Today the UK Royal College of Psychiatrist’s launched a brand new position statement “supporting transgender and gender-diverse people”.
Their statement endorses ‘watchful waiting’ for trans children.
“The College believes that a watch and wait policy, which does not place any pressure on children to live or behave in accordance with their sex assigned at birth or to move rapidly to gender transition, may be an appropriate course of action when young people first present.”
It does not acknowledge that a watchful waiting approach, as commonly understood, entails a blanket one-size fits-all approach that recommends delayed transition for all trans children.
‘Watchful waiting’ does not make it clear what we are meant to be watching and what we are meant to be waiting for. In the experience of parents of trans children, watchful waiting means watching your child get sadder and waiting for them to become completely without hope.
When a child continually asserts their identity there is no ‘neutral’ reaction that does not equate to rejection and shame. What answer do the ‘watchful waiting’ proponents suggest a parent give when their child asks to be acknowledged for who they are? They don’t advocate we tell them they are wrong (aka conversion therapy) but what do they suggest? Should we just pretend we haven’t heard them? For how long? Shall we just change the subject? Every day? For how many years?
For insistent, persistent, consistent trans children who are very distressed at being rejected by their families, being mis-gendered and being forced to act out a lie, watchful waiting causes harm. It causes children to feel shame. It causes them to feel that they are wrong. Unacceptable. Un-loveable. It advises parents that they should not tell the child that they are not trans, but equally must delay accepting them as the gender they are asserting
Not accepting a child’s identity is the same as rejecting their identity. To that child. They notice their parent avoiding pronouns. They notice their parent refusing to call them a girl (for example). They notice their parent not sticking up for them at school. This rejection causes transgender children to put on hold their hopes of a happy and carefree childhood. Their one and only childhood. A childhood they will never get back.
I’ve seen my child move from a miserable child when she was being continually rejected and mis-gendered, to our now happy girl getting on with her life, loving school. I know so many other children who have flourished once given a chance to be accepted and acknowledged.
There is no medical intervention for young children so watchful waiting is nothing less than denying social transition. Denial of pronoun change. Denial of acceptance.
And for what? You’d better have some damn strong evidence to deny my child her happiness. Her childhood. Her education.
We know the benefits of social transition.
We know how children not supported by their families struggle.
We know few children revert to a cis identity – and even if they do, there is no harm in a second social transition so long as the child is listened to and respected. “Let the child lead the way”.
The Royal College of Psychiatrists position paper ignores available evidence supporting affirmative approaches, showing that affirmed trans children flourish, as so many parents have seen.
It does not provide a single piece of evidence that watchful waiting is better than affirmative care. What arrogance on behalf of the Royal College of Psychiatrists to condemn yet another generation of trans children to spend their one and only childhood in denied transition, leaving us parents to watchfully wait as their self-confidence crashes, as they stoop their shoulders in shame, as they drop out of education, as they self-harm and learn to hate themselves for being so ‘wrong’.
There’s increasing evidence of the appropriateness of an affirmative approach:
“being trans or gender diverse is now largely viewed as being part of the natural spectrum of human diversity” (RCH, 2017)
“there is a durable biological underpinning to gender identity” (Endocrine Society, 2017)
“Transgender children do indeed exist and their identity is a deeply held one.” “Early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.” (Olson, 2015 and Fast, 2017)
“Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex. (Olson, 2015)
“Social transitions are increasingly common for transgender children. This study examined self-reported depression, anxiety, and self-worth in socially transitioned transgender children compared with 2 control groups. (Socially transitioned) transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers and they reported marginally higher anxiety. Compared with national averages, (socially transitioned) transgender children showed typical rates of depression and marginally higher rates of anxiety. These findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. (Durwood, 2017)
“The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”. (RCH, 2017)
Where is the up to date evidence in favour of a watchful waiting approach?
