. It would be more genuine and accurate to say “X leading scientists and gender specialists have found X Y Z evidence for a physiological element to gender identity”. Presenting this view point as the vague “some people” gives little credence to this view, despite this being the conclusion of a wide number of credible gender identity specialists.

It seems to contrast this with the statement that “others argue that current research hasn’t found a major difference between boys and girls brains”. It seems to give this alternative argument greater credibility by reference to an “academic psychologist” and directly linking to a book (that outlines a lack of scientific evidence to support gender stereotypes about women being innately better at map reading or worse at parking). You may be aware that this text is popularly cited by a minority who claim that (trans)gender is a social construct and therefore argue that trans people don’t exist. This is not helpful GIDS Tavistock.

It is inappropriate to present these two (gender identity having a physiological element and male and female brains not being completely different) as alternative options. It is easily possible for both to be true.

There is clearly growing evidence backing up a physiological and pre-birth element to gender identity, and though this evidence is limited, it is misleading to ignore it or dismiss it as “some people think”.

It is entirely possible for there to be some tiny physiological element to gender identity, without there being two binary and totally distinct ‘male and female brains’. The concept of a ‘male’ brain, as completely distinct and separate from a ‘female brain’ is clearly nonsense, but I don’t see anyone arguing this. Yes, some trans people use the phrase ‘female brain in a male body’ or vice versa, but most people are using this as a short hand vernacular way of explaining that they identify as the other gender.

Most people I know who are deeply interested in this subject view gender as a complex spectrum and a complex interplay of identity, culture, expression, interests, preferences.  To introduce this strawman (or rather scarecrow!) debate on the first page is highly disingenuous, and appears to discredit those who feel that they have ‘been born this way’.

Nowhere does this section give the view of the recent Lancet report which clearly states “to date, research has established no clear correlations between parenting and gender incongruence”

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00683-8/fulltext

This section is actively unsupportive GIDS Tavistock: 1/5

Where can I get help for myself?

This section does not provide any links to the main organisations that are able to provide support to parents. Mermaids (http://www.mermaidsuk.org.uk/) is clearly an important organisation in this space, though there are also other groups that can support. This section recommends parents get support from their GP. If you had consulted properly with parents when developing this website we would have informed you that a GP is not a reliable source of advice. There is no systematic training for GPs on gender identity issues, especially for children, and many of us have encountered GPs who at best are ignorant and dismissive.

This section needs to acknowledge that GP knowledge and awareness of gender identity issues is patchy, and needs to provide clear alternative sources of support. This is critical both due to the long waiting lists to see GIDS, and also as often a GP referral is needed to even get on to the waiting list – parents needs support in these early stages, especially if their GP is un or ill-informed and refuses to refer.

This section is not at all helpful GIDS Tavistock: 1/5

 

When is the right time to ask for professional help?

This section states that “if a young person is demonstrating distress at any time we would encourage you to initially seek input from local services such as CAMHS”. Many parents that I know have been turned away from CAMHS if their child’s distress is purely down to gender identity. The advice on this website should match up with the reality of what CAMHS sees as their role in supporting children who are distressed ‘just’ about their gender identity. The advice to seek support from the mental health service should also be prefixed with the consensus that being transgender is not in itself a mental health issue..

One other concern with advising parents and young people to contact CAHMS, is this will add significantly to the already very long wait (with a waiting time to see CAHMS, and time for CAHMS to refer on to GIDS). If your child is in severe distress about their gender identity the last thing you want as a parent is additional barriers to reach the help they need.

Could do better GIDS Tavistock 3/5

Should I use my child’s preferred name and pronouns?

Well done GIDS Tavistock. This section is written with kindness and understanding of what parents are dealing with at its heart. This tone of emotional support is so important in supporting gender questioning and transgender children and their families.

Good work GIDS Tavistock 5/5

How do I know whether or not this is a phase?

