Ten Dangerous Cass Review Recommendations

The Cass Review final report has now been published. It has been received with jubilation by transphobic hate groups, by conversion therapy proponents, by those advocating against trans rights, by those who do not believe in the existence of trans children. The report has been praised and endorsed by all major UK media outlets, by MPs from the Conservatives and Labour, with both main parties committing to the fulfilment of all Cass recommendations.

The report has been met with horror and fear by trans communities, by trans healthcare professionals around the world, by families supporting trans children. Trans healthcare scholar Ruth Pearce has collated such responses here.

The Cass Review is biased and prejudice-driven in its design, delivery, analysis and approach to evidence, as documented in my peer reviewed analysis, published in the leading journal for trans healthcare.

In this short blog I will not revisit the very many methodological, conceptual, interpretive, evidencial and policy failings of the Cass Review. Instead I will here summarise and very briefly comment on ten significant recommendations of the Cass Review, each of which will cause significant harms to trans children. Here I am summarising ten of the recommendations that have me concerned, drawing from across the full 400 page report. These are not the recommendations that Cass has chosen to draw attention to in the 5 page summary document (these are analysed by Gemma Stone here) but are recommendations embedded across the longer Cass Review document. Each of the recommendations summarised below is built on a foundation of prejudice, ignorance, cisnormativity and pathologisation of trans lives, running in direct opposition to the evidence base, and running in direct contravention of an NHS duty of care to children’s rights, children’s welfare, healthcare equality and healthcare ethics.

These Cass Review recommendations have already been endorsed by powerful politicians from both the Tories and Labour. They have been endorsed by powerful healthcare stakeholders from BPS to BMJ, and there is significant high level commitment and motivation to quickly rolling these recommendations out into practice in the NHS. This roll out is a very significant safeguarding risk for trans children in England and Wales (where I refer to the NHS from here onward, it refers to the NHS in England and Wales).

  1. A current complete ban on NHS access to puberty blockers.

The Cass Review recommends a complete ban on access to puberty blockers outside of a research trial, with the research trial not yet developed. There is no current route to trans children accessing puberty blockers through the NHS. All previous access routes have been closed and no new children are accessing blockers. This is not labelled as a complete ban (although it is a complete ban currently in practice) as there is reference to a potential future research trial. NHS documents have been very clear that the current ban will continue even if the proposed research trial never commences. The trial has not yet been developed, and it is unlikely that such a trial would ever receive ethical approval to commence. Even if a trial does at some future point go ahead, it is likely to be highly restrictive and unethical.

2. Legitimisation of conversion therapy

The Cass Review recommends therapeutic practices that run counter to an affirmative approach that welcomes trans lives as equal to cis lives. The Cass Review endorses ‘exploratory therapy’, a re-branded title for conversive practices. The Cass Review is careful to avoid actively calling for conversion therapy, but Cass has appeared in the media since the report’s launch speaking against a ban on conversion therapy, highlighting that such a ban could impede the type of ‘therapeutic practice’ that Cass recommends.

3. Intrusive and abusive ‘assessments’

The old GIDS service was criticised for assessments (as part of gaining approval for transfer to endocrinology) that were abusive and intrusive. Cass recommends the new service takes this intrusive approach to questioning a step further. Here this is not even a discrete step in eligibility for endocrinology (as under 16s will never be eligible for medical intervention) but an ‘assessment’ for its own sake, enforcing a prolonged intrusion into trans children’s lives. Cass recommends that trans children are questioned on a bewildering range of intrusive topics, on sexuality, on masturbation, on porn viewing, on experiences of abuse, on family violence, on mental health, on anything and everything that could have influenced them to be trans. This type of expanded questioning deeply problematises transness, and is a deeply pathologizing and abusive approach for children who just happen to be trans. It is particularly harmful for the trans children who are without support, who are left feeling there is something deeply wrong or shameful about who they are to justify such ongoing intrusions. In the old GIDS intrusive ‘assessment’ was tied to referral to endocrine services, with at least a theoretical end in sight. In the new system I see no safeguards to protect trans children from intrusive assessments that never end.

4. An immediate removal of 17 year old access to adult healthcare clinics

The Cass Review recommended an immediate cessation of 17 year olds being able to access adult gender clinics (an approach that had been adopted following the huge delays in children’s services). NHS England immediately adopted and actioned this recommendation, pulling away hope from trans adolescents. Trans youth who have already been waiting for 5+ years for access to healthcare, who some of whom were counting the weeks to the 17th birthdays, have had this hope immediately pulled. Some 16 year olds are taking this news very hard. The NHS does not have any idea or concern for the well-being of trans adolescents who are left without healthcare.

5. Clinical control over social transition

The report recommends caution on social transition, proposing that showing respect and support for a trans child be considered an active intervention that necessitates engagement with clinical services, and by inference, clinical oversight. The process and timelines for gaining clinical permission to socially transition are unclear, but I can foresee children waiting years without clinical permission to socially transition, especially for younger trans children. Delays to social transition are harmful, shaming, and abusive, with a direct impact on trans children’s happiness and mental health. Delays to social transition are a form of conversion therapy. This approach will have particularly damaging implications for trans children in care, where care providers or foster carers may not feel able to support a child without clinical permission. It is also likely to increase delays and barriers to social transition in families who are lacking in trans-positivity, or where parents are divided in their supportiveness. My recent peer reviewed article on social transition synthesised all existing evidence on social transition, with a wide range of evidence of the benefits of social transition, and zero evidence on harm.

6. Potential restrictions for young adults

The Cass Review has already expanded into having a view on adult trans healthcare, proposing a Cass-style review of the evidence base supporting trans adult services. Given the major flaws and prejudices of the children’s Cass Review, any parallel endeavour in adult services is a very significant concern. The Cass Review talks in vague terms about changing the service for 18-25 year olds. This raises concern that this will lead to barriers to healthcare for young adults. It does not seem a coincidence that this vague recommendation aligns with the policy priorities of anti-trans actors who have long sought to restrict healthcare access for 18-25 year olds – indeed the Cass Review relies upon exactly the same flawed and misinterpreted studies on brain maturation that are used by anti-trans campaigners to advocate that trans adults are too young for mature decision making.

7. A ban on peer concordant puberty (with severe HRT restrictions even for 16 and 17 year olds)

Best practices worldwide for trans healthcare includes the option of trans adolescents taking HRT at the same time as their peers. There is growing evidence that peer concordant puberty is important for emotional well-being, physical health and educational attainment. For many trans youth, waiting until 16 to access HRT is too late, with implications for their mental and physical health.

The Cass Review recommends that even HRT at 16 and 17 be seen as an exception, with a majority denied any access to medical intervention until adulthood. The Cass recommendations to restrict HRT to 16 year olds also appear to make it harder for those who have accessed puberty blockers and HRT privately to transfer back into NHS services at 16, completely isolating trans under 18s who have gone private from returning to NHS healthcare. These approaches lead to significant inequalities between those who can access private healthcare and those who cannot, between those with or without the financial means to afford private healthcare until age 18.

8. Recommends CQC restrictions on private healthcare

The Cass Review recommends the Care Quality Commission intervene in private healthcare provision to ensure Cass recommendations are equally enforced in private healthcare. This ensures the Cass approaches, with their ban on puberty blocker access, their intrusive questioning, their ‘exploratory’ therapy, is the monopoly approach in the UK, preventing the development of any affirmative provision in private or non-GIC healthcare services. This is immediately a threat to any existing services who want to provide affirmative healthcare for trans 16 and 17 year olds outside of the Cass model. It also provides a more significant barrier to any future CQC registered private providers supporting trans under 16s. This guidance reinforces the monopoly of the Cass position.

9. Recommends Pharmaceutical Council intervention in overseas prescriptions

The Cass Review recommends the General Pharmaceutical Council takes action to prevent pharmacies from fulfilling gender affirmative prescriptions from overseas clinics. In a country where there are zero NHS or CQC registered healthcare providers prescribing for trans under 16s, action to prevent or deter pharmacies from fulfilling private prescriptions would close down the only current route to healthcare for trans under 16s. This would force desperate families into emigration or black market provision. Cass has no consideration of the NHS’s duty to adopt a harm reduction approach.

10. Problematisation of trans identities

The Cass Review has worsened pathologisation and problematisation of trans identities, legitimising those who seek discrimination under the banner of it being justified to ‘protect children’. The Cass endorsed problematisation of transness has implications for how trans children and trans communities are treated across our society.

The Cass Review reinforces a number of myths about likely parental, social, peer, abuse or porn related influences on a trans child’s identity. There is no acknowledgement that some children are trans and this is fine (or even to be celebrated). There is no recognition that being trans is a healthy part of human diversity. This message and the concerns around negative factors that can cause a trans identity in childhood can be devastating in sphere like family courts, social services, schools. It is likely to discourage parental support and provide legitimacy to abusive anti-trans families. These messages of a trans child being created through outside influence can be particularly harmful in custody battles between affirming and rejecting parents. There is no consideration of the need to protect and safeguard the well-being of trans children.

Fear, hope and resistance

Last night I couldn’t sleep.

Today I can hardly breathe.

The weight on my chest and heart and spirit feels too much to bear.

In the UK right now, as a trans person, as a parent of a trans little person:

  • I do not feel safe
  • I do not feel hope
  • We do not feel safe
  • We do not feel hope

How do we protect those we care about from a society where there is so much hate. So much prejudice. So much injustice. So much indifference.

How do we endure such overwhelming oppression?

I’m trying to help my child stay afloat in the face of injustice and persecution. I’m trying to keep us afloat. But it is rough. It has been rough for years and keeps getting rougher. I am tired of the struggle. We are all so tired.

  • I can’t withstand this on my own.
  • My child can’t withstand this on her own
  • We can’t withstand this on our own.

We need community. We need solidarity. We need resistance.

I feel particularly isolated and alienated (and gaslit) when I see supposed allies participating in our oppression. Seeing a prominent LGBT org ‘welcome’ the Cass Review felt like a stab in the heart. Over the past few years I continue to feel let down by UK civil society. The child rights or LGBT or trans rights organisations who look the other way, who do not stand with trans kids, who minimise current harms

As we face and endure state violence, it hurts to see parts of civil society complicit in such violence.

We need ‘allies’ to call out state violence and systemic oppression. Instead too many are afraid to challenge the Cass Review – too afraid to challenge the opinion of a medical doctor, even when the approach and findings are so clearly wrapped in prejudice. Instead staying quiet or siding with our oppressors.

It is not good enough.

We are all sinking.

So many trans folks I know are struggling right now. I’m struggling. So many trans kids I know are struggling.

We need to acknowledge state violence. That is a very low expectation of our supposed allies.

We need to acknowledge systemic oppression and persecution.

We need to be talking about strategies of resistance.

Trans communities, and especially trans children, need to resist state violence in the UK right now. Trans kids need to resist and endure the violence endorsed and recommended in the Cass Review, the violence in government policy, in media discourse, in school policy, in hostile and abusive homes.

Now is not the time for complicity in such oppression.

Now is the time for reaching out to trans people who are scared and without hope. I have a lot of relative privilege, and I am scared and low on hope today.

Now is the time for those of us with any privilege or power to stand up and be counted. Now is the time to pull together, acknowledging state violence and oppression, and focusing on strategies of resistance.

It is not easy to resist state violence. Especially for a child.

It is not easy to support a child to resist state violence, especially when isolated and threatened.

We all need hope. We all need community. We need genuine solidarity.

None of that can come from denial or minimisation of current harms.

We need to acknowledge that the UK is a seriously hostile location for trans people and especially trans children. We need to talk about resistance and survival.

We need to support each other. We especially need to support the trans children we know and love, to withstand the many current injustices, and those we see on the horizon looming down on us.

Solidarity. Justice. Resistance.

Sending love to all who are struggling. Sending love to all who will help. We need each other.

Cass Review Final Report – Media Briefing

The Cass Review final report is released tomorrow. I’ve seen the summary and it is as expected.

After a 4 year process the Cass Review final report is a deeply depressing outcome. I have repeatedly, over many years, called for paediatricians to take a role in trans children’s healthcare. In other countries paediatrician-led care has helped shift trans children’s healthcare from harmful and pathologising conversive practices endorsed by those who treat transness as a mental health disorder, into modern, child-centred, trans-positive healthcare. In this, Dr Cass has failed.

The Cass final report fails to take any meaningful steps to improve the lives of trans children. It fails to depathologise trans lives. It fails to centre trans children’s rights. It provides a veneer of credibility to policies, practices and systems that are backwards, pathologising, abusive, and deeply damaging to trans children and young people.

The Cass final report repeats the failings of earlier Cass publications. I have published a peer reviewed analysis and critique of all earlier Cass related reports in the leading journal on trans health (the International Journal of Transgender Health). This analysis highlighted four major concerns with the Cass approach and outputs.

The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children

These concerns relate to (1) prejudice; (2) cisnormative bias; (3) pathologisation; and (4) inconsistent standards of evidence.

Each of these concerns impacts the Cass Review’s approach to trans children’s healthcare, with negative repercussions for trans children’s healthcare rights and well-being.

Trans children face unbearable challenges at present in the UK. The scale of hurt, pain and trauma is hard to describe.

There is currently no accessible NHS healthcare for trans adolescents, in part due to the Cass Review. Newly proposed centres will not offer timely affirmative medical intervention, care that is recognised as essential and life-enhancing for many trans adolescents.