Here is the American Academy of Pediatric’s position on watchful waiting, published in 2016:
Delayed Transition: Prolonging Dysphoria
Certain clinicians, along with non-expert critics of transgender advocacy, have taken a position that they describe as “watchful waiting.” They contend that most children with gender dysphoria do not become transgender adults and, therefore, early social transition may be unnecessary, even harmful. They advocate waiting until adolescence, or even adulthood, to permit any type of gender transition. Because watchful waiting is a general phrase that could also apply to affirming a child’s gender identity as they grow, we use the phrase “delayed transition” to more specifically describe this approach.
It is true that most gender-expansive children, and even some children with gender dysphoria, do not become transgender adults. Indeed, some children become more comfortable with their assigned gender as they reach adolescence. Unfortunately, delayed-transition advocates often support their claims with misleading interpretations of research. More important, competent clinicians generally can tell transgender kids apart from other gender-expansive children. Many delayed-transition advocates say this is impossible until a child reaches puberty, but their own studies contradict them, identifying early characteristics that predict whether gender dysphoria will continue. Persisters in these studies had more cross-gender behaviour and more intense gender dysphoria during childhood, as measured on various psychological tests. Interviewed later, they also described their childhood experiences with gender differently. For instance, persisters recalled insisting that they were the “other” gender, while desisters had said they wished they were that gender. Many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition.
As in most areas of medicine and life, there is no perfect test to predict what is best for each child. But delayed-transition advocates treat unnecessary or mistaken gender transition as the worst-case scenario, rather than balancing this risk with the consequences of the delay. There is no evidence that another transition later on, either back to the original gender or to another gender altogether, would be harmful for a socially transitioned child — especially if the child had support in continuing to explore their gender identity. More important, untreated gender dysphoria can drive depression, anxiety, social problems, school failure, self-harm and even suicide. Delayed-transition proponents have few answers for children and families in the throes of these symptoms. What’s more, we know little about the long-term consequences of prolonging gender dysphoria.
Those who advocate delayed transition say it allows a child to explore gender possibilities without pressure in a particular direction. While this may be their intent, the delayed transition approach actually makes it impossible. Children may be permitted to express certain gender-expansive behaviours, such as play preferences or dress, but they are prohibited from other forms of self-expression, like adopting a gender appropriate name and pronouns, that they may ardently wish to take. These constraints communicate to the child that being transgender is discouraged. Tragically, youth whose families fail to affirm their sexual orientation, gender identity or gender expression are at significantly increased risk of depression, substance abuse and suicide attempts.
While delaying a child’s gender exploration can cause serious harm, a deliberate approach is wise. Some children need more time to figure out their gender identity, and some do best by trying out changes more slowly. For these children, rushing into transition could be as harmful as putting it off. The problem with “delayed transition” is that it limits transition based on a child’s age rather than considering important signs of readiness, particularly the child’s wishes and experiences. A gender-affirmative approach uses this broader range of factors, with particular attention to avoiding stigma and shame.
“Waiting to transition…was not an option if we cared anything about [our son’s] health. The despair he went through…was not manageable. But when he did transition, it was like a light switch. We had a happy, healthy kid. And it has been that way ever since — four years and counting.” Peter Tchoryk Father of a seven-year-old transgender boy
Here is the ANZPATH (Australian Professional Association for Transgender Health) position as reflected in their 2017 guidance:
“increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved”.
“Avoid causing harm”. “withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications”
“Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach”.
“for children, family support is associated with more optimal mental health outcomes”
“trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”.
“social transition should be led by the child and does not have to take an all or nothing approach”
“social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers”.
“The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.
Key roles for a clinician of younger child:
Supportive exploration of gender identity over time
Work with family to ensure a supportive home environment
Advocacy to ensure gender affirming support at school
Education (to child and family) on gender identity and signposting to support organisations for child and for parents
If child is expressing desire to live in a role consistent with their gender identity, provision of psycho-social support and practical assistance to the child and family to facilitate social transition
Here’s the Australian Psychological Society’s Information sheet, produced in 2017:
“Support from families, as well as broader social support, is crucial to transgender and gender diverse children’s mental health.