You say: “it is a fact that whilst many young people retain the gender identity they develop in childhood or adolescence, some do not”. This is helpful, although you place the emphasis on the children who do not continue in the gender identity they develop in childhood. It would be helpful if your acknowledgement that “many children retain the gender identity they develop in childhood” came across more clearly in both your publications and in the media articles with which you collaborate (the recent Times article quotes you as having stated that 80% do not continue in their childhood gender identity – this is further discussed below).

In your communications, it often feels as though your priority is on the few children who might not retain the gender identity they develop in childhood, at the expense of clearly supporting the many young people who do retain that gender identity.

Pretty good here GIDS Tavistock 4/5

How can I help my younger child?

You state: “During this same time of life, children learn about gender roles and what is expected from each sex in their community i.e. ‘things that boys/girls do or like.’”

And:

“Our ideas of what ‘boys do and like’ or what ‘girls do and like’ changes over time”.

And:

“There is nothing ‘wrong’ with any child who explores interests and activities outside of the current gender stereotypes.  Indeed, it is probably helpful for all children to be encouraged to play with a range of toys, friends, activities and emotions in order that they can find out what works best for them as this will likely help them grow into rounded and accepting adults”.

More of this:

“parents may want to influence how a child plays or behaves in order to protect their child from stigma, but it is important not make the child feeling like they are doing something wrong”

And this:

“When a child’s interests and abilities are different from societal expectations, he or she can be noticed or even discriminated against by others”

Come on GIDS Tavistock, you were doing so well! A transgender identity is not about gender roles or things that boys or girls do or do not like or dislike. Why can’t you unpick this? Why not say “a boy liking dolls or dresses and a girl liking football or trousers does not mean they are transgender. These children do not need to be supported by a service like GIDS Tavistock.

GIDS Tavistock is to provide support to children and young people with a gender identity that is different from the gender identity they were presumed at birth. This service is for children who state “I am a girl” or “I’m not a boy” (when assigned male at birth), or “I’m neither”. Of course there are more complicated situations, and it can be hard for parents and children when gender identity is not clear or when there is confusion about whether the underlying issue is one of gender identity or expression / gender roles, and the GIDS Tavistock can support young people to explore these issues. But for a child who feels that they are a boy, and is a boy who likes playing with stereotypically girls toys, or likes stereotypically girls’ clothing or who has a more gentle play behaviour or is perceived to be more feminine, this is not a relevant service.

This service is surely for the small percentage of children for whom gender identity has become a critical issue in their development, not for children who might prefer non-stereotypical play or dress.

Gender isn’t all that matters.

You say: “Try and get a balance between paying attention to a child’s gender-related preferences whilst not allowing gender to become the only way in which you understand your child.  Allow your child access to all sorts of toys, friends and activities, associated with both boys and girls. “

What? Oh come on GIDS Tavistock. How is this relevant to children like mine who feels that they are a different gender. For children (assigned male at birth) who do not give a damn what toys or friends or activities they play with as long as they are acknowledged as a girl. Gender IS all that matters when you have a child who is severely distressed about their gender identity. Are you aiming this advice towards parents of transgender children (surely your target audience?), or aiming it at parents of ‘gender non-conforming children’. If the latter, please put this in a different section. Sure, gender non-conforming children may get bullied for non-stereotypical behaviour, activities, friends, clothing preferences. Sure parents who have very fixed ideas about gender roles and norms may need reassurance about what toys their child can play with, but this is not advice for parents of transgender children.

Even worse, this may lead some parents of gender non-conforming (but not transgender) children to question whether their child is transgender – making your near eternal wait times even longer. How is this helpful GIDS Tavistock?!

Woeful GIDS Tavistock 0/5

Social transition? 

You say: “Based on knowledge of child development and our experience of working with families, we know that some younger children benefit from a period of ‘watchful waiting’ when they appear to be questioning their assigned gender.”