There is a real risk that professionals in new NHS centres will be emboldened to adopt pathologising conversion practices that cause immense harm. The Cass Review’s ‘caution’ on social transition will lead to more trans children enduring the harm, shame and trauma of delayed or denied transition, with significant consequences for trans children’s self-esteem and mental health. There is a growing body of global evidence on the benefits of social transition and no evidence of harm. Current guidance will deny many trans children the chance for a shame-free and joy-filled childhood.

Trans children face severe barriers to equality in education, with many experiencing trauma in UK schools.

Too many trans children face rejection and abuse at home, including from families who are mis-led into anti-trans practices by lobbying organisations who fundamentally reject the very existence of trans children.

Trans children face harm and injustice at every turn. The Cass Review’s final report does nothing to help trans children live happy, healthy, safe and confident childhoods.

I hope that those who actually care for trans children will take action today – calling out the dire situation for trans children in the UK and highlighting the failures of the Cass Review. I hope more people will stand up alongside trans children, resisting the most outrageous harms, and defending trans children’s rights.

Trans children have a right to safe, supported and happy childhoods.

Trans children’s experiences in primary healthcare in the UK

This is a pre-publication version of an article on trans children’s experiences with GPs in the UK.

Abstract

Background: Increasing numbers of trans children and parents are engaging with primary healthcare providers. There is limited research on the primary healthcare needs and experiences of this group.

Aim: This research aims to understand the primary healthcare experience of socially transitioned trans children and their families.

Design and Setting: Qualitative research with supportive families with trans children from England, Scotland and Wales.

Method: Interviews were conducted with 30 parents of trans children average age 11 (range 6-16) who socially transitioned at average age 7 (range 3-10. In-depth semi-structured interviews generated data on experiences in healthcare, in families and in education. This article analyses a subset of data on experiences in primary healthcare, applying reflexive thematic analysis within Nvivo.

Results: Findings showed a range of negative experiences with GPs, including dismissal and ignorance about trans children, encounters with prejudice, and approaches grounded in fear and a narrow view of risk, leading to refusal of care. Many families reported losing trust and confidence in health professionals, while others highlighted the positive impacts where GPs listened to families, were willing to learn, and provided empathetic trans-positive care.

Conclusion: Trans children and supportive parents’ negative experiences in primary care indicate a need for greater education, trans awareness and commitment to trans de-pathologisation in UK healthcare. GPs can play a critical role in encouraging and supportive parents to affirm and provide trans-positive care for trans children.

Keywords.

Transgender persons, primary health care, general practice, qualitative research, gender identity, health services, adolescent, child

How this fits in:

Trans children and their families are known to experience challenges within healthcare settings, though there is limited research into experiences specifically within primary healthcare. This study examines these challenges, highlighting experiences of dismissal, prejudice, or refusal of care, with parents losing confidence and trust in primary healthcare providers. The study highlights significant opportunities for progress and positive impact, emphasising how primary healthcare providers can support parents, in turn supporting trans children’s mental health and well-being. The study concludes with recommendations for primary healthcare providers to better meet the needs of trans children and their families.  

Introduction

Lesbian, gay, bisexual and transgender (LGBT) communities are known to be at risk of experiencing poor care, due to a lack of awareness or prejudice within healthcare (1). A national survey of over 14,000 trans and non-binary respondents over the age of 16 by the UK Government Equality Office reported 21% had experienced healthcare professionals ignoring their specific needs in the past year, and 18% stated they avoided seeking healthcare for fear of discrimination or intolerant reactions (2). Trans adults commonly report additional barriers to routine healthcare, experiencing systemic inequality in cisnormative services not designed for trans service users, encountering transphobia and discrimination, as well as experiencing ‘trans broken arm syndrome’ where all medical concerns are ascribed to being linked to trans specific medical care (3). Within primary healthcare, a survey using a convenience sample of 92 trans adults reported 60% experiencing discrimination from a general practitioner (GP), noting that trans patients felt unable to complain “because they did not expect to be taken seriously… and felt powerless” (4).

Poor experiences and negative expectations can be a deterrent to trans people accessing healthcare from providers including in primary care (3,5,6). Healthcare systems have made some efforts to ensure services are welcoming to all, with initiatives like the doctors’ licensing body, the General Medical Council (GMC) producing LGBT patient guidance on rights to equality and dignity in healthcare (7). This guidance explicitly confirms that doctors must not deny trans people access to treatment or services based on personal beliefs, and that doctors must not express personal beliefs in a way that is likely to cause a patient distress.

Trans people face a range of barriers in primary care, including experiences of bias and prejudice, insensitive care, and encounters with professionals who lack knowledge of trans healthcare or broader trans lives (8). The UK’s General Medical Council has authored guidance on supporting trans adults, although his guidance does not cover trans children and families (9). As with adult gender services, trans child and adolescent tertiary care services in the NHS have waiting lists of many years, with many trans people forced to rely on private healthcare services. For pre-pubescent trans children, gender affirmation comprises a social transition, with a child being socially accepted as their gender, commonly including a change in pronoun. At and after puberty, medical transition can include access to puberty blockers and sex hormones, although not all trans adolescents desire to pursue a medical transition.

Current literature on trans-inclusive primary healthcare focuses predominantly on the experiences of trans adults, or on the experiences and perspectives of healthcare professionals (3,10). Research with trans adolescents has emphasised the importance of creating a welcoming primary care environment for trans youth, with respect for affirmed name and pronoun (11). One study with parents of trans children has highlighted specific barriers to primary healthcare providers engaging in shared care for trans adolescent healthcare (12). Existing literature provides limited insight on the primary healthcare experiences of younger trans children or their parents, presenting a critical knowledge gap. Our study aims to explore the challenges and barriers to healthcare faced by trans children and their families, highlighting areas for improvement, alongside recommendations for policy and practice.

Method

In-depth interviews were conducted to explore the experiences of supportive families with trans children in England, Scotland and Wales. 30 parents of trans children, with parents accessed through six closed support groups for parents of trans children in the UK. Interviews were conducted remotely via Microsoft Teams during the period December 2020 to September 2021 (during periods of COVID-19 pandemic related restrictions). Access to hard-to-reach families and children was enabled by the author’s positionality as a non-binary parent of a trans child, helping overcome trust related barriers to hearing from this cohort.

Semi-structured interviews, covering broad topics including healthcare, education and families, lasted 1-3 hours (average 2 hours). This article examines a sub-set of the wider data corpus considering references to primary care. References to primary care came from responses to questions such as “Tell me about your experiences with healthcare professionals”, or following prompts used flexibly to elicit further responses, for example “What happened when you discussed your child with your GP?”.

Interviews were transcribed by the first author and coded in Nvivo, applying reflexive thematic analysis (13), adhering to the 20-point checklist for quality reflexive thematic analysis (14). The analysis combined indictive and deductive coding, with the major themes, experiences in primary care and confidence in primary care, mirroring interview questions on 1) what were your experiences in primary care? and 2) how have your experiences impacted you and your child? The analysis comprised re-reading each transcript to become familiar with the data and generation of initial codes, coding sub-themes diversely without pre-conceived coding categories. The initial sub-themes were then reviewed to ensure they were internally coherent, consistent, distinctive, and accurately captured the dataset. Each sub-theme was analysed, and interpreted, including with reference to existing literature. Indicative quotations from a range of interviewees were selected to accurately illustrate each sub-theme. The research built in ethical best practices for trans-related research (15).

Results

30 parents of trans children were interviewed, discussing experiences with 30 trans children (15 girls, 12 boys and 3 non-binary children) who socially transitioned at average age 7 (range 3-10 years old), and whose average age was 11 at the time of the interview (range 6-16 years old). All parental interviewees were cisgender, 27 were white, 28 were female and 7 were disabled.  

Challenging experiences with GPs

The first section of the results presents findings relating to challenging experiences with GP. Four sub-themes are presented, considering experiences of 1) dismissal 2) negativity 3) disrespect and 4) hostility to trans healthcare.

1. Dismissal of a trans child’s identity

A common theme in parental accounts was dismissal of their child’s identity, with GPs telling parents that their child would ‘grow out of’ being trans, that it was a passing phase. Some parents were told not to take their child’s identity seriously, to ‘give it six months’. For these families who had come to their GP for support and advice, dismissal left them feeling disregarded and not listened to, or as one parent described it ‘a bit fobbed off’.

‘Well, first of all, I went to see the GP who said, don’t worry about it, it’s nothing to worry about, give it six months, it’s no big deal kind of thing. So I felt a bit fobbed off’.

Several parents referenced their GP believing that their child was ‘too young’ to be trans, using age to dismiss their identity or to dismiss their parent’s request for advice.

‘Your GP generally is completely freaked out by this stuff, thinks your child is too young and doesn’t know what to do’.

Several parents were reassured by their GP that being trans would be temporary.

‘When she was about five, we went to the GP. And I had a GP who kind of patted my arm very reassuringly, and was like, “Don’t worry, they grow out of it”’.

Others were told that all children go through such as phase, dismissing their current identity. This parent was thankful that they didn’t listen to their GP and dismiss their child’s identity.

‘So the GP initially told us, don’t worry about it. Everyone goes through this, come back at the age of eight, if there’s a problem. This is, you know, and I went to them at age four. Thankfully, I didn’t listen to them’.

2. Negativity

A common theme in parental accounts was a perception that GPs held negative attitudes or biases towards trans children or towards parents supporting a trans child. Parents noted negativity through GP language or body language. One family noted their GP’s discomfort, interpreting this reaction as a sign of trans negativity or prejudice.

‘The first time we went to the GP to be referred. That’s when we really encountered some bigotry, straight up bigotry… She could not wait to get us out of her room. She was so uncomfortable, like visibly, visibly, uncomfortable, that I brought a child in with this thing…like, viscerally upset, that it was even a thing…she implied that my daughter had got the ideas from outside, not from herself’.

This parent’s GP suggested that something external had caused a child to assert a trans identity, a suggestion that other parents had also encountered. One parent was shocked that their GP insinuated their child being trans was likely a result of child abuse.

‘We had an appointment at the doctors, and [the Dr] basically blamed my husband said that he must have done something to her when she was younger. To make her want to be a girl rather than a boy’.

Several parents reported that they avoided discussing their child’s identity with their GP through fear of GP trans negativity or judgement.

I’ve never taken her to the GP about her gender ever. Purely because I felt like talking to a load of old white men about something that historically, they were probably going to judge me on was not going to be helpful. it’s probably a bad judgement to make, but I just didn’t feel comfortable doing it’.

Another parent who had brought their young trans child to an appointment to discuss their identity and ask for GP advice and support, shared her experience of GP trans negativity, and its impact on her child.

‘The doctor turned to me with [Child] in the room and said “If you told [him] to behave [himself], you wouldn’t be doing this”. I literally collapsed internally. I really did…And as we were leaving the doctor’s surgery, he (child) said, “Am I naughty? Am I naughty for being [Child’s affirmed name]?” And I had to say, “Don’t listen to that doctor”. I mean, how messed up is that to say to a 5-year-old? That’s like saying, when the lollipop lady tells you to cross the road? Ignore her. She doesn’t have a fucking clue what she’s talking about’.

The parent felt their child had been let down in this encounter, with potential negative impacts on their child’s self-confidence or trust in GPs. Several parents perceived that their GP’s approach was influenced by bias or negativity towards a child being trans.

3. Disrespect towards trans children

A majority of families referenced examples of feeling they or their child was disrespected during encounters with their GP. One parent described their GP responding to a request for support with derision.

“I did (go) to a doctor’s initially, and the doctor laughed me out of the office…the doctor basically said they couldn’t help me. And then I said about her gender dysphoria and stuff and she, almost – she smirked at me really. It was almost, she was trying to stifle a bit of a laugh. And so, I just, you know, I left and nothing else ever came of that’.

Several parents reported their GP being unwilling to respect their child’s identity, title or pronoun. For one family, their GP continued to use inappropriate pronouns in clinical appointments with their child.

‘The doctors have been very reticent to use the pronouns that we’ve put on the application forms’.

Another family encountered GP unwillingness to update administrative records, leading to their child being misgendered and outed publicly when attending an appointment.

‘So we went to the doctor, and they changed her name, but they still had Mr. At the front of it. And it was on this big TV. We’re surrounded by people’.

For other families, unwillingness to respect a child’s identity influenced their approach to wider identification, with the GP refusing to support an application to update their sex marker on their passport.

‘She had spoken to, like the people who assess risk, the lawyers, whoever they are, for the doctors. And the recommendation was not to write the letter to change the name on the passport. And her language, I found quite disturbing in terms of either ignorance, or anti trans but her response was, “I’m not – we’re not going to do that”’.

Several of these families felt themselves and their children were not treated with respect in primary healthcare.

4. Hostility to trans healthcare.

Parents perceived GP hostility to trans healthcare in a number of ways, through words, actions and refusals to support. One parent’s GP refused to sign a referral to NHS tertiary gender services, even when asked to do so by secondary care professionals.

‘So CAMHS (Child and Adolescent Mental Health Services) then referred back to the doctor and said, yeah, this child should be referred on to GIDS (Specialist Gender Service). The doctor still refused to sign the referral form’.

Another parent was aware of their GP’s hostility to trans healthcare, having been told that supporting a trans child was ‘against God’s will’.

‘(Current GP) refuses point blank to have anything to do with [Child’s] medical needs around (being trans). Who has phoned me up and told me that I’m going against God’s will- I should be ashamed of myself… And as such as a practice, they will not have anything to do with the prescribing of medication for this’.