Affirm your child’s expressed gender
It is essential to their child’s wellbeing that parents, caregivers and families support the child and affirm the child’s gender.
- Support your child in his or her gender expressions in the form of dress and activities.
- Use the names and pronouns that the child expresses (rather than those they were assigned at birth).
The degree to which parents and caregivers are positive and supportive has an impact not only on the child but also on all those around them, such as extended family, community, and schools, as they often seek their cues from how the child’s family is responding.
There is no right age for your child to let you know they are transgender or gender diverse. Some children know as young as three years old and others may only realise when they are teenagers. Often a child has known for a long time before they find the courage to talk to someone. There is also no right or wrong way to be transgender or gender diverse. Each child will be different.
Seek support from a mental health professional
Even though being transgender or gender diverse itself is not a mental health issue, getting some support from a mental health professional who affirms your child’s gender is likely to be helpful for children and their families as they navigate daily experiences and longer-term decisions. A mental health professional can help:
- Affirm your child’s gender and help them to feel accepted and normal for who they are.
- Help you navigate society’s expectations of gender that can cause anxiety and depression.
- Assist with social transition as your child decides to show or let people know their preferred gender.
- Assist with access to gender-affirming medical treatment. Having the option of treatment in the form of hormone blockers (to delay puberty) or gender-affirming hormones can have a significant positive impact on the mental health of TGD children in particular.
The Australian Psychological Society recommends mental health practices that affirm transgender people’s experiences.
The Royal College of Psychiatrists include absolutely no reference to the most recent publication on this topic, capturing the most up to date evidence (published in 2018):
Diane Ehrensaft, Shawn V Giammattei, Kelly Storck, Amy C Tishelman & Colton Keo-Meier (2018): Prepubertal social gender transitions: What we know; what we can Learn – A view from a gender affirmative lens, International Journal of Transgenderism, DOI:10.1080/15532739.2017.1414649
This new paper is a really important read. There is no excuse for clinicians at the Royal College of Psychiatrists not having read it and for not citing it.
The paper’s conclusion is:
“Newer research suggests that socially transitioned prepubertal children are often well adjusted, a finding consistent with clinical practice observations. Analysis of both emerging research and clinical reports reveal evidence of a stable transgender identity surfacing in early childhood.”
The full paper is essential reading for anyone interested in transgender children. it includes a direct critique of the ‘watchful waiting’ approach. But it is a journal article behind an academic paywall, a barrier to parents keeping up to date with the research (this is literally the job of the experts). To help those who are not in academia I will include a long quote – those less interested in the detail can skip to below the quote.
“Those transgender youth who have families that support their transitions and affirm their identities have significantly better physical and mental health outcomes than those who do not (Hill, Menvielle, Sica, & Johnson, 2010; Kuvalanka, Weiner, & Mahan, 2014; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Travers et al., 2012). It should be mentioned here that it is not specifically medical gender-affirming interventions that are the kingpin, but more generally all experiences gender expansive and transgender individuals are afforded—medical, psychological, behavioural, social, or legal—that facilitate a person to live in their authentic gender. As a result, most professionals, regardless of their theoretical orientation, have come to believe these interventions are necessary for the overall well-being of their patients.
The WPATH guidelines (SOC 7 from 2011) included a cautionary note on prepubertal social transition on two counts: (1) the persistence/desistence studies indicated a relatively low rate of persistence of gender dysphoria in children studied; and (2) transitioning back to one’s original gender role can be stressful for a child, based on evidence of one qualitative report of two youths who experienced distress when desiring to do so (Steensma & Cohen-Kettenis, 2011).
The cautionary note specifically invited families of children under the age of puberty to consider in-between solutions or compromises, rather than facilitation of a full social transition from one gender to another, with a message delivered to the child that they are always free to revert to their original gender position.
