Following a Cass Review recommendation, the NHS has commissioned a pilot (the R22 Project) for trans kids under 10.

Very little information is publicly available on this pilot, with its existence first mentioned here, including an embedded link to the R22 referral form (discussed below).

A project proposal for R22 has now been emailed (not to me) sent in response to an FOI. I have had an opportunity to read this project proposal / outline (R22 Project Quality Improvement Full Proposal). I will present my key takeaways here (I’ll share a public link to the documents if/when I receive one).

Social transition as a risk

In order to access this pilot, families will be referred to the pilot by their GP. Their GP will fill out a “R22 project referral form”. The form asks whether “safeguarding risks have been identified”, including “safeguarding concerns” and “open to/referral made to children’s social care”. Perhaps noting whether there are any generic safeguarding concern or engagement with social care is active is standard for a GP referral.

Beyond these two boxes, in a section “Any other risks identified” it asks about “bullying or victimisation”. It then asks about “Risk due to social transition (current or future).” Here risk due to social transition is explicitly labelled a risk factor. Of course there is nothing about ‘risk due to family cis-ignorance’, ‘risk due to conversion practices’, ‘risk due to parental transphobia”, ‘Risk due to parental rejection”. Social transition, or even ‘future social transition’ is to be considered a risk.

The pilot has a risk identification section. It talks about a ‘risk’ of equity complaints from families of under tens who are not able to access the pilot. It does not include a risk of complaints from families and advocates related to the harms of the pilot. It completely fails to recognise the highly well established ‘risk’ of the pilot causing significant harm to trans children whose childhood rejection is encouraged and enforced by this ‘support’.

Astonishing levels of knowledge erasure

The project starts from the false Cass Review claim that a majority of trans kids grow out of it in childhood, so long as they are not supported or respected or allowed to socially transition.

The study proposal contains extremely limited references.

Four key references are presented as shaping this project:  

• 1968 Kohlberg Gender Constancy Theory
• 1981 Gender Schema Theory
• 1950 Identity Development Theory
• 1966 Marcia Adolescent Identity

These are all incredibly old references. They are extremely dated pieces of work, written at times where trans children’s identities were not understood in academia. They aren’t even focused on trans kids. They provide nothing of use of trans children.

[I wrote a blog 8 years ago on how bad the NHS was back then on looking to older Zucker literature on ‘gender constancy’ in order to reject the existence of trans kids. I am somewhat shocked to see how much worse they have got in the past 8 years, here focusing on literature from up to 76 years ago].

This is par for the course with the NHS, who continue to rely on really old irrelevant and unethical studies to guide their whole approach to trans children – see here.

Modern psychology research on trans children is completely missing. There is zero reference to work specifically on the same topics refenced above, that actually focused on trans children, including:

2015 Olson, K.; Key, A.; Eaton, N. Gender Cognition in Transgender Children

2018 Gender Development in Transgender Preschool children Olson & Fast

These studies of trans children’s identity development is omitted for purely political reasons. Because it directly contradicts the base assumptions of this whole pilot.

Sample of 12.

One of the key goals for this pilot is to “learn about early presentation of gender non-conformity/distress”.

The one year study, costing over a quarter of a million pounds, aims to target 12 families of children referred to the gender service under the age of 10.

If they are interested in learning about childhood experiences, you might have thought they would at least build from existing literature.

I will note that my own PhD research focused on UK trans children who come out under the age of 10 (a sample who would all have be eligible for this pilot). My own PhD reached 30 such children and families. I had no funding at all for my own research, that was in many ways more ambitious than this current study. Self-funded, and done in my evenings, I reached a sample of 2.5 times what the NHS is aiming for. Unlike the NHS, my study focused on qualitative interviews, actually listening, in detail, to the experiences of trans children and families.

From my PhD I published multiple peer reviewed articles in world-leading journals. These are all on the experiences of trans children who come out as trans under the age of 10:

Experiences in UK schools:

Horton, C. (2022). Institutional cisnormativity and educational injustice: Trans children’s experiences in primary and early secondary education in the UK. British Journal of Educational Psychology.

Horton, C. (2022). Reducing Gender Minority Stress – Support for trans pupils in our schools. International Journal of Transgender Health.

Horton, C & Carlile, M. (2022) “We Just Think of Her as One of the Girls”: Applying a Trans Inclusion Staged Model to the Experiences of Trans Children and Youth in UK Primary and Secondary Schools Teachers College Record.