In both these examples, GP attitude created a barrier to healthcare access. Parents described GPs having discomfort or hostility to families who accessed private healthcare. Several parents described their relationship with their GP deteriorating when they accessed private healthcare whilst on a multi-year wait list for NHS services. One GP initially agreed to support a trans adolescent with taking blood for hormone monitoring, but then withdrew the offer of support.

‘(When) we went with [Provider], you know, the private provider. She was a little bit less supportive. With us choosing to go down the private route. Initially said she’d do bloods and then withdrew it… I think when we went private, she then distanced herself from us a little bit. Cos she didn’t want to be seen to be supporting us going private’.

The parent felt the withdrawal of support was prompted by the GP wanting to avoid any association with private healthcare. A parent who felt private healthcare was critical for their adolescent shared their experience when asking for GP support in administering a private prescription.

I spoke to the GP hoping they might support us with a private injection from (Private Provider). My GP said I should think about because it might be seen as a child protection issue. I’ve just was so, so, upset when I came off the phone to her – cried, and I just – I had the day off work, couldn’t work. I was so upset. I just feel – you just feel like there’s all these barriers being put up and you’re kind of pushing them down, and then another one will come up. So it’s just been a nightmare’.

The parent described the significant impact the GP response had on them, feeling their GP was yet another barrier or threat to their child receiving critical healthcare. Parents noted that GPs were uncertain how to support trans adolescents seeking medical transition, with responses grounded in fear.

‘But it just felt like a fight in so many different places. You know, and especially at the doctors – like that surprised me. The lack of understanding, information, and the lack of like clear procedures and practices, you know, they just have no idea and they’re so afraid to do anything’.

Parents perceived that uncertainty or discomfort with trans adolescent healthcare left GPs ‘afraid to do anything’, with trans adolescents and supportive families left without GP support.

Negative impacts on parents and children

The second section of the results presents findings relating to the impacts of experiences with GPs on families. Three sub-themes are presented on 1) a loss of confidence 2) a search for trans-positive GPs and on 3) GP learning.

1. Loss of confidence in GPs

Loss of confidence in GPs was significant theme across many parental accounts. One parent summed up the impact of poor experiences in primary healthcare.

‘I’ve lost faith and I’ve lost trust in the health care system’.

Another parent spoke of exhaustion related to poor experiences with GPs, holding low expectations for future care.

I haven’t got the energy to defend myself against services that are not supposed to be there to degrade what you’re trying, when you’re trying to do the best for your child. I have not – I could not. Right now I could not fight’.

The parent chose to avoid any engagements with primary healthcare professionals, rather than risking further judgement or hostility. This distrust between parents seeking the best care for their child, and primary healthcare providers, risks driving children and families towards less safe methods of healthcare, and risks deterring families and children from engaging with routine non-trans healthcare needs. Several parents whose own experiences of hostility had contributed to anxiety and depression, had deterred, or avoided seeking their own mental health care from their GP, due to their apprehension of GPs.

‘I avoid GPs at all costs, if I can’.

Another parent described how negative experiences with a GP had put their child off wanting to see a GP under any circumstance.

‘It was an awful experience with both [Child] and I. And she didn’t want to go see a doctor at all after that’.

These accounts highlight significant ongoing impacts on supportive parents and trans children, with a loss of confidence in their GP.

2. A search for a trans-positive GP

Several parents spoke of their search for, or wish for, a trans-positive GP, someone who would support them and their child without displaying trans negativity or hostility. Parents spoke of how hard and stressful it is to search for a trans positive GP for a trans child.

You never know what their stance is on this particular topic because it’s quite contentious’.

The parent felt that GP stance or bias directly impacted on their capacity to provide trans positive care. Several spoke of their inability to complain about poor practice. Feeling their concerns would not be taken seriously, or even that complaints could put them in a more precarious position.

‘Because it’s our only GP surgery locally, I didn’t (complain). I was too scared to – to be honest with you. I was too scared to’.

Several spoke of wanting to find a trans positive GP, but not knowing how to locate one.

I want to, I really want to find a new doctor. But I don’t even know how to go about doing that…(how do I) find out if they’re trans friendly and trans friendly towards children?’.

3. GP learning to provide respectful care for trans children and families

A final sub-theme relates to GP learning, with parents sharing examples of GPs adapting and growing in their ability to provide respectful care for trans children and their families. For all our interviewees, their child was the first trans child their GP had encountered. Despite inexperience, several GPs demonstrated their ability to provide respectful care. One GP emphasised that they had never supported a young trans child but was able to build upon their experience with trans adults.

‘I was like, I don’t know if you’ve ever come across this before? And he was, no, I definitely have, this is just the youngest person I’ve ever come across this with…And he was very good’.

Another parent shared an example of a GP whose initial reaction was not respectful or well-informed, but who reflected upon their approach, and phoned the parent back to apologise.

‘He rang me back… the same GP and he said, after you left, I went online, I was online for about four and a half minutes, and I realised my approach was really wrong… Because he said, I have children. And because none of them have done this, I didn’t recognise this. I didn’t recognise this. And I pushed that on to you. So this is an apology.

This example demonstrates the importance of GP willingness to reflect and learn, especially when GPs are unfamiliar with trans children and their healthcare needs.

Discussion

Summary

Parents of trans children and trans children themselves have encountered a wide range of poor experiences with their GPs, characterised by scepticism, dismissiveness, and lack of knowledge of how best to care for trans children. In several cases GPs failed to treat trans children and families with respect, dignity, and empathy. In many cases families experienced refusal to provide both medical and non-medical aspects of healthcare. Several families experienced acute prejudice, and many felt unable to challenge poor practice. Negative experiences reduced parent and child confidence and trust in primary care providers, and risk deterring access to healthcare.

Strengths and limitations

This research provides qualitative insights into an under-researched group, examining the primary care experiences of parents who have supported and affirmed their trans children in pre-adolescence and is the first study to focus on this cohort. The research provides indirect insights into the experiences that trans children have with GPs, highlighting an area for further research. Importantly, the research does not illuminate the experiences with GPs of trans children or teenagers with unsupportive parents, nor does it consider the experiences of trans teenagers who come out at adolescence. The parental sample is diverse in several respects, though a large majority were cisgender white women, with scope for future research with individuals facing multiple axes of marginalisation, including children within the care system.

Healthcare bias

Existing literature has examined how healthcare professionals’ attitudes, prejudices, lack of knowledge, lack of training or lack of cultural competency can negatively affect their ability to effectively care for trans people (16–19). Studies have explored trans adults’ experiences in healthcare, with examples of trans adults encountering ignorance, prejudice or refusal of care (3,5,20). Experiences of discrimination or stigma in healthcare can lead to distrust and disengagement from healthcare services, contributing to wider health disparities in trans populations (6). This study contributes to the literature, examining trans children and their families’ encounters with ignorance, prejudice or hostility in primary healthcare, highlighting the negative impacts on their confidence in healthcare providers.

Minority Stress

Research has documented the challenges parents of trans children face when engaging with under-informed or prejudiced professionals (21–24). Parents and carers of trans children can be vulnerable to associative stigma and minority stress caused by interactions with institutions and individuals, including healthcare professionals, who respond to parents of trans children with ignorance or hostility (25,26). This study adds to the literature on parental minority stress, illuminating how negative experiences in primary healthcare contributes to parental stress, worry and distrust of healthcare professionals.

Safeguarding child mental health

Family affirmation is known to be critical to trans children’s mental health (27,28). Many parents of trans children initially struggle to understand and support their trans children, with research highlighting the importance of trans-positive information and affirmative support from professionals (29–31). This study highlights an opportunity for GPs to provide trans-positive reassurance to parents of trans children, playing a critical role in safeguarding trans children’s well-being and mental health.

Implications for research and/or practice
A trans-positive and well-informed GP can make a significant difference to trans children and family experiences in primary care. In the absence of UK guidance on support for trans children and families in primary care, healthcare professionals can look to international guidance, such as guidance for GPs contained in the ‘Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents’ (32). Fear of GP prejudice and ignorance can leave trans children and supportive families isolated and afraid, with distrust in primary healthcare providers risking negative impacts on current wellbeing, on social determinants of health and on future equality of healthcare outcomes. These findings reinforce the critical importance of GPs building knowledge and competence to work with trans children and their families. GPs need the confidence and trans-positivity to affirm, depathologise and de-problematise childhood gender diversity.

Poor primary care practice also misses a critical opportunity to educate unsupportive or uneducated parents of trans children. Trans children who are supported, respected and affirmed, especially by their families, are known to have good levels of mental health, whereas family rejection is strongly correlated with poor mental health, depression, self-harm and suicidal ideation (27,28). With family affirmation a key protective strategy to safeguard trans children’s mental health, GPs may need to reorient their interpretation of ‘risk’, prioritising the protection of trans children’s mental health and well-being.

Trans positive reassurance from primary health care providers like GPs is a critically important preventative mental health intervention that would be expected to deliver double mental health benefits. A supportive GP will reduce the minority stress burden on supportive parents of trans children, helping them to better care for their children. Trans positive advice from GPs to unsupportive or uneducated parents can help provide safe, nurturing family environments for trans children, facilitating trans children’s wellbeing and mental health.

Further research bringing together GPs, supportive families, trans children and trans adolescents can explore the barriers to affirmative primary care for trans children and their families. Such research can explore how to build GP confidence and competence; how to ensure safe and trans-positive access mainstream healthcare. Additional research can also explore how GPs can support access to affirmative trans healthcare for trans adolescents, drawing lessons from countries where trans adolescent healthcare is managed in primary or secondary, rather than tertiary healthcare.

Families reported the enormous difference made by having a GP who understood trans children’s healthcare, understood the failings in the NHS system for trans children, and who would put their child’s wellbeing as their top priority. Parents of trans children highlighted that they wanted to have GPs who are:

Trans-positive, with understanding that childhood gender diversity is not a problem or something to be pathologised (33), that trans children thrive with love and support.

Knowledgeable about research that emphasises the importance of family supportiveness, of respecting a child’s identity at any age, the importance of using a child’s pronoun, or having identification that matches their identity. Evidence shows that supported and socially affirmed trans children have good levels of mental health.

Aware of the prevalence of misinformation on trans children’s healthcare, the prevalence of transphobic attitudes or ignorance including from professionals, and the negative impacts of isolation, transphobia, hostility and minority stress. 

Child-Centred, applying the above knowledge to ensure primary care providers put a trans child’s wellbeing at the heart of their approach.

References

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22.       Galman SC. Parenting Far from the Tree: Supportive Parents of Young Transgender and Gender Nonconforming Children in the United States. In: Ashdown BK, Faherty AN, editors. Parents and Caregivers Across Cultures: Positive Development from Infancy Through Adulthood [Internet]. Cham: Springer International Publishing; 2020 [cited 2020 Apr 12]. p. 141–53. Available from: https://doi.org/10.1007/978-3-030-35590-6_10

23.       Katz-Wise SL, Galman SC, Friedman LE, Kidd KM. Parent/Caregiver Narratives of Challenges Related to Raising Transgender and/or Nonbinary Youth. J Fam Issues. 2021 Sep 20;0192513X211044484.

24.       Kuvalanka KA, Munroe C. Parenting of Trans Children. In: Goldberg A, Beemyn G, editors. The SAGE Encyclopedia of Trans Studies [Internet]. Thousand Oaks: SAGE Publications, Inc.; 2021. p. 597–601. Available from: http://sk.sagepub.com/reference/the-sage-encyclopedia-of-trans-studies

25.       Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Prof Psychol Res Pract. 2012;43(5):460–7.

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27.       Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics. 2016 Mar;137(3):e20153223.

28.       Russell ST, Pollitt AM, Li G, Grossman AH. Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. J Adolesc Health Off Publ Soc Adolesc Med. 2018;63(4):503–5.

29.       Kuvalanka KA, Weiner JL, Mahan D. Child, Family, and Community Transformations: Findings from Interviews with Mothers of Transgender Girls. J GLBT Fam Stud. 2014 Aug 8;10(4):354–79.

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31.       Pullen Sansfaçon A, Robichaud MJ, Dumais-Michaud AA. The Experience of Parents Who Support Their Children’s Gender Variance. J LGBT Youth. 2015 Jan 9;12:39–63.

32.       Telfer MM, Tollit MA, Pace CC, Pang KC. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. Melbourne: The Royal Children’s Hospital; 2018.

33.       Horton C. Depathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Child Soc. 2022;37(753–770). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/chso.12625

Ban on social transition is cruel and anti-science

In December 2023, the UK government released school’s guidance, proposing restrictions on social transition, including a complete ban on social transition at primary school.

The guidance is non-statutory, meaning schools do not need to follow it. Indeed, leaked civil service legal advice revealed that even government lawyers recognise the guidance as likely to be illegal, and likely to fail when it will be challenged in court. Any school considering following this guidance needs to know that their actions will likely be found unlawful when challenged in court.

Here I want to outline the reasons the guidance is not just cruel, but also anti-science. I will focus on one aspect of the guidance, the proposed restrictions on social transition, and the proposed ban on social transition at primary school. I am well-qualified to write on this topic, having focused my entire PhD on researching the experiences of trans children and families who socially transitioned at primary school in the UK, and being myself a parent of a trans child who similarly socially transitioned at primary school.

The guidance claims to be an effort to address ideology, but it is very clear that the guidance is entirely driven by anti-trans ideology, rather than by evidence, science, or indeed by listening to the experiences of those with lived experience of being or supporting a trans child.