There is an inherent bias in SOC 7 toward the “watchful waiting” approach to pediatric gender care (Cohen-Kettenis & Pf€afflin, 2003), in which a child is given safe spaces to explore their gender but asked to wait until puberty to transition from one gender to another. This bias is evident in both counts of the cautionary note and the reliance on the studies of persisters and desisters in which most young children in the clinical studies were no longer evidencing gender dysphoria by adolescence. However, some of the persister/desister data have been reanalyzed to indicate that more children than originally cited in the data (Steensma & Cohen-Kettenis, 2011) were found to be persisters (Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013) and reevaluation of the data revealed early childhood indicators that could identify a group of young children who were asserting a gender identity that did not match the sex assigned to them at birth and would remain stable in that identity into adolescence, and beyond. Furthermore, the persister/ desister data which inform the SOC 7 guidelines on social transitions only measured children’s gender dysphoria, not their sense of their gender identity or the nature of their gender expressions, the latter two to be differentiated from each other and also measured separately from gender dysphoria (Ehrensaft, 2017). Lastly, the research results may include inflated percentages of desisters, as counted among their number were those who did not return to the clinic for care; therefore, reporting all patients lost to attrition as “desisters” represents an assumption that has never been validated, and rates of persisters and desisters cannot be verified unless these patients are tracked down. Ehrensaft (2016, 2017) guided by her own clinical observations of children, perceived that the studies were actually talking about two separate categories of children who could readily be identified early in life if the proper measures were employed: some young children would be centrally exploring their gender identities while others would be exploring or articulating their gender expressions. In fact, a reevaluation by the Dutch team of their research on persisters and desisters corroborated Ehrensaft’s perception by identifying early factors that differentiated persisters from desisters, including: the statement, “I ama…” rather than “I wish I were a…”; consistent, persistent, and insistent articulations of an asserted gender identity other than one that matched the sex assigned at birth; evidence of body dysphoria (unhappiness about the genitals they had); and an early history of gender-expansive behaviors, perhaps as young as the toddler age (Steensma et al., 2013). If we are to have SOC regarding social transitions that reflect the realities of transgender children who are clear from an early age of their gender identity and are persistent, insistent, and consistent in the articulation of that identity, they will best be based on both research studies and collated clinical observations that assess the more salient variable: the child’s articulated gender identity, whether or not it is accompanied by dysphoria.
Lastly, the reference in the SOC 7 to the problems of “desocial transitioning” for pubertal or postpubertal youth with an early social transition is based on the slimmest of evidence—a case study of two youths. In the youth referenced by Steensma and Cohen-Kettenis (2011) in their short note in Archives of Sexual Behavior, two girls in the desisting group of their study had transitioned, using their own terminology, to a masculine gender role in elementary school, desired to return to their original feminine gender role, but expressed fear of teasing and shame about having been wrong about their gender, culminating in an extended period of distress. Because of the above mentioned conflation of gender role and gender identity underlying the research protocols and lack of mention of a change in name and pronouns, it was not clear from the reported evidence whether these youths had completed a full social transition or simply presented as more masculine and now wished to evolve to a more feminine self in middle school. (Ehrensaft asserts that it is not clear from the paper whether the two girls had socially transitioned – from reading the underling PhD it is clear that they had not – they had not changed pronoun).
Further, the fear of being teased or shamed for having been wrong may be a response to external lack of supports, rather than evidence of an internally based problem. Such stress is typically dependent on social stressors, in this case a social milieu, evident throughout the world, in which there is no acceptance for a child to be fluid in their gender expressions. With that said, the more reasonable standard of care would not be to hold a child back from a social transition but instead ensure social supports for any child who may discover new aspects of their gender over time, including an alteration or shift in gender identity and expression of that identity, with no aspersion cast on their character. If such supports are not in place or achievable through therapeutic supports, within a comprehensive standard of care, the alternative approach would be to support the child in their self-knowledge of their asserted gender identity and communicate an understanding that the impediments to social transitions are externally located, that is, there are not adults available to support the transition, rather than that there is something wrong with the child for desiring the transition or simply desiring to have others mirror back to them their authentic gender identity.