Experiences in UK families

Horton, C. (2022). “Euphoria”: Trans children and experiences of pre-pubertal social transition. Journal of Family Relations.

Horton, C. (2022). “I was losing that sense of her being happy” – Trans children and delaying social transition. LGBTQ+ Family.

Horton, C. (2022). “I never wanted her to feel shame”: Parent reflections on supporting a transgender child. Journal of LGBT Youth.

Experiences with UK trans healthcare

Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

Horton, C. (2022).“Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies.

Experiences fo Horton, C. (2022). Experiences of puberty and ‘puberty blockers’ – Insights from trans children, trans adolescents and their parents. Journal of Adolescent Research.

Horton, C. (2022). “I didn’t want him to disappear” Parental decision-making on access to puberty blockers for trans early adolescents. Journal of Early Adolescence.

All of these studies provide meaningful insights into the experiences of trans children under the age of 10, the key goal for this ‘pilot’. They are completely ignored by this project-R22. As are all the other literature on the experiences of trans children under age ten from around the world.

All of this literature is ignored, in favour of really old psychology texts from 1968 because ALL of the modern literature about trans kids provides really clear evidence of the complete wrongness of the NHS approach.

The NHS side-steps this inconvenient truth by sticking its fingers in its ears and pretending modern research with trans children hasn’t happened. It pretends there is a blank slate ready to be filled by this 1-year study of 12 children and families.

Ensuring the NHS gets there quickly

The pilot is explicitly designed so that NHS providers can quickly access the youngest children referred to the gender service. The goal of this quick referral is explicitly to avoid “families seeking advice from non-NHS sources” while on the waiting list, who might “receive guidance that may be discordant with an approach later taken by CYPGS”. The whole goal of the service is to get to families before they hear from other sources i) the huge importance of support childhood social transition (for trans kids who want to be affirmed) ii) the enormous body of research backing up the critical importance of childhood affirmation iii) the body of research backing up the harms of childhood rejection.

“A developmental approach”.

The pilot commits to a ‘developmental approach’ – the NHS’s latest buzzword for non-affirmative and heavily conversive approaches that problematise and reject trans identities.

The service goal is to “safeguard children from narrowing options and opportunities for development of childhood and adolescent identity formation”. The word safeguarding is used by the NHS to remove all opportunities for a depathologised and supported trans childhood.

The document states that “No gender or self-identity outcome is favoured by this approach”. Clearly the NHS thinks this statement is sufficient to guard against accusations of conversion practices. It is contemptible to claim that no outcome is favoured when social transition is explicitly presented as a ‘safeguarding risk’.

This pilot is a continuation of the conversive approach taken by the NHS to trans kids.

Assessment after assessment

As with everything else in the NHS approach to trans children, the pilot is assessment heavy, with questionnaire after questionnaire. The tools utilised are inappropriate and will be completely ineffective in meaningfully understanding the needs and experiences of this cohort. The assessment is itself deeply problematising. I’ve written about the types of questionnaires used here

Only trans kids?

In the past I would have confidently said that the only kids getting through to the NHS gender service are trans kids, or kids who are seriously considering whether they are trans.

In this new world, I am less confident.

The service cannot even say the word trans. It talks frequently about gender non-conformity.

Will little cis boys be sent to the service just because they like dolls and makeup? Will little cis girls be sent to the service just because they like sport?

Is the NHS taking gender non-conformity back under clinical scrutiny? Are we going back to the 1950s? Who knows.

Adding no value – potentially causing significant harm

The pilot proposes providing ‘education’ to families of trans children. Whilst denying the existence of all modern research. Whilst providing advice that is directly contradicted by all modern research. Let’s be clear – this is not education – this is miseducation. Disinformation. Propaganda. Training parents to enforce cis norms on trans kids – training (and scaring and threatening) parents to reject their trans kids.

One of my specific articles showed the experience of parents who reject their trans kids. This study showed the significant harms of months or years of childhood rejection, focusing on families who came to eventually, in mid or late pre-adolescence support their trans child.

Other articles of mine (for example) drawn from this same cohort of younger trans kids, showed the life changing positive impact of childhood support. Social transition allows trans kids to have a happy childhood. A summary of the literature on childhood social transition showed significant evidence of benefits, and zero evidence of harms.

This pilot is designed for the exact opposite.
To educate parents to reject their child.

To deny social transition.

To ensure schools do not support social transition at primary school.

To deny trans kids any opportunity of a safe and happy childhood.