Last week I published my 14th peer reviewed article on the topic of trans children. Within science and evidence based policy-making, peer review in credible journals is a vital part of assessing evidence, ensuring our decisions are based on the best available evidence. My latest peer reviewed article analyses and synthesises all existing studies on the topic of social transition. It examines them in detail, clarifying what evidence underpins their conclusion. Within all modern (post 2013) literature, evidence concludes that social transition is either beneficial, or neutral. The vast majority of studies conclude that social transition is beneficial for trans children. Just two studies conclude that social transition is neutral, neither beneficial nor harmful. My latest article examines one of those two studies, highlighting a wide range of limitations that undermine its stated conclusions.

The latest government guidance states that social transition is not neutral, raising the suggestion that it is either beneficial or harmful. If they looked to the evidence they can see that there is zero modern (post 2013) evidence that social transition is harmful, and multiple studies, of multiple types (qualitative, quantitative, retrospective), from multiple countries (UK, USA, Spain) demonstrating that social transition is beneficial, indeed critical for trans children’s well-being, self-esteem and happiness.

Claims that social transition is harmful are supported by the most pathetically flimsy of evidence, comprised of two main strands.

One flimsy strand of evidence used by opponents of social transition, looks to a 2011 published study of 2 Dutch girls, who changed their gender expression (wore trousers or cut their hair short) and then regretted changing their clothing and haircut due to the bullying that ensued. Neither child asked to be seen as a boy, neither child changed pronoun. There was no social transition in this study, nor is it clear that the children in question were even trans. I wrote about this back in 2017. The 2011 study on two girls who never socially transitioned was used by WPATH in their standards of care version 7 (published in 2013) to caution against social transition, guidance that has caused uncalculated harm across the world. (This poor science from 2011 also made it to version 8 of the standards of care).

You cannot tell me that 2023 social policy on social transition should be governed by a 13+ year old study of two children, neither of whom socially transitioned, or even asked to socially transition. The fact this same study is influencing gov guidance in 2023, ignoring all the continually growing body of modern evidence that social transition is vital and life-saving, is beyond belief.

The second flimsy strand of evidence used by opponents of social transition, argues that it is social transition itself that makes children remain trans. It argues that support for social transition somehow changes a child’s future trajectory, keeping children trans who would otherwise escape into a life of cis normality. The evidence for this claim of social transition ‘concretising’ identity is entirely speculative. Anti-trans voices look to the high degree of consistency in trans children in 2023, where a majority (but not all) of socially transitioned trans children continue to identify as trans into adolescence and adulthood. They compare this with studies from the 1950s-2000s, where children in gender clinics did not commonly identify as trans in adolescence. There is one humungous problem with this pet theory. Gender clinics in the 1950s-2000s did not focus on trans children at all. Instead they focused on boys who were deemed excessively and problematically feminine, boys who were referred to by research study leaders as ‘sissy’ or ‘proto-gay’. Clinics were not focused on trans children at all, instead they were focused on making feminine boys ‘man-up’, lest they become either gay or trans in the future. A scholar who experienced such gender clinics as a boy, who has written about the deep harm the experience had on him, is now a gay man. He wrote how conversion therapy at gender clinics left him feeling that there was something deeply wrong with him, that he was unacceptable for being gender non-conforming. These older abusive studies should in no way guide modern practice for two reasons. One, they did not focus on trans children. Indeed, one analysis from this cohort claimed, without no self-awareness, that they had deducted that a good way of distinguishing the children who would grow up to be a trans woman from those who would grow up to be a gay man was to actually ask them, whether they were a girl, with the majority i) not identifying as a girl and ii) not growing up to be a trans woman. Almost like researchers need to actually listen to those whose lives they seek to understand! The second reason to discount the findings from these earlier studies conducted from the 1950s onwards, is that there were deeply abusive and coercive sites of conversion therapy, a practice now recognised as abusive and harmful.

Literature conducted in the modern era in fact reveals the opposite conclusion to that speculated by anti-trans actors. A study by Olson et al concluded that social transition did not concretise identity, but was in fact a consequence of the children who felt most strongly and consistently being most likely to be supported to social transition.

All modern (post 2011) studies on social transition shows either neutral or positive impacts. The vast majority of studies show overwhelmingly positive impacts of social transition. The only two studies that show neutral impacts, were situated in gender clinics and have significant study limitations, including not bothering to actually ask the children in question for their views.

Positive benefits concluded by a majority of studies on the topic include reduced anxiety, reduced depression, increased self-worth, reduced suicidal ideation, reduced suicidal behaviour, improved mood, increased confidence, increased happiness.

Trans children have a right to their identity. They have a right to health, happiness, equality. They have a right to social transition. Denying a child’s social transition is oppressive, abusive and harmful.

For more detail, please do click on this article here:

The importance of child voice in trans health research: a critical review of research on social transition and well-being in trans children

Please see these articles on experiences of social transition:

“Euphoria”: Trans children and experiences of prepubertal social transition

“I never wanted her to feel shame”: parent reflections on supporting a transgender child

Read this research on the harms of denying social transition

“I Was Losing That Sense of Her Being Happy”—Trans Children and Delaying Social Transition

And these articles on trans children’s experiences at school:

Gender minority stress in education: Protecting trans children’s mental health in UK schools

Institutional cisnormativity and educational injustice: Trans children’s experiences in primary and early secondary education in the UK

Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools

Trans children have a right to a safe and happy childhood. Trans children have a right to social transition.

You can respond to the government’s abusive proposal here

Trans kids in 2023: Optimism and defiance

Caring about trans kids in 2023 continues to be heart-breaking. Worry and far too many tears.

Over the past 4 years, most ‘spare’ hours in my day (or more usually in the night) have been focused on my PhD: “Cis-supremacy: Experiences of trans children and families in the UK”. I chose to embark on a PhD in frustration at the bad science that informed policy and practice across the UK, frustration borne from failed attempts to advocate for trans children’s rights since 2015.

I have now submitted my PhD (phew), having already published 12 peer reviewed articles on the experiences of trans children and supportive families (research that has to date been ignored by UK media, NHS and policy makers…).

At this point of transition from PhD to what comes next, I’ve been taking stock on the last 7+ years of trying to advocate for trans children in the UK.

At first, my reflection was rather subdued. Since 2015, year upon year, across a host of different indicators of progress, the situation in the UK has got worse. Healthcare for trans kids has gone from abysmal to worse than abysmal. Media coverage has got worse. Discrimination appears harder to combat. Guidance for schools has got worse.

Having tried for so many years to help build a better world for trans kids than the one I saw in 2015, it has been beyond dispiriting to see everything year upon year seem worse. Year upon year it has been harder to make room for hope.

But

That is not the end of the story.

I was actively searching for the signs of optimism that I need to keep up the fight.

The thing I ended up on, our greatest strength, (and the reason why we will win) lies in supported and self-confident trans kids.

Since 2015, year upon year, more and more trans kids are being supported by their families. Amidst private forums, the numbers of affirming families continue to rise. Families whose kids know that they are respected, valued and cherished for who they are.

Year upon year I have seen families supporting trans kids at a younger age, families waiting shorter and shorter periods before affirming and embracing their trans kids, requiring trans kids to fight less hard for parental love. Year on year I have seen more families react with instant positivity, affirmation and love to a child sharing their identity. A noticeable shift from even 5 years ago when that was a rarity.

Year upon year I have seen majority discourse within family support groups shift from a focus on ‘loss’ or worry about a child’s identity to love and pride.

Year upon year I have seen more families stand up alongside their child at any age and argue for their equal rights.

Year upon year I see more trans kids who can speak up and claim their rights even in primary school (not that I think trans kids should carry this burden…)

Year upon year I see more families and kids demand genuine equality and respect from their wider families, schools and communities, not settling for tolerance or segregated accommodations.

I see within communities of trans kids the difference that this trans positivity makes. I meet trans kids who have been supported, who have grown up expecting to be treated as genuine equals to their cis peers. Trans kids surrounded by love and support can grow up without the heavy blanket of shame that so many older folks carry through our lives (see toxic shame).

When I look back over the past years of advocacy, the issue that gives me most pride is every family who I have in some small way supported to gain the knowledge and confidence to support and advocate for their trans kid. Every single supported trans kid makes a difference.

Those supported trans kids go out into the world a bit stronger, a bit less kicked down by this trans-hostile world. Many such trans kids and trans positive families end up providing a safe space for trans kids without affirming families. Many trans kids (whether supported at home or not) end up supporting a whole network of trans youth, providing peer advice, validation and mutual aid.

Every trans kid makes the world a better place.

This is why transphobes are so afraid of social transition.

Because trans kids who are supported young are less likely to grow up overwhelmed by shame or self-hatred.

Trans kids with self-respect will fiercely demand their rights. And they will fight even harder for the rights of their friends.

Trans kids are no longer isolated and alone.

Some trans kids stand on many strong pillars of support and trans-positivity. Some trans kids wobble on only a few. Every bit of support and trans-positivity matters.

Transphobes, including in the NHS, are trying to formally discourage social transition. To deny trans kids support. To deny them connection. To instil in them shame.

But, in the internet age, that boat has already sailed. Trans kids can’t be kept in the dark any longer. Their route to self-knowledge and self-actualisation cannot be controlled by the NHS, the media, transphobic parents or transphobic politicians.

Families of trans kids are now able to connect to each other. Amongst private parent support groups the case for social transition is recognised fact. Family after family after family report what is glaringly obvious to any trans person. Trans kids need love and support, and with love and support they can thrive.

So yes, the UK context is dire. It is dire in a way that continues to cause immense harm to trans people, especially trans children.

But, the fight does not primarily lie in legislation or in policy or in the NHS. Those fights are vitally important and will continue.

But even while those fights are slow, demoralising, unjust and depressing as hell, the real victory is coming from every single trans kid who grows up without being overwhelmed by shame. From every trans kid who grows up expecting equality. From every trans kid who believes there is space for them in this world.

That is where the real battle lies. And that is where we will win.

Because trans kids are easy to love. They are easy to respect.

Trans kids who have love and respect will claim their place. Trans kids can and do have childhoods filled with excitement and joy.

Trans kids change the world, family by family, school by school, community by community.

Happy trans kids change the world. Pissed off and angry at all the bullshit trans kids change the world.

Every single time you show love and support for a trans kid (or for a family struggling to stick up for a trans kid) you are shifting our world towards a better place. Towards a kinder place.

So, for everyone beaten down by cis-supremacy and transphobia – think how many individual lives you have touched in some way with trans-positivity. That matters.

For every family who is struggling to keep their trans kid happy and safe – know that being affirmed and celebrated in childhood is setting your kid up for the future, and that is a huge part of this fight.

It is so easy to be overwhelmed by fear and stress.

It is so easy to see no light at the end of the tunnel.

Focus on the trans kids in our world. They probably don’t even want to go through that tunnel anyway. Follow their lead (with swords at the ready).

Keep up the fight.

Diagnostic Overshadowing

In this short blog I want to draw our attention to the term ‘diagnostic overshadowing’ and its use by anti-trans actors to mask attempts at conversion practices.

Diagnostic overshadowing is a medical term used to describe the situation where one medical condition or diagnosis ‘overshadows’ another one, leading to mis-diagnosis.

Trans communities will recognise the concept in the well documented ‘trans broken arm syndrome’. Transphobic or inexperienced medical practitioners can go into panic when treating a trans person, and mistakenly attribute completely unrelated medical issues to a person being trans or taking gender affirming hormones.

Trans patient: Look, my arm is clearly broken in several places, I need a plaster cast.

Emergency care Dr: Oh, you are trans! Are you on HRT? I don’t know how to treat you, we’d better send you to the psychologist.

In trans communities this type of ‘diagnostic overshadowing’ is recognised as a problem that we want and need medical providers to acknowledge and avoid. Trans people should not receive poorer medical care from professionals who presume their transitude is at the root of unrelated health conditions.

In these cases, diagnostic overshadowing is a problem, and something to be avoided.

HOWEVER,

Transphobes like to use the term diagnostic overshadowing in a different way, one that we need to be aware of and protect against.

Transphobes do not recognise self-identification as trans. They focus on transness as a diagnosis or medical condition, with an emphasis on people suffering from the condition of ‘gender dysphoria’. Rather than considering a trans person ‘being trans’ with affirmative healthcare are a route to self-actualisation and gender euphoria, they focus on a person ‘suffering from gender dysphoria’ with affirmation one of many potential ‘treatments’ for that distress.

 Transphobes then use the term diagnostic overshadowing in a manipulative way that masks their true intentions.

For a transphobe, a trans child or teen is likely to have ‘mis-diagnosed’ themself as suffering from gender dysphoria. They are likely to ‘misattribute’ their anxiety, depression or suicidal ideation as being wrapped up in their mis-diagnosis. They are likely to argue that gatekeepers should ‘protect’ trans youth from mis-diagnosing their depression or anxiety as being linked to dysphoria or to being trans in a transphobic world. Transphobes argue that the first step in any service is to look for other causes and other ‘treatments’ for anxiety or depression before enabling affirmation. They argue that an affirmative approach (where clinicians accept a child’s identity) is going to result in ‘diagnostic overshadowing’ of other past traumas or mental health issues. Transphobes do not accept that being trans is a healthy part of human diversity, and do not recognise the mental health burden of being trans in a transphobic world. Importantly, their transphobic approaches to ‘treating’ gender dysphoria by denial of affirmation are already proven to be harmful, unethical and ineffective.