GIDS Tavistock have you read the latest US American Academy of Pediatrics publication “Supporting Caring for Trans Children”?

http://hrc-assets.s3-website-us-east-1.amazonaws.com//files/documents/SupportingCaringforTransChildren.pdf

This is a fantastic publication that actually helps parents of transgender children with some really clear advice. In this, they rightly clarify the term ‘watchful waiting’ as ‘delayed transition’. It would be more honest if the term ‘delayed transition’ was used here.

More broadly – please take a look at this US publication. This is the kind of material I was hoping to see on the GIDS Tavistock website. Clear and informative.

Some further reading needed GIDS Tavistock 2/5

Looking after yourself

You say: “Some parents tell us that they wonder whether they are to ‘blame,’”.

This would be a good place to reiterate the recent Lancet article conclusion “to date, research has established no clear correlations between parenting and gender incongruence”.http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00683-8/fulltext

Well done GIDS Tavistock for acknowledging the difficulties parents face trying to support their children within a sometimes hostile society 4/5

Evidence base: http://gids.nhs.uk/evidence-base

I don’t really know how to start here GIDS Tavistock. The section on ‘evidence base’ is extraordinarily biased, selectively sourced, and lacking in evidence. The NHS GIDS Tavistock should think harder about which pieces of evidence to present in a section entitled evidence base. Such a section should also include proper referencing so that people can read the source material.

Further, the only GIDS publication that is referenced in this section is a presentation (not a peer reviewed publication) that does not seem to be publically available. This section should honestly present and weigh up a cross-section of the evidence that is available. It should acknowledge areas in which evidence is lacking, and should not overstate the case in areas where the evidence base is weak or contested.

How many people continue with their transition?

Oh come on GIDS Tavistock. In a section titled “evidence base” you present a very one-sided view of a subject that at very best can be described as contested (I would describe these statistics as discredited).

“In the majority of cases these feelings seem to discontinue either before, or early in, puberty (Steensma et al, 2013).“

This often repeated assumption appears in NHS, NICE and WPATH guidance, yet the evidence base is extremely weak and the supporting literature e.g. (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984, Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008, de Vries et al 2010, Steensma et al 2011), have multiple flaws e.g. self-selecting participant groups, small sample sizes, outdated definitions of gender roles, philosophical underpinnings which have been criticised as homophobic or misogynistic, lack of follow-up. Findings have been used to make sweeping unsupported conclusions.

“Across all studies approximately 16% continue with their gender identification (Steensma et al, 2013).”

These statements are simply not supported by recent scientific literature. The few studies that give rise to similar statistics have been criticised roundly as flawed, and most importantly, they include gender non-conforming as well as transgender children. They include boys who like playing with dolls, alongside natal males who say ‘I am a girl’. These are clearly two different categories, and putting both in the same pool is clearly meaningless – the fact that boys who like playing with dolls end up being men is not in any way relevant to the question of whether natal males who say ‘I am a girl’ will continue to identify as female into adulthood.

The quoting of this cross study % figure is irrelevant and confusing given the admission that “It should be emphasised that most studies did not use the fairly strict criteria of DSM-5, and children might previously have received a diagnosis based only on gender-variant behaviour”. A cursory reading of the studies looked at by Steensma & Cohen-Kettenis reveals that many (all?) were flawed, and lacked basic rigour for cross comparison.

It would perhaps be more appropriate to simply state as in the WPATH guidelines that

“The current evidence base is insufficient to predict the long-term outcomes of completing a gender role transition during early childhood” and that “additional research is needed to refine estimates of its prevalence and persistence in different populations worldwide”.

Where evidence is weak, this should be stated. See for example the following for summaries of problems with the evidence:

• https://gidreform.wordpress.com/2016/07/26/media-misinformation-about-trans-youth-the-persistent-80-desistance-myth/
• http://www.huffingtonpost.com/brynn-tannehill/the-end-of-the-desistance_b_8903690.html
• https://vimeo.com/132256588

 

You should not be self-selecting which pieces of evidence to present in a section on “evidence base”. This section should honestly present and weigh up the evidence that is available and honestly state where evidence is weak or contested.