The watchful waiting approach evolved from the first model of care for transgender children developed in the Netherlands, often called the Dutch Protocol. The Dutch Protocol is informed by the belief that gender dysphoria, or a transgender identity, persists into adolescence in only a small minority of people (Steensma & Cohen-Kettenis, 2011). As outlined earlier, this research suffers from potential methodological flaws and the way the data have been interpreted suggests that providers be more concerned about the rare cisgender child being treated for gender dysphoria at the expense of the many transgender and gender-expansive children who would be helped if social transition were an option. The result of this interpretation has the potential to have profound negative impacts on treatment practices in pediatric transgender healthcare (Winters, 2014). In general, the watchful waiting approach is a cautious practice in which assertions of gender diversity and the consideration of a social transition are either tempered or held as possibly true and beneficial, but not until it is determined that the child is capable of knowing their gender with great validity, usually sometime after the advent of puberty (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003). When a child’s gender identity is unclear, the watchful waiting approach can give the child and their family time to develop a clearer understanding and is not necessarily in contrast to the needs of the child.
For children who are clear about their gender but are prohibited from exploring or experiencing the benefits of affirming their gender through a social transition, the watchful waiting approach can create potentially harmful disruptions by negating a young child’s gender identity and delaying the development of their asserted gender identity, especially in cultures that do not support gender diversity.
Similar to the watchful waiting approach, the gender affirmative approach has a foundation of collaboration with children and families to understand and affirm a child’s gender and works to meet the child’s needs as they develop. In contrast to the watchful waiting approach, however, the gender affirmative model does not involve waiting for puberty or adolescence to facilitate a child’s affirmation of their authentic gender, instead endorsing prepubertal social transitions where appropriate (Ehrensaft, 2012; Hidalgo et al., 2013). Gender affirmative care places substantial significance on a child’s understanding of their own gender and allows the child, and their knowledge of their gender, to lead the way to interventions. Social transitions are viewed, explored, and supported as an important and effective intervention that nurtures a transgender or gender-expansive child’s health and well-being. The gender affirming approach has allowed for a salient “ex-post facto test” (i.e., response to intervention) that enables us to discern the profound and overwhelmingly positive effects a social transition can have for gender-expansive children. With the help of social transitions, some children previously struggling with serious mental health and behavioral issues, carrying multiple diagnoses and treated with various psychotropic medications eventually settle into a significantly more stable life free of such issues, (mis)diagnoses and medications (Nealy, 2017).
The Royal College of Psychiatrists exclude a number of critical pieces of evidence (particularly Olson 2015, Olson 2015, Fast, 2017, Elhrensaft 2018) that support the benefits of an affirmative approach, the latter of which critiques the harm of a watchful waiting approach. And the Royal College of Psychiatrists do not provide a single scrap of evidence of why watchful waiting is better than affirmative care.
Remembering that watchful waiting entails denial of transition as long as possible until the child and family decide to ignore their experts. How is that expert advice? Wait until you no longer trust our advice and then start supporting your child. Wait until your child is desperate and self-harming? Wait until when exactly?
Those who advocate watchful waiting sometimes describe ‘affirmative care’ inaccurately. Affirmative care does not mean encouraging, much less forcing transgender children to socially transition. It does not mean social transition will be appropriate for every transgender child, and certainly not for every gender expansive or gender non-conforming child. Affirmative care just means listening to each child as an individual, respecting their identity and supporting those who need and wish to socially transition to do so without shaming them into living a lie, without forcing them to sit and wait as their chances of a happy childhood tick by.
The UK medical establishment’s un-evidenced commitment to ‘watchful waiting’ may be marketed as careful and benign, but it causes real harm.