Transphobes then wield the term ‘diagnostic overshadowing’ to criticise affirmative healthcare. They say that any healthcare professional who accepts a child or teenager’s ‘self-diagnosis’ of transitude or dysphoria or transphobia as at the root of their mental health problems, is practicing ‘diagnostic overshadowing’ – allowing a self-diagnosis of gender dysphoria to explain other mental health issues (that, transphobes claim, are instead driving their gender confusion). Transphobes argue that to avoid ‘diagnostic overshadowing’ health professionals and teachers and parents need to take a ‘critical’ approach to a youth’s self-understanding. Clinicians need to look for ‘causes’ and ‘treatments’ for all areas of trauma, neurodiversity, depression, anxiety etc BEFORE enabling affirmation.

Florence Ashley’s scholarship is relevant here see (here, here and here)

The Danger

Diagnostic overshadowing is already recognised as a ‘bad practice’ in healthcare. Something that we all want to avoid.

So, when transphobes say ‘we want to avoid diagnostic overshadowing’ this can easily be interpreted as something benign, as something positive.

BUT they are manipulating the term, to enable conversive practices. To enable harm to trans youth.

I am therefore extremely concerned to see the term used multiple times by Cass, including in her recent response to the draft NHS service specification.

I am extremely concerned at a lack of community push back to Cass’ use of this term – I have spoken to folks who didn’t really understand the term and simply assumed it was something benign, which is why I wanted to publish this blog.

I do think ‘diagnostic overshadowing’ is a genuine problem in trans healthcare. But in a transphobic NHS it is primarily a problem leading to denial of trans healthcare. Youth who are neurodiverse, disabled or mentally ill routinely experience ‘diagnostic overshadowing’ with clinicians focusing on their co-existing differences as a potential driver of their gender distress, with neurodiverse, disabled or mentally ill trans youth denied affirmative healthcare.

 Cass is not tackling this type of ‘diagnostic overshadowing’. Instead, she is presuming that the NHS at present is allowing self-identification as trans to ‘overshadow’ other mental health problems or allowing mis-diagnosis as trans to get in the way of more pressing need to ‘treat’ anxiety or depression (without gender affirmation).

This interpretation is baked into the proposed service specification.

A service that was trying to ensure neurodiverse, mentally ill, disabled or traumatised trans youth have equitable access to trans healthcare would be designed with steps to ensure those youth have equitable access without their diversity counting against them. The new service spec does the opposite.

The new service spec instead looks for ‘solutions’ and ‘treatments’ outside of affirmation and affirmative healthcare.

This way conversion therapy lies.

Cass is enabling this without clearly saying so, using the term ‘diagnostic overshadowing’ to justify a marked shift to a conversion therapy adjacent model.

Cass is dangerous because she is enabling conversion practices by saying ‘we need to avoid diagnostic overshadowing’. This unclear term leads most people to just nodding in agreement, assuming the NHS knows best, always underestimating the power of institutional transphobia and trans-pathologisation.

When folks caution about the rise of fascism they remind us that fascism doesn’t (always) come with Heil Hitler salutes and swasticas, it comes with calls to protect family, nation, tradition.

We need to similarly recognise that a return to conversion therapy doesn’t come with a banner saying ‘Conversion here’. It comes wrapped in ‘gender exploratory therapy’ and a call to avoid ‘diagnostic overshadowing’.

I’m deeply concerned for trans children and teens under the NHS

I’m sick of folks (and organisations) giving Cass the benefit of the doubt just because she avoids inflammatory rhetoric.

Trans kids deserve better – they have a right to evidence-based affirmative healthcare. They have a right to safety from harmful conversive practices.

Mermaids – Time for Trans Accountability

Susie Green has been at the helm of Mermaids for more than 7 years, taking Mermaids from a tiny unknown, unregistered cis parent support group (with varied levels of trans positivity) to a substantial, internationally recognised, multiple award winning, formalised charity, with many trans staff members, a multi-million pound budget, and high commitment to the rights and well-being of trans children. I have an enormous amount of respect for Susie and how she has fought for trans kids against pressures and challenges that would have broken many other people.

Today it was announced that Susie is no longer in post, with a short statement from Mermaids reporting that an interim CEO will shortly be appointed.

Mermaids has been of vital importance to my family – to many, many trans kids and families. Mermaids remains an important stakeholder in supporting trans children and their carers, in advocating for trans kids’ rights to healthcare, to education, to safety, equality, and well-being.

At this moment in time, strong, trans-positive leadership from Mermaids is critically important.

The threats to trans children in 2022 are more worrying than ever. There are threats to trans kids’ rights at school, threats to access to healthcare, even threats to trans kids’ ability to socially transition and be safe from the harms of conversion practices.

We cannot afford to have weak or conservative cis leadership at Mermaids. We need a Director in post who understands the severity of the threats to trans children of all ages – a person who will stand up and be counted. We need a strong and trans positive leader of Mermaids, now more than ever.

I publicly call on the Mermaids board to take the opportunity at this exact moment in time to strengthen accountability to trans communities.

I call on the Mermaids board to appoint a Trans Advisory Panel to oversee the recruitment of the new Mermaids CEO.

One option for forming this Trans Advisory Panel, would be to seek guidance from existing trans led governance forums, specifically, the Good Law Project and the Trans Learning Partnership, both of which have effective Trans Advisory Panels and might take a role in establishing Mermaids’ own Trans Advisory Panel.

Mermaids needs to retain trust and confidence from both the trans community and the community of parents and carers of trans children, through this period of change. Taking this opportunity to improve accountability to trans communities would be a powerful signal that service users can maintain confidence in the future direction of Mermaids as a world leading trans support and advocacy organisation.

Please join me in this call for the Mermaids board to strengthen accountability and oversight to trans communities before appointing a new CEO.

NHS service specification: A dangerous attack on trans kids

NHS England has just released a consultation on a revised Service Specification for trans children and adolescent health care.

The revised specification is dangerous, ideologically-driven, and will cause serious harm to trans kids in the UK.

There are many many deficiencies and areas of outrage in the draft.

It has been written with dangerous bad intent (I wonder who in NHS England wrote it).

We need collective action to fight for trans kids’ rights, so I’m putting my work-in-progress analysis here for others to build from.

I have divided my feedback into 27 categories:

1. Inclusion of outdated and ill-informed presumptions on trans children’s identities.

2. Omission of modern & relevant evidence on trans children’s identities

3. Inclusion of outdated, mis-placed & mis-interpreted evidence on social transition

4. Omission of modern & relevant evidence on social transition

5. Cisnormative, pathologising, unevidenced approach to social transition being an ‘intervention’

6. Omission of harms of denied transition

7. Fails to condemn conversion practices

8. Pathologising & incompatible with ICD-11

9. Intrusive and inappropriate assessment

10. Redefining EA2010 protections to remove & medicalise rights for trans children

11. Misapplication of ‘safeguarding’ to threaten access to life-saving healthcare

12. Ignorant of flaws in dysphoria definitions

13. Ignorant of potential for harm in adding extra GP layer into referral

14. Ignorant of harms of denial of healthcare

15. No centring of child rights to healthcare

16. No centring of healthcare accountability or mechanisms to empower service users

17. Presentation of psychoeducation as treatment for dysphoria

18. No emphasis on psycho education to raise trans positivity

19.  No centring disability & neurodiversity rights

20. Failure to recognise gender minority stress as key driver of mental health differentials

21. Suggests intrusive search for causation

22. Leaves space for gender exploratory therapy

23. Uses dated and unscientific language for ideological purposes to illegitimise and disenfranchise

24. Emphasis on MDT

25. Failure to centre endocrine care pathways

26. Failure to engage with trans expertise

27. Under-planning for expected population

  1. Inclusion of outdated and ill-informed presumptions on trans children’s identities.

[Service spec page 1] “clinical support around the development of their gender identity”.

Framing support for trans children around ‘development’ of their gender identity is ill-informed, prejudiced against trans people, and unrepresentative of the modern evidence base (see point 2 below)

[Service spec page 2] “being mindful that this may be a transient phase, particularly for pre-pubertal children”.

This statement is unreferenced, and does not align with modern evidence (see point 2). Documents that do provide a citation for such a claim tend to rely on a number of very old citations that used old diagnoses that included children who were gender non-conforming rather than trans. A majority of these children did not end up trans because they were not trans in the first place. Using older research to claim that trans children’s identity is likely to be a transient phase is harmful bad science, at best a misunderstanding of the meaning of the older evidence base, at worst the knowing mis-representation of older evidence for ideological goals.  

[service spec page 8] “research will include” “prediction” “the course of gender querying”

The service’s research goals are aligned with cis people’s fears, not with trans children and adolescent’s needs.

[service spec page 8] “an individual’s route will be determined by…. The clarity, persistence and consistency of gender incongruence”.

This requirement discriminates against trans children who assert their identity at puberty, those who were not distressed in early childhood, those whose families do not recognise the period of their distress, those who need healthcare without being currently distressed, and those who hid their identity out of fears of rejection or societal judgement. It also fails to consider the timeliness of healthcare needs especially for those experiencing an significant increase in distress at the point of puberty, and the fact that interventions such as puberty blockers are particularly valuable for those adolescents who arrive at the service at the cusp of puberty with fear and distress requiring immediate access to puberty blocking support.

[service spec page 12] “assessments will focus on the child’s understanding of gender”

Trans children do not need to have a theoretical or conceptual understanding of gender and should not be expected to demonstrate to clinicians an understanding of gender. Existing research shows that children experience intrusive questioning on gender irrelevant, intrusive and harmful.

[service spec page 13] “psycho-education material for children, parents… will include information on gender identity development including research evidence and how to support an exploratory approach”.

Given how poorly this service spec reflects existing evidence, I would be extremely concerned about the materials provided to parents. Misguided and misinformed information sent to parents will cause harm and undermine support for trans children.

[service spec page 13] “the clinical approach in regard to pre-pubertal children will reflect evidence that suggests that… in most pre-pubertal children, gender incongruence does not persist into adolescence”.

The above cites the Endocrine Society statement “combining all outcome studies to date, gender incongruence of a minority of prepubertal children appears to persist in adolescence”.

It is important to note that the Endocrine guidelines themselves provide a longer quote on this topic

“However, the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/ gender incongruent in adolescence (Source: Steensma TD, Kreukels BP, de Vries AL, Cohen-Kettenis PT. Gender identity development in adolescence. Horm Behav. 2013; 64(2):288–297.

Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). In adolescence, a significant number of these desisters identify as homosexual or bisexual. It may be that children who only showed some gender nonconforming characteristics have been included in the follow-up studies, because the DSM-IV text revision criteria for a diagnosis were rather broad. However, the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood (41, 42). With the newer, stricter criteria of the DSM-5 (Table 2), persistence rates may well be different in future studies.”

The NHS has here chosen to omit the important clarification within the Endocrine guidelines, that highlights that even back in 2017 it was recognised that the ‘desistance’ statistics rely on old definitions that focused on gender non-conforming children rather than trans children, and that newer studies focused specifically on trans children expect to find a different outcome.

The citation about collective studies showing high rates of desistance from the 2017 Endocrine society cites a 2013 study by Steensma, which in turn cites a 2011 literature review again by Steensma.

Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology and Psychiatry. 2011;16(4):499-516. doi:10.1177/1359104510378303

In this 2011 literature review, statistics are drawn from studies published in 1968, 1972, 1979, 1984, 1986, 1987, 1987, 1995, 2008, 2008. The vast majority were published last millennium, drawn from research conducted even earlier, research that focused on gender non-conforming children who were problematised lest they grow up to be gay. Several of those studies were outright conversion therapy studies for gender non-conforming children, with methods that were coercive and abusive.

Ten studies are included in the 2011 literature review and these are the ten studies upon which the NHS is basing 2022 clinical practice. Take a look at the titles of these ten studies:  

Bakwin H. (1968). Deviant gender-role behavior in children: Relation to homosexuality. Pediatrics, 41, 620–629.

Davenport C. W. (1986). A follow-up study of 10 feminine boys. Archives of Sexual Behavior, 15, 511–517.

Drummond K. D., Bradley S. J., Peterson-Badali M., Zucker K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental Psychology, 44, 34–45.

Green R. (1987). The “Sissy Boy Syndrome” and the development of homosexuality. New Haven, CT: Yale University Press.

Kosky R. J. (1987). Gender-disordered children: Does inpatient treatment help? Medical Journal of Australia, 146, 565–569.

Lebovitz P. S. (1972). Feminine behavior in boys: Aspects of its outcome. American Journal of Psychiatry, 128, 1283–1289.

Money J., Russo A. J. (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.

Wallien M. S. C., Cohen-Kettenis P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.

Zucker K. J., Bradley S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press.

Zuger B. (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.

Even from the project titles you can see these early research projects had a problem with femininity, ‘sissy-ness; ‘effeminancy’ or ‘proto-homosexuality’ in boys. These were not research projects on trans kids, but on kids who were deemed insufficiently masculine, many with explicit goals of teaching young boys to toughen up to prevent them becoming a ‘homosexual deviant’. The fact that many of these young boys grew up to be gay men rather than trans women tells us nothing about outcomes for today’s trans kids.

The authors of the above studies are also synonymous with key figures in conversion practices, especially conversion practices to try to prevent homosexual outcomes. Bryant, the child who in the 1970s was at the centre of the ‘sissy boy’ research project (Green, 1987, included above) went on to in the 2000s write his PhD on the damage of this research, how he felt rejected and coerced and was deeply harmed (see Bryant, 2005).

These abusive studies predominantly on boys who were deemed insufficiently masculine are entirely meaningless in driving clinical practice for trans kids in 2022. Why are they guiding clinical practice on trans kids and social transition in 2022? And why does the NHS cite them via a citation in a 2017 Endocrine Society endocrine guidance note that cites a 2011 literature review that cites the above texts, rather than actually owning up to based clinical practice on 50 year old conversion therapy literature?

I’ve been writing about this for over 5 years see https://growinguptransgender.com/2017/03/04/a-plea-for-better-transgender-research-on-the-perpetual-myth-of-desistance-and-the-harm-of-social-transitioning/

In the time since the publication of the Endocrine guidelines in 2017, the validity of the claim that trans children ‘desist’ in their identities has been strongly critiqued in the literature.

Even focusing just on the more recent of those studies, those published in 2008, gives serious cause for concern, with those studies widely condemned as both flawed and misinterpreted (Ehrensaft et al., 2018; Priest, 2019; Temple Newhook et al., 2018a, 2018b), critiqued for “methodological, theoretical, ethical, and interpretive concerns” (Temple Newhook et al., 2018a, p. 1). 

These older statistics on ‘desistance’ are also challenged by more modern research, with recent longitudinal studies from Australia (Tollit et al., 2021), USA (Olson et al., 2022) and Spain (De Castro et al., 2022) showing a large majority of trans and non-binary children and adolescents continuing to identify as trans or non-binary (96% across child and adolescent age groups in Australia over a ten-year period, 97.5% of children under 12 at 5 year follow up in the USA, and 97.6% of children and adolescents at 2.6 year follow up in Spain). 

[service spec page 13] “the approach will focus on careful observation of how gender dysphoria develops as puberty approaches and is reached”.

This statement that gender dysphoria needs to be observed (and the inference it is likely to change or desist) as puberty approaches is not evidenced.

Within older literature there is one study that mirror this language, which is now considered discredited as a source on this topic.

Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011;16(4):499–516.

This older 2011 paper has in the past been cited to suggest puberty is diagnostically important for determining which children will persist in their identity. This study in fact does not demonstrate this, it instead demonstrates the following:

Social divisions: 25 people aged 14-18 reminisced about their experiences at the age of about 10, a time when social divisions between boys and girls increases in the Netherlands. 14 children who were still registered with the gender identity service in adolescence recall at that time of increased social division having wanted to be grouped with the children of the opposite gender to their assigned gender and wanting to socially transition. 11 children who had left the service before the age of 12, recall having wanted to be grouped with their assigned at birth gender and having not wished to socially transition.

View of puberty: 11 children who were in the service in childhood but left the service before the age of 12 and did not apply for puberty blockers, remember not having been distressed by the idea or the reality of pubertal changes. 14 children who were still in the service in adolescence and who applied for blockers remember being distressed at pubertal changes.

Sexual attraction: In a sample of 25 people registered at the gender clinic in childhood, when interviewed in adolesence, 14 transgender people were heterosexual, 5 cisgender girls were heterosexual and 6 cisgender boys had a variety of sexual orientations.

None of the above is evidence that puberty is diagnostically important for distinguishing between children who will or who will not need medical intervention at puberty. The study mis-cites the conclusions that can be drawn from the evidence at hand, and these mis-citations cannot still be influencing policy over a decade later when they have been called out time and again as flawed and mis-used.

[service spec page 13] “family/social circumstances that may impact on a child’s gender dysphoria”

There is no evidence that family circumstances impact on gender dysphoria, whereas there is significant evidence that family rejection impacts on poor mental health in trans children who are not affirmed.

  • 2. Omission of modern & relevant evidence on trans children’s identities.

Research by Olson (2015) and Fast (2017) shows that:

“Transgender children do indeed exist and their identity is a deeply held one.”

“Three- to 5-year-old socially transitioned transgender children did not differ from controls or siblings on gender preference, behaviour, and belief measures.”

“Transgender children aged 5-12 viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender control groups.”

“These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.”

(research) “findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.”

Olson, K.; Key, A.; Eaton, N. (2015) Gender Cognition in Transgender Children Psychological Science

Fast, A & Olson, K. (2017) Gender Development in Transgender Preschool Children, Child Development

Research has shown that trans children’s may hide their identity for months or years before disclosing it to family, and hence a ‘sudden’ assertion to a parent or outsider may commonly have been long thought about by a child.

  • 3. Inclusion of outdated, mis-placed & mis-interpreted evidence on social transition

[service spec page 10] “in some cases a further consultation may be appropriate following further local assessment and intervention and or a process of watchful waiting”.

[service spec page 13] “support an exploratory approach that allows a child time and opportunity to consider different options in a flexible and non-judgemental context”.

[service spec page 14] “the clinical approach has to be mindful of the risks of an inappropriate gender transition and the difficulties that the child may experience in returning to the original gender role upon entering puberty if the gender incongruence does not persist into adolescence”

This reference to ‘difficulty returning to original gender role’ relies on one single (uncited) source which can be traced back to a letter to the editor from 2011 ((Steensma & Cohen-Kettenis, 2011) referencing the case of two Dutch children. A closer analysis reveals that neither of the two children referenced in that letter, in fact none of the children in that study, had experienced social transition according to today’s definition (Ashley, 2019a). They had non-conforming gender expression, but did not change pronoun or name, and they remained referred to as their gender assigned at birth (Steensma et al., 2011). The usage of this case, involving a small number of children who did not socially transition, to justify restrictions on supporting trans children, can be considered inappropriate, and ethically flawed (Ashley, 2019a).

Critiques of the shoddy evidence base on supposed harms of social transition are now well established and its continued use to caution against social transition is unacceptable in 2022.

This part of the NHS specification contrasts strongly with the 2017 Australian standards of care which state “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”.

[service spec page 14] “for pre-pubertal children the clinical approach… will be a watchful approach overall….with a more individualised approach where the child’s level of global functioning may be maintained or improved through a carefully observed process of exploration of social transition”

[service spec page 15] “not all adolescents will want or benefit from social transition”

This sentence conflates two very different concepts.

The part on adolescents not benefitting from social transition is completely unevidenced. It also fails to consider the harms of attempting to prevent an adolescent from social transition and the control and coercion associated with such denial of self-actualisation.

‘Watchful waiting’ as a clinical approach is not supported by evidence, and is better framed as ‘delayed transition’. Significant critique is available of the harms of preventing or delaying transition (as explored further below).

[Service spec page 15] “approaches to support social transition may be considered in cases where 1) gender dysphoria is diagnosed, consistent and persistent”

Gender dysphoria does not need to be diagnosed for a social transition. Nor does it need to be consistent or persistent. This is not evidence based.

[Service spec page 15} “AND the young person…fully understands the implications of affirming a social transition (informed consent)”

A young person, particularly a young child, should not be expected to understand or predict the implications of a social transition before being affirmed in their identity. A social transition is not a medical intervention or a medical decision and inclusion of informed consent is not appropriate here. Denying a child or adolescent’s identity is a far bigger intervention and interference, than supporting a child’s identity. This is wrong and harmful. It also fails to recognise that ‘understanding implications’ is likely to focus on the risks of being trans in a transphobic world, and is likely to scare a child into trying to conform to their assigned identity. It is inherently a conversion practice.

[service spec page 15] “AND the clinical approach is necessary for the alleviation of clinically significant distress”

Whilst social transition can certainly ameliorate clinically significant distress, trans children should not experience, or demonstrate the potential of experiencing, clinically significant distress before being supporting in their identity. There also needs to be consideration of trans joy – of maintaining the potential for trans children and adolescents to have a happy childhood. Protection of trans joy, or trans normal levels of well-being are as important as preventing clinically significant distress.

[Service spec page 15] the clinical approach will involve a focus on exploring or supporting social transition through psychological support, family work/therapy…”

This fails to recognise that supported trans children living in supportive trans positive environments do not need psychological or family therapy. This needs to be stated explicitly here.

[service spec page 15] “Young people and their families will be supported in making difficult decisions regarding the expression of a gender role that is consistent with their gender identity”

This fails to consider the harms where a child suppresses their gender expression or identity. It fails to focus on the reason why it may be difficult, which is inherently life in a world where trans identities are problematised or where prejudice exists. This needs to emphasise that in this situation the difficult decision centres around building safe environments for that child to thrive in, rather than considering options where a child’s is compelled to suppress their identity.

This whole section also very much suggests a social transition is a one time event (or a mistake) rather than a step that can be taken several times, that can be itself part of exploration and self-discovery, that can be a light-hearted journey rather than a heavy and weighty diagnosis and medicalised intervention.

[service spec page 16] “Decisions about gender expression are thoughtfully considered…(even) if a young person has changed gender role prior to being seen by the service”

Why is a medicalised gender service getting involved in children’s gender expression. It does not need to be thoughtfully considered in clinical practice.

  • 4. Omission of modern & relevant evidence on social transition

Affirmative approaches advise supporting a child in their identity, prioritizing current well-being without age based barriers on acceptance (Ehrensaft et al., 2018; Temple Newhook et al., 2018b). This approach views family acceptance as critical for child self-esteem and mental health, for those children whose identity will remain constant into adulthood, as well as for those who may have a more fluid identity, including those who may go through two or more ‘social transitions’ (Ehrensaft, 2021; Keo-Meier & Ehrensaft, 2018b; Temple Newhook et al., 2018a).

A growing body of evidence supports affirmative approaches that include support for pre-pubertal social transition (Durwood et al., 2021; Olson & Gülgöz, 2018; Rae et al., 2019). Research on socially transitioned trans children has shown positive mental health and well-being outcomes, in contrast to high levels of depression, self-harm and suicidal ideation in those denied affirmation (Durwood et al., 20172021; Olson et al., 2016; Olson & Gülgöz, 2018). Research highlights the importance of family support in trans well-being, with contrasting research demonstrating the links between family rejection and suicidality, PTSD and depression (Katz-Wise et al., 2018; Klein & Golub, 2016; Pollitt et al., 2021; Russell et al., 2018; Simons et al., 2013; R. Travers et al., 2012). 

A majority of healthcare guidance published since 2015 supports pre-pubertal social transition, recommending affirmative approaches to supporting trans children, including guidance from the American Academy of Pediatrics (Rafferty et al., 2018), the Pediatric Endocrine Society Special Interest Group of Transgender Health (Lopez et al., 2017), and from national healthcare standards in Australia (Telfer et al., 2018) and New Zealand (Oliphant et al., 2018).

A study with 73 socially transitioned trans children aged 3 to 12 years found they had high levels of mental health, with levels of depression similar to cis children (Olson et al., 2016). A follow-up study on 116 socially transitioned trans children aged 6 to 14 years found high levels of mental health and self-worth in socially transitioned trans children, concluding “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 et al., 2017, p. 1).

UK based research has highlighted the benefits of social transition

Parents within this sample also evaluated the benefits of social transition, describing it as protective for their child’s happiness and well-being. Parents rejected any suggestion that supporting a pre-pubertal social transition was risky, instead emphasizing the risks of continuing to reject their child. Parents reflected upon advice for other families, emphasizing how positive it had been for their child. Parents were unanimous in recommending other parents to follow their child’s lead, affirming them in the present, perceiving this as safeguarding their child’s well-being, happiness and self-esteem.

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

Other UK research has included children’s voices and perspectives on social transition

The first major theme explored experiences pretransition, with subthemes on children correcting assumptions, becoming distressed, struggling alone, reaching crisis, or growing withdrawn and frustrated. The second major theme examined experiences posttransition, with subthemes on a weight being lifted, validation at school, and well-being. This qualitative research complements existing quantitative evidence on the importance of social transition, with childhood affirmation critical to the happiness and well-being of trans children.

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

  • 5. Cisnormative, pathologising, unevidenced approach to social transition being an ‘intervention’

A ‘social transition’ need not entail an end point, and may also provide an opportunity for self-understanding through, rather than just before transition (Ashley, 2019b). Bioethicist Florence Ashley (2019b, p. 6) points out that “changing names, pronouns, and undergoing transition-related interventions is routinely used by trans people in an exploratory manner, largely to positive effect.”

Ashley highlights that the categorization of ‘social transition’ as a clinical ‘intervention’ requiring justification and evidence is itself a deeply cisnormative approach; they argue that delaying or preventing a child from having their identity respected is a more active intervention in the child’s life, requiring greater evidence to justify it, than an approach that respects a child’s self-knowledge (Ashley, 2019b).

  • 6. Omission of harms of denied transition

Critics of ‘delayed transition’ argue that any potential risk of transition needs to be weighed up against the risks or harms of denying social transition (Ashley, 2021; Ehrensaft et al., 2018).

Research has shown the harms of delayed transition, with UK based research demonstrating the challenges, frustration and trauma of trans children who have experienced rejection and delay. UK research highlights that such harmful delays occur even within families who appear to be, or who have come to be affirming, with entrenched cisnormativity impeding affirmation.

“Families within this sample were unified in their positivity about supporting and affirming their child, with the only regrets spoken about being regrets at having been too slow in supporting their child. Families in this sample had experience-based insights into the negative repercussions on their child’s well-being of delay, dismissal and rejection, with every interviewee emphatic on the harms intrinsic to ‘delayed transition”. see: Horton, C. (2022). “I was losing that sense of her being happy” – Trans children and delaying social transition. LGBT+ Family Studies.

