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

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

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

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

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

Let’s look at a more realistic scenario.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Update:

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

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

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

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

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