In trans children’s healthcare there is so much intentionally bad science, so much science that fundamentally misunderstands (or chooses to misrepresent) trans experiences.

The quantity of bad science overwhelms – we challenge some, whilst other pieces of bad science slip through undetected.

I just this morning had my attention drawn to some fundamentally bad science (I read about it on the website transfemscience https://transfemscience.org/articles/puberty-blockers/ ) and realised that yet another bad faith move had somehow escaped my attention.

The Cass Review makes the claim that puberty blockers don’t reduce ‘Gender Dysphoria’. In recent discussions on this topic I have argued that this is likely both true and irrelevant. Puberty blockers shouldn’t be expected to reduce gender dysphoria, they don’t magically make trans kids feel better about their primary sexual characteristics. Instead they prevent the increase in gender dysphoria that can occur at puberty, if adolescents denied blockers are forced through the distressing development of unwanted secondary sexual characteristics. I have argued, including in recent media interviews, that puberty blockers shouldn’t be expected to reduce dysphoria, instead they prevent an increase in dysphoria at puberty.

HOWEVER. The term gender dysphoria has multiple meanings. One meaning refers to ‘physical gender dysphoria’, how we feel about our bodies, and particularly how we feel about the parts of our bodies that are impacted by sex hormones. A second meaning refers to ‘social gender dysphoria’, relating to our experiences navigating the world, including how we feel when we are mis-seen and misgendered. A third meaning references the diagnosis of ‘gender dysphoria’ from the Diagnostic and Statistical Manual of Mental Disorders, which has distinct definitions for children or for adolescents and adults, which operates as a proxy for a medical diagnosis of being trans.

In healthcare research a research question that is arguably valid and good faith is ‘does affirmative healthcare reduce physical and social gender dysphoria’. Asking this question about puberty blockers alone would be mis-placed (an error I thought the Cass Review was making) because puberty blockers don’t reduce physical and social dysphoria, they prevent it from getting worse.

However, this isn’t what they are talking about at all,

Let’s take a 2021 UK GIDS (NHS children’s gender clinic) research article on puberty blockers as an example (GIDS research has tended to be so filled with flaws, methodological, analytical, ethical and interpretive, that it is exhausting to read or critique, which is one reason the flaw highlighted in this blog has escaped me until today).

The 2021 article is titled: Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK

The article talks about the purpose of blockers “used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes”. So we are talking about physical and social gender dysphoria, right? I’m pretty sure we’re not talking about identity…

The paper talks about measuring the intensity of Gender dysphoria. “The Utrecht Gender Dysphoria Scale (UGDS) is a self-report measure used to assess the intensity of GD validated for age 12+”. This is the only information on gender dysphoria provided in the article. If you don’t already know the Utrecht scale, you are left in the dark on what is being meant and measured here.

The article concludes that “Gender dysphoria changed little across the study”. Again, a finding that intuitively sounds predictable for physical and social gender dysphoria. I would expect them to remain the same (rather than worsen) if accessing puberty blockers. The idea we are talking about physical dysphoria appears to be reinforced by the next sentence “This is consistent with some previous reports and was anticipated, given that GnRHa does not change the body in the desired direction, but only temporarily prevents further masculinization or feminization”.

The article is not clear what is meant by gender dysphoria, and it includes several references to puberty blockers preventing secondary sex characteristics, so I do not blame past me for assuming we were talking about physical gender dysphoria.

BUT – then I went and looked at the measurement tool being used. The Utrecht gender dysphoria scale.

This is a simplified version of the Utrecht scale. It shows the measures that puberty blockers are being criticised for failing to improve:

1. I prefer to behave like my affirmed gender.
2. Every time someone treats me like my assigned sex I feel hurt.
3. It feels good to live as my affirmed gender.
4. I always want to be treated like my affirmed gender.
5. A life in my affirmed gender is more attractive for me than a life in my assigned sex.
6. I feel unhappy when I have to behave like my assigned sex.
7. It is uncomfortable to be sexual in my assigned sex.
8. Puberty felt like a betrayal.
9. Physical sexual development was stressful.
10. I wish I had been born as my affirmed gender.
11. The bodily functions of my assigned sex are distressing for me (i.e. erection, menstruation).
12. My life would be meaningless if I would have to live as my assigned sex.
13. I feel hopeless if I have to stay in my assigned sex.
14. I feel unhappy when someone misgenders me.
15. I feel unhappy because I have the physical characteristics of my assigned sex.
16. I hate my birth assigned sex.
17. I feel uncomfortable behaving like my assigned sex.
18. It would be better not to live, than to live as my assigned sex.

(The original, longer, and more misgendering version of the Utrecht is available here (trigger warning for a really outdated and offensive measurement tool). I would guess GIDS likely used the more offensive and outdated original version. I’ve put the simplified and more modern version above so readers don’t have to get the severe ick that comes from reading the original versions)

They are criticising puberty blockers for failing to show improvements across these 18 questions.

They are criticising puberty blockers for failing to cure transness.

How can we fight this level of bad science at every turn?

Why can’t they even be honest and clear? They could say ‘we expect healthcare to change young people’s answers to the above 18 questions. We consider it a shortcoming of puberty blockers that they do not lead to improved answers to the above 18 questions. We were hoping that puberty blockers would make people not trans. Without evidence of blockers making people not trans, we will not give them to trans youth. Our goal for trans healthcare is to make young people not trans’.

At least be honest about your anti-trans intentions, don’t hide it behind a measurement scale that only gender clinic measurement geeks will understand. Don’t hide beneath a term like gender dysphoria that has multiple meanings.

When stakeholders talk about the goal of NHS services being to ‘reduce gender dysphoria’, if they use the Utrecht scale, they mean, to make people not trans. When they say ‘to reduce gendered distress’ they mean make young people not trans.

When they measure gender dysphoria against the Utrecht scale, they are seeking to cure or reduce transness.

Puberty blockers are ineffective in making people not trans (reducing gender dysphoria according to the Utrecht scale). So, we need ‘talk therapy’, to make people not trans.

 It is conversion therapy all the way through. The conversion therapy is hidden in language of ‘gender dysphoria’ (a term that is used very differently in trans communities’). They know the term gender dysphoria has multiple meanings. It provides a perfect cover for conversive practices.

We need to reduce gender dysphoria they say.

We need to make children not trans they mean.

The level of bad faith, bad science and establishment transphobia is overwhelming. No amount of evidence that affirmative healthcare leads to reduced physical and social dysphoria will ever be enough – because this is not the measure they care about.

They just care about making trans kids into cis kids

This is all they ever care about.

Transphobia and transphobic bad science continues to enable harmful clinical policy and practice.