These findings also reinforce retrospective research on the negative mental health toll of childhood rejection, drawn from research with trans adults and trans youth (Ehrensaft et al., 2018; Katz-Wise et al., 2018; Priest, 2019; Turban et al., 2020; Wallace & Russell, 2013).

Further insights into the impacts of childhood rejection can be gained from retrospective research with trans adults (Kennedy, 2022; Turban et al., 2020), 

extensive literature drawing a connection between safe and affirming homes and trans youth well-being (Hill et al., 2010; Pollitt et al., 2019; Riggs et al., 2020; Russell et al., 2018).

  • 7. Fails to condemn conversion practices

explicit attempts to convert or coerce a trans child into a cis identity are condemned by mainstream health professionals (AusPATH, 2021; British Psychological Society et al., 2017; Coleman et al., 2012). Pediatric medical institutions across a number of countries have emphasized that efforts to convert trans children to a cisgender identity are both ineffective and unethical (Telfer et al., 2018). The UN Independent Expert on Protection Against Discrimination based on Sexual Orientation and Gender Identity called conversion practices “degrading, inhuman and cruel” (UN Human Rights Council, 2020, p. 21). 

A number of studies have outlined the harmful effects of conversion therapy, with the effects most pronounced on trans people who endure conversion therapy in childhood (Turban et al., 2020). Research has shown that exposure to conversion practices before the age of ten is significantly associated with severe psychological distress and lifetime suicide attempts (Turban et al., 2020). Children exposed to such practices are known to experience a severe loss of self-esteem and a sharp increase in depression, leaving them at risk of school drop-out and substance abuse (Turban et al., 2020). 

As explicit conversion therapy has moved outside of what is deemed acceptable, or in some locations legal, there remains a significant gray area, with conversion practices continuing, including from healthcare professionals, but without explicit labeling as such (Ashley, 2022). The UN report on conversion therapy underscored the harm of therapies that aim to change a child’s gender identity from trans to cis, or that hold a child being cis as preferable to a child being trans (UN Human Rights Council, 2020). The same report also emphasized that “practices aimed at changing gender identity include preventing trans young people from transitioning” (UN Human Rights Council, 2020, p. 11).

  • 8. Pathologising & incompatible with ICD-11

[service spec page 8] “research will include” “epidemiology”

[service spec page 14] “clinicians should remain open and explore…”

There is also no examination of the cisnormative bias in clinicians needing to be open and explore trans identities, when there is no such clinical exploration of cis identities.

Being transgender is now recognized by the medical establishment as a non-pathological part of human diversity, with space for trans lives to be celebrated and normalized, as a valued and important part of our families and communities (AusPATH, 2021; World Health Organisation, 2018). A medical shift away from the problematisation and pathologisation of gender diversity, has significant implications for trans children, who until relatively recently would have been diagnosed with a ‘disordered’ identity, growing up with isolation, rejection and shame (Bryant, 20062007; Gill-Peterson, 2018). 

This service specification has not grappled with the shift from ICD-10 with gender diversity pathologised, through to today’s ICD-11 where gender diversity is celebrated as part of human diversity.

Indeed the very intention of the shift to ICD-11 is to destigmatise and improve access to healthcare with the WHO stating:
In 2020, we have a better understanding of the issues surrounding this condition, and they are not related to a mental health condition.  Treating gender incongruence in a mental health chapter was causing additional stigma for an already stigmatized condition. WHO officials added the hope that adding this condition to a sexual health chapter of the ICD codes would “help increase access to care for health interventions” and “destigmatize the condition.” 

https://www.who.int/standards/classifications/frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd#:~:text=ICD%2D11%20has%20redefined%20gender,incongruence%20of%20childhood%E2%80%9D%2C%20respectively.

The harms of continued pathologisation and NHS responsibilities to drive forward active depathologisation are outlined in this research

Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

  • 9. Intrusive and inappropriate assessment

[service spec page 12] “assessment will focus on psychosexual development and any sexual experience.

Literature has evidenced the harms of such intrusive and inappropriate questioning

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. 1(1-2):47-70

  • 10. Redefining EA2010 protections to remove & medicalise rights for trans children

[Equality and health Inequalities Impact Assessment section on ‘gender reassignment’]

This section is entirely unacceptable, effectively seeking to medicalise and disenfranchise trans children and adolescents through an interpretation of the protected characteristic of ‘gender reassignment’ that does not accord with the EA2010.

It suggests trans children need a diagnosis of gender dysphoria to be protected, which is not true.

It states that medical intervention is necessary to be protected, which is not true.

It even goes so far as to suggest that adolescents accessing HRT privately may not be protected under the EA2010 characteristic of gender reassignment.

Having an NHS gender service, that should be advocating for trans children and adolescent rights, instead actively seek to confuse or undermine existing rights and legal protections, is extraordinary and a dire indictment of the prejudice and poor judgement underpinning this whole service specification.

  • 11. Misapplication of ‘safeguarding’ to threaten access to life-saving healthcare

[Service spec page 12] “assessments will focus on… risk including safeguarding… including impact of any unregulated medications”

[service spec page 16]

The service needs to understand that families and adolescents looking outside of the NHS do so where the NHS has failed in its duty of care for trans youth. In my opinion, the NHS at present, and even more so in this specification, is actively harmful for trans youth. Taking steps to access essential healthcare whilst protecting trans children from the harms within the NHS model of care, is entirely appropriate. Whilst the NHS fails to provide timely depathologised healthcare, families and adolescents need to be able to access private healthcare, whilst keeping their GPs up dated.

Families with trans children, and trans adolescents already have serious trust issues with parts of the NHS. Guidance that further breaks down trust with GPs, and guidance that makes families or adolescents fear that conversations with GPs will lead to safeguarding interventions, only increases the chances of families and adolescents distancing themselves from the NHS, with consequences for wider healthcare needs.

[service spec page 18] “nor will it enter into shared care arrangements”

A blanket ban on the NHS supporting any part of healthcare sourced privately, including routine blood tests or drug administration, makes access to essential healthcare through private providers even more inaccessible, especially for families on low income. It directly prejudices against trans youth who do not have wealthy families, who will be able to access care abroad or through private provision regardless of the in-availability of shared care.  

[Equality and health Inequalities Impact Assessment section on ‘families on low income’]

Fails to consider how low income families are disproportionately impacted by failures in NHS care.

[service spec page 18] “where a young person has been prescribed hormones outside of the eligibility and readiness criteria…the service will not accept clinical responsibility…”

This means that any young person who is forced into accessing private healthcare (due to failures in NHS delivery and accessibility) will be kept out of NHS services until the age of 18. This can leave families needing to pay private healthcare costs for many years. Where family circumstances change and a family cannot continue to afford private healthcare, or where an adolescent can no longer rely on family funding, it leaves adolescents completely without access to essential medication, with no consideration of the physical and mental health risks where care is discontinued.

  • 12. Ignorant of flaws in dysphoria definitions

[service spec page 21] “appendix a diagnosis of gender dysphoria”.

The specification does not at all engage with the known deficiencies in the DSM-V diagnosis criteria.

Australia national healthcare guidance in contrast critiques the known flaws in the DSM diagnosis and makes allowances for how to provide non-stereotyped care for trans youth.

[service spec 23] “options for children who have degrees of gender incongruence but do not meet the diagnostic criteria for gender dysphoria”

Particularly the diagnosis for children is very based in stereotype, meaning that trans children who do not adhere to regressive gender stereotypes can be found sub-threshold for diagnosis, despite being trans, being socially transitioned and potentially needing access to medical intervention at puberty.

The specification notes that the DSM diagnosis will shift to the ICD-11 diagnosis, but again fails to engage with the relevance of that change in diagnostic category.  

  • 13. Ignorant of potential for harm in adding extra GP layer into referral

[service spec page 9] “referral to the service will require a consultation meeting attended by the relevant local secondary health care team and or GP”

This introduces a screening process where the child and their needs are represented by the GP. It fails to consider a huge range of problems with this model. There is significant evidence that GPs can be prejudiced, uneducated, ill-informed in this area. The small percentage of people who are at present not referred to GIDS by their GP often correspond to those who have a transphobic GP who refuses to refer to the service out of transphobic prejudice.

[service spec page 9] “outcomes following the screening process include discharge with psychoeducation”.

[service spec page 10] “in some cases a further consultation may be appropriate following further local assessment and intervention and or a process of watchful waiting”.

Giving such GPs power to represent the child’s interests in the screening discussion leaves significant room for the child to be failed in a context where GPs have no education or support on trans children. It also leaves open to yet another round of intrusive questioning of trans children – if the GP needs to represent the child in the screening process the GP will themselves need to get to know the child’s experiences, a task that many GPs are underqualified for, and a process that can be harmful to a child’s well-being and wider confidence and trust in healthcare professionals.

[service spec [page 9] “If after professional consultation between a referrer and the service a child is considered suitable for assessment, the referrer will be advised to proceed with the referral via a standardised referral form”.

This additional layer adds yet another delay in a process that is already very heavily delay-ridden. How is this in any way centring child healthcare needs or making the system more efficient and effective.

  • 14. Ignorant of harms of denial of healthcare

[service spec page 13] “implications of medical treatment (and non-treatment)”.

The second part of this statement should not be in brackets and the specification needs to much more significantly present the evidence of the harms of denial of medical treatment.

The Endocrine society, in its recommendation in support of puberty blockers, states the following:
These recommendations place a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm from early pubertal suppression.”

  • 15. No centring of child rights to healthcare

[service spec page 8] “an individual’s route will be determined by… family and social context”

This leaves it open to trans children and adolescent’s path to healthcare being blocked by family or social context – it fails to consider child rights or how the service will centre the child and their wellbeing through the care pathway.

[service spec page 12] “the hopes and expectations of their family members/carers”

This section needs to distinguish between the need for family member support and education to help them support their child’s needs, and the potential for family members to cause harm by impeding access to healthcare.

[service spec page 14] “Medical interventions will not be considered until at least puberty…”

This feels inappropriate phrasing – a better phrasing would be to state that medical interventions are not needed in this cohort until puberty.

[service spec page 15] factors that could influence the complexity and length of the intervention include…”

Here a long list of factors that can extend assessments and delay healthcare are provided, with no consideration of child rights to care, including rights for those with mental health problems, safeguarding issues, unsupportive families, or difficulties providing consent. A child-centred approach may need to devote additional resources or effort to support children will more complex situations, but this also needs to prioritise ensuring such children are not kept in extended assessment or denied access to time-sensitive healthcare.

[Equality and health Inequalities Impact Assessment section on ‘looked after children’]

Fails to actively consider how to ensure looked after children, and those without parental advocates, are not discriminated against in healthcare access.

The specification fails to outline the necessity of trans healthcare. The Endocrine society states:
““These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary”

  • 16. No centring of healthcare accountability or mechanisms to empower service users

Existing evidence has highlighted the potential for abuse of power and child powerlessness in clinical care

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. 1(1-2):47-70

While other research has demonstrated the flawed mechanisms for accountability in the GIDS system.

Accountability and avoidance of areas of unlimited clinician control is critical especially in an area affected by potential for clinician prejudice.

  • 17. Presentation of psychoeducation as treatment for dysphoria

[Service spec page 2] “The primary intervention…. Is psychosocial (including psychoeducation) and psychological support and intervention, the main objective is to alleviate distress associated with gender dysphoria”.

This is entirely unevidenced, can be interpreted as a form of conversion therapy, and suggests psychological support is a means of alleviating gender dysphoria. There is no emphasis here on psychological support to cope with the challenges of living in a trans hostile world, or psychological support to deal with gender minority stress, bullying, abuse or family rejection. This seems to support psychosocial support itself will change a person’s experience of gender incongruence or dysphoria and is entirely unevidenced, goes against modern healthcare best practices, and will cause direct harm to trans children and adolescents.

[service spec page 8] “research will include” “outcomes of psychological treatments to reduce distress”

There is no consideration of the place for talk therapy in helping youth deal with transphobia or gender minority stress. The phrasing is left open for conversion therapy.

[service spec [age 9] “outcomes following the screening process include discharge with psychoeducation”.

This needs to justify why a child or adolescent who has wanted and needed referral to the service would be discharged with psychoeducation. It fails to consider who the psychoeducation is for, what its purpose is. It strongly leaves the specification open to an interpretation that the screening can identify who is ‘really trans’ and who can be assigned psychoeducation to reconcile with their assigned gender. It leaves space for conversion practices that are unacceptable in modern healthcare.  

[service spec page 14] “psychological support will focus on alleviating emotional problems” “The overall aim is to reduce distress in the individual”

This approach leaves open the interpretation that psychological support is an effective treatment for gender dysphoria, rather than psychological support to deal with gender minority stress.

In contrast, the endocrine society states that the purpose of counselling linked to social transition is to help manage other people’s reactions:

“During social transitioning, the person’s feelings about the social transformation (including coping with the responses of others) is a major focus of the counseling.”

  • 18. No emphasis on psycho education to raise trans positivity

[service spec page 13] “psychoeducation”

The section on psychoeducation focuses on gender identity development, not on the very important topic of raising trans positivity.

Other literature has highlighted the importance of education on trans identities and trans positivity, especially for cis parents.

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

  • 19. No centring disability & neurodiversity rights

[service spec page 8] “an individual’s route will be determined by… the presence and impact of other clinical needs”

This leaves it open to trans children and adolescent’s path to healthcare being blocked or disadvantaged if they are disabled or neurodivergent – it fails to consider disability and neurodiversity rights or how the service will centre the child and their wellbeing through the care pathway, making sure disabled youth are not discriminated against.