The endorsement of ‘watchful waiting’ causes parents like me who love and accept/support our daughter to be painted as fringe or even reckless (despite this being absolutely mainstream advice from gender experts in other countries). The endorsement of watchful waiting directly makes my life harder, entrenching and emboldening those people who have accused me of child abuse in person, and daily on social media.
I can see how happy acceptance, support and social transition has made my child – so I take frequent accusations of child abuse on the chin. I take on the chin the fact that I have lost close friends over this, who genuinely believed support for social transition was harming my child. I take on the chin the responses of scepticism or hostility I get whenever I mention I have a trans child. I take it on the chin that I stand unsupported – with the enormous toll this has taken on my mental health, stress levels and well-being. I take it on the chin that I stand vulnerable to reporting to social services, and stand thankful that I’m not at the whim of a potentially ignorant judge in a child custody case against an unsupportive partner.
I find it harder to stomach the fact that the UK medical establishment’s endorsement of ‘watchful waiting’ makes life harder for my child. It makes it less likely that she will be fully supported by her teachers. It makes it less likely that she will be fully supported by her GP. It gives credibility to groups who campaign ardently to minimise her rights – groups who would rather transgender children just disappear. Adherence to a ‘cautious’ and ‘watchful’ approach, dissuades would be allies, including transgender adults, from sticking up for my child. It directly translates into the current situation where no one in the UK medical establishment ever advocates for transgender children in the UK media.
In countries like US, Australia, Canada, where experts adopt an affirmative approach, advocacy for trans children in the media is standard practice and considered a standard part of their remit as people who are meant to help transgender children. See the media engagements of Ehrensaft, Spack, Olson, Lopez, Rosenberg in the US. See Telfer advocating for trans children in court cases in Australia. See experts from children’s gender services publicly endorsing a critique of a fake diagnosis in Canada. This never happens in the UK, and the UK’s endorsement of ‘watchful waiting’ is a key reason why the UK never stands up for trans children in our hateful media.
I feel heart broken for those trans children living in the UK today who would never be supported by bigoted and transphobic parents – transgender children who are enduring childhoods of cruelty, rejection and loneliness. I hope they see that the future will be brighter, once they are older. I hope they can make it through the wait.
But my main emotion right now is anger for those transgender children who could be living supported and happy childhoods right this minute in the UK. But who are not. Whose parents are desperate to tell them that they are loved and accepted just as they are. Parents who with the right support and advice could accept and support their trans child. But parents who hold so much trust in the wisdom of UK ‘experts’ that they make their child ‘wait’. Parents who are encouraged to passively ‘watch’ as their child goes downhill. Parents who are watching and waiting for permission from UK ‘experts’ to go ahead and love unconditionally their child. Those children are being denied a happy childhood right now. And this is directly down to the cis-normativity, entrenched transphobia and ivory tower arrogance of the UK medical establishment and the UK College of Psychotherapists.
I know no one in the UK will care. Who cares about sad, depressed, lonely, shamed, hopeless transgender children? Does anyone in the UK medical establishment care even a tiny bit? And who outside of the UK medical establishment will hold them to account for their continual failings? It can’t just be me speaking up.
Will anyone stand up for trans children?
And one side question. Now that we know there is a “biological underpinning to gender identity”. Now that we know that it is not a mental health disorder. Now that we know it is just another part of human diversity. Now that we know that transgender children’s identities are as real as cisgender children’s identities. Now that we know that transgender children who are affirmed, accepted, supported have good levels of mental health and wellbeing (similar to cisgender peers). Now that so many families are seeing the happiness that comes to their children when they ignore UK medical ‘advice’. Isn’t it about time to say that there is no place for psychiatrists in having any power over healthy, well-adjusted transgender children? My daughter does not need a psychiatrist. And I am done listening to transphobic ‘experts’ who don’t give a damn about transgender children.