Where evidence is weak it would be very reassuring to see you acknowledge this. Better still, to help all of us, it would be good to see your commitment to GIDS data being used properly by researchers to improve the evidence base. It is not helpful that one piece of evidence that you list in this section ‘GIDS Audit: Retrospective Look at Cases Closed at GIDS, presented at WPATH 2016’ does not appear to be available. If data is not made available, it cannot enhance understanding of this important topic.

This is a complex and contested subject. An honest review of the evidence would acknowledge this. Must try harder GIDS Tavistock 1/5

Social transition age

You say: “Quantitative and qualitative follow-up studies by Steensma et al (2011; 2013) present evidence to strongly suggest that early social transition does not necessarily equate to an adult transgender identity.  The qualitative study reports on two girls who had transitioned when they were in elementary school and struggled with the desire to return to their original gender role.  Fear of teasing and feeling ashamed resulted in a prolonged period of stress. One girl even struggled to go back to her previous gender role for two years.”

Reading the Dutch studies I found it difficult to reach this conclusion. This hinges on the use of the term ‘transition’, though as Steensma & Cohen-Kettenis (2010) state:

“None of the boys completely transitioned, that is they did not live in the preferred gender role on a daily basis (including a name change and change in pronouns). The boys were still treated as boys (be it a different type of boy) by other children. In contrast to the boys, the girls reported wearing boys’ clothing all the time. Most of them also had boyish haircuts. None of the girls ‘officially’ transitioned by changing their name or informing other children that they wanted to be referred to as ‘he’. However, as a result of their appearance and behaviour, virtually all the girls were largely perceived and treated like boys.”

To be clear, none of these children had transitioned including the two children on which such strong conclusions are made. This is very very weak evidence on which to base any conclusion on social transition. In your conclusion, for this section on social transition, you again talk about gender roles not about identity:

You say: “As such, in our approach, we would encourage exploration of gender roles in this younger cohort, with a view to keeping options open and not having any pre-conceived ideas as the longer term outcome. This could be summarised as a ‘watch, wait and see’ approach”.

This ‘guidance’ contrasts very strongly with the actually useful guidance in the new American Academy of Pediatrics publication which is worth quoting at length:

“Competent clinicians generally can tell transgender kids apart from other gender expansive children. Many delayed-transition advocates say this is impossible until a child reaches puberty, but their own studies contradict them, identifying early characteristics that predict whether gender dysphoria will continue. Persisters in these studies had more cross-gender behavior and more intense gender dysphoria during childhood, as measured on various psychological tests. Interviewed later, they also described their childhood experiences with gender differently. For instance, persisters recalled insisting that they were the “other” gender, while desisters had said they wished they were that gender.”

And:

“It is clear that many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition”.

Further:

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

You would also be recommended to look to the American Academy of Pediatrics publication for a helpful summary of ‘Gender Affirmative Approaches’.

Your ‘evidence’, GIDS Tavistock, appear to be entirely ignoring the recent studies on the gender affirmative model see for example:Hidalgo et al (2013)  The Gender Affirmative Model: What We Know and What We Aim to Learn  and,

Hill et al (2010) An Affirmative Intervention for Families With Gender Variant Children: Parental Ratings of Child Mental Health and Gender

You are falling out of touch GIDS Tavistock. Please keep up with more recent research and publications GIDS Tavistock 1/5

Case studies of young people

I’m not going to review these in any detail, but would like to feel more confident in how you’ve selected which case studies to include. It might be helpful to present these each in the same way unlike the current site in which a story of a girl who did not continue to transition is presented differently to the case studies of four trans boys. I was struck by the fact there is not a single case-study of a trans girl. Is there any reason for that?

Conclusion: 

I added up your marks GIDS Tavistock- you got 22/40 so 55%.

It is a good start but I do feel you are letting yourself down in a few areas. We know you can do better and would love to help you improve to be the best you can be.