[service spec page 12] “assessments will focus on …neurodevelopmental needs and their relationship with gender incongruence”

Neurodivergent trans children should not need to explain or define the relationship between neurodiversity and gender incongruence.

[service spec page 15] “more intensive clinical interventions may be needed…to address other clinical diagnoses”

The service is not committing to upholding the rights of disabled trans youth, including disabled or mentally ill trans youth.

[Equality and health Inequalities Impact Assessment section on ‘disability’]

Fails to consider the reality that disabled children are likely to be discriminated against with greater barriers to timely healthcare. Fails to put in place strategies to ensure those with disabilities, co-existing mental health conditions and neurodiversity are not discriminated against in access to timely healthcare.

  • 20. Failure to recognise gender minority stress as key driver of mental health differentials

[Service spec page 2] “experience co-existing mental health… and or family or social complexities in their lives”.

[service spec page 11] “increased prevalence of mental health needs such as depression anxiety risk-taking behaviours”

This section entirely fails to deal with the significant body of evidence that demonstrates that mental health issues, or family and social issues are highly likely to not be co-existing, but directly caused by societal prejudice and gender minority stress. The stress of living in a trans hostile society places a significant burden on trans children and this service specification needs to recognise that in many cases mental health differentials and family/social difficulties are not caused by gender incongruence, but by societal, community, peer and family responses to that gender incongruence. It is absolutely vital to recognise that the ‘problem’ is not internal to the child, but one of the reaction to the child. This places a very significant emphasis on the need to undertake responses at family, community and society level, not at the level of the child.

These references to co-existing conditions also fail to recognise that denial of essential healthcare is a known driver of such mental health difficulties.

[service spec page 12] “assessments will focus on… impact of gender incongruence on educational attainment, bullying or harassment”.

This needs to clearly distinguish that it is not gender incongruence that has this impact, but societal prejudice.

[service spec page 14] “The overall aim is to reduce distress in the individual”

Fails to understand that solutions to tackle GMS should not focus on the individual but on the surrounding environment.

Trans children and adolescents are known to be at risk of poor mental health, with a wide variety of studies noting high levels of depression, anxiety or suicidal ideation (Srivastava et al., 2020; Strauss et al., 2020; Veale et al., 2017). A growing body of research has also shown that poor mental health is not intrinsic to being trans, with evidence demonstrating a wide range of external factors that correlate with good mental health, including family support (Katz-Wise et al., 2018; Klein & Golub, 2016; Pullen Sansfaçon et al., 2019; Simons et al., 2013; Travers et al., 2012), social affirmation (Durwood et al., 2017; Olson et al., 2016; Whyatt-Sames, 2017), and safe and welcoming trans-inclusive primary and secondary education (Horton, 2020; McGuire et al., 2010).

Trans children’s experiences of Gender Minority Stress in education in the UK are evidenced here:

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

  • 21. Suggests intrusive search for causation

[Service spec page 2} “the relationship between these aspects (mental health, neuro-developmental and or family or social complexities) and gender incongruence may not be readily apparent and will often require careful exploration”.

This phrasing leaves itself open to the interpretation that gender incongruence may be ‘caused’ by family disfunction, mental health issues or neurodiversity, suggesting that such causes ‘often’ need to be ‘carefully explored’. This is an outdated approach that has been tried for many decades and found to be harmful and abusive. Existing research shows that trans children and families find such ‘exploration’ intrusive, harmful and irrelevant.

[Service spec page 5] “build and document the history and nature of gender incongruence”.

It is striking that despite citing the Endocrine society elsewhere in this specification, it does not mention a key conclusion of the Endocrine society that gender identity has a “durable biological underpinning”

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” Journal of Clinical Endocrinology & Metabolism (JCEM), Nov 2011.

The Endocrine society position paper states:

The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder. 

https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

[service spec page 8] “a care plan should be tailored…following careful therapeutic exploration”.

The fact a care plan can only come after careful therapeutic exploration suggests this is mandatory, and that it is therefore neither therapeutic nor exploratory. Therapeutic exploration is client driven not clinician driven. Mandatory exploration is something quite different, and instead is an intrusive and abusive exercise in clinician power over a trans youth. This approach fails to consider the power wielded by clinicians (some of whom hold transphobic prejudices), and the need to centre trans children’s right to not engage in forced exploration before having access to a care plan. It is a one-size fits all approach that fails to recognise that many trans children have no need of, and will be harmed more than helped by therapeutic exploration, and that mandated exploration is neither therapeutic nor exploratory. To the contrary, there is evidence that mandated exploration can put trans youth into a position of defending their identity, reducing space for genuine exploration, and leading to worse outcomes.

Furthermore, work by Ashley has demonstrated that self-guided reflection and exploration is a process that should take place through the process of wider healthcare, not as a step before access to a care plan.   

  • 22. Leaves space for gender exploratory therapy

[service spec page 14] “clinicians should remain open and explore…”

Gender exploratory therapy is a rebranded label for conversion therapy, and the service specification, with numerous references to exploration retains space for this harmful practice.

  • 23. Uses dated and unscientific language for ideological purposes to illegitimise and disenfranchise

[service spec page 3] “biological sex”.

In this section the NHS has redefined the diagnosis of gender incongruence to include the inaccurate term of “biological sex”

The WHO ICD-11 instead defines gender incongruence thus:

“Gender incongruence is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex”.

The NHS has rewritten the WHO’s definition to include inaccurate and transphobic language of ‘biological sex’ rather than ‘assigned sex’ with this change likely to delegitimise and disenfranchise.

[Service spec page 6] “biological sex”

In this section the NHS propose the whole system’s outcome monitoring system records by ‘biological sex’, with this inaccurate and harmful categorisation likely to other, delegitimise, insult and harm trans children and young people. Such monitoring is also likely to lead to service users refusing to participate in data gathering – services need to maintain service user trust and confidence for any effective collaboration including in basic data gathering. Having a monitoring system that is designed to monitor by “biological sex” is cisnormative and harmful – every monitoring report will misgender and harm its service users. This is unacceptable.

The Endocrine society (who are the only citation in this specification) specifically advise against use of the phrase “biological sex”. They state that “the terms biological sex and biological male or female are imprecise and should be avoided.”

The phrase biological sex rather than sex assigned at birth is an ideological inclusion in this document, with potential to illegitimse and disenfranchise trans people, especially given existing political discourse around ‘sex’ and ‘single-sex spaces’. This phrase should be nowhere near a document purporting to serve and support trans children and young people. It is a direct microaggression, serving to signify to readers that the service is not designed in their interests.

[Equality and health Inequalities Impact Assessment section on ‘sex’]

This section misgenders and delegitimises trans children and adolescents, ascribing them as ‘natal males’ and ‘natal females’. This is unacceptable language in a specification supposed to help trans children.

  • 24. Emphasis on MDT

[Service spec page 8] “the provider will deliver the Service through an integrated MDT”

There is no consensus on what an MDT for trans youth healthcare looks like, and within the Helen Webberley GMC proceedings, expert witnesses (leading clinicians from the US) gave extensive testimony on the inappropriateness of an MDT for trans youth healthcare. The NHS needs to take this expert testimony on MDTs into account here.

  • 25. Failure to centre endocrine care pathways

Being trans is not a medical condition. This is clearly established under ICD-11. Trans children and adolescents mainly need to have specialist healthcare support when they require endocrine interventions. Having a specialist gender care pathway that barely engages with a focus on endocrine care, is deeply regressive and fails to recognise that for many trans children, endocrine care is the sole reason for engaging in trans healthcare. Support with gender minority stress could be found outside of tertiary trans healthcare care, support for families can be found through more informal structures, and support for social transition often does not require and would even be harmed by incorporation into specialist healthcare.

  • 26. Failure to engage with trans expertise

The draft specification is unbelievably bad. This is what happens when healthcare is ideologically influenced, and when trans expertise is explicitly excluded. The NHS needs to do so much better. Trans kids deserve evidence-based trans-positive healthcare.

27. Under-planning for given population

I noticed in the spec that they mention lower referrals for 2020-1 without contextualising the referral numbers were artificially low because of the pandemic.

I also noticed that in their consideration of referral numbers they entirely fail to consider the trans youth who have not bothered to get an NHS referral recently because they know the wait list is 4+ years – those who have had to go private or who have waited for adult services (knowing GIDS won’t help them before adulthood anyway) are entirely unconsidered in the specification’s analysis of the size of the population the new service will cover.

Steph’s place did some further important analysis of the under-planning for the population in their blog:

Additional important critique of the service spec is in this blog

Evidence-based medicine: What do we mean by ‘low quality’ evidence in Trans Healthcare?

In 2021 the NHS (NICE) reviewed the evidence for the use of puberty blockers within trans adolescent healthcare. They concluded that the evidence was of “very low certainty”, a finding that was then repeated across national media, with the headline “Evidence for puberty blockers use very low, says NICE”. This unsurprisingly prompted increased demands, including from politicians, for withdrawal of trans adolescent healthcare.

Several people have written about the flaws in the NICE review, including this excellent article by AJ Eckert. I’ve examined parents of trans children’s concerns with the NICE approach to evidence in a recent peer reviewed article in which parents of trans children described puberty blocker Randomised Control Trials as “conversion therapy” or akin to “eugenics”.

A recent expert report from the US indirectly challenges the NICE approach, and merits further reading.

Background

In 2022 the Florida Agency for Health Care Administration published a biased and ideologically driven report claiming that medical care for gender dysphoria does not meet generally accepted medical standards. A group of experts linked to Yale University responded with an analysis and critique of the poor science underpinning Florida’s report. Their full report is here.

Evidence Quality

One section of the Expert report from Yale University focuses on evidence quality. Their analysis has relevance for conversations on trans adolescent healthcare happening in the UK (including the Cass review), so this blog will shine a spotlight onto this section of the report.

*Note: In the below quoted sections, BPW refers to sources cited in the original (and misleading) Florida report. The June 2 report refers to the original, and flawed Florida report.

The following italicised text is taken directly from the Yale report. Please take time to read this section through:

…the BPW analysis reaches the conclusion that there is little or no evidence for the benefits of medical care for gender dysphoria.

The BPW analysis is highly deceptive, because it dismisses nearly all existing studies of medical treatment for gender dysphoria as “low quality,” without explaining that this is a highly technical term and not a natural-language condemnation of the studies. By contrast, the GRADE system, which the authors purport to use, is quite clear about its quality rating systems and its limitations.

In general, only randomized controlled trials (RCTs) are coded as “high” quality evidence in the GRADE system. A randomized controlled trial is a study that divides patients randomly into a control group (no treatment) and a treatment group. In contrast, an observational study records information about patients in a real-world setting that is more reliably generalizable, e.g., a cohort of patients seen at a clinic. Under the GRADE guidelines, observational studies are coded as “low” in quality.

The key point is that “low quality” in this context is a technical term and not a condemnation of the evidence, because “low quality” studies regularly guide important aspects of clinical practice. Indeed, the GRADE system, which the BPW document claims to use, specifically notes that GRADE should not be used to dismiss observational studies or to give absolute priority to RCTs: Although higher quality evidence is more likely to be associated with strong recommendations than lower quality evidence, a particular level of quality does not imply a particular strength of recommendation. Sometimes, low or very low quality evidence can lead to a strong recommendation.

The methodology adopted by the BPW document will thus, predictably, conclude that any body of scientific literature that does not contain RCTs is “low” in quality. Had BPW begun, as they should have, with a literature review of the evidence on puberty blockers and hormones, they would have seen that the evidence consists primarily of observational studies (for the good reasons discussed below). Thus, the 30 pages that it takes the authors to lay out their methodology is misleading: a knowledgeable reader would know that if there are few or no RCTs in the literature, then the BPW technical conclusion is foregone and, as importantly, is not a sound guide for clinical recommendations.

Put in simpler terms, if we coded apples as “high quality fruit” and bananas as “low quality fruit,” then any fruit bowl that has only bananas would predictably be technically coded as “low quality.” But that technical conclusion conveys very little information without context. For example, if no apples exist, then bananas may be a nutritious choice.

The drafters of the GRADE system emphasize that technically “low quality” evidence can support a strong clinical treatment recommendation. For example, pediatricians now agree that children should not be given aspirin for fevers. This recommendation is based on observational studies that showed an association between aspirin treatment during viral illnesses and the development of Reyes syndrome (a rapid and progressive disease of neurological dysfunction that can be fatal). Based on those studies, it would be unethical to conduct an RCT giving some children aspirin, and so the strong, consensus treatment recommendation is based entirely on “low quality” studies.

The critical fact is that RCTs are not, and cannot be, the gold standard for medical research on gender dysphoria. In the context of treatments for gender dysphoria, randomized controlled trials would often be inappropriate for ethical reasons. Medical care has long been shown, by reliable scientific methods, to address gender dysphoria and improve mental health: as we have repeatedly noted, these treatments have been recommended by rigorous clinical practice guidelines issued by WPATH and the Endocrine Society and endorsed by every major medical organization. Given this medical consensus, which is based on solid scientific evidence, it would be unethical to conduct an RCT that involved denying standard medical care to a control group of individuals.

Similar ethical issues, along with practical barriers, leave many areas of consensus medicine supported by observational studies and not RCTs. Many surgical procedures, for example, are not supported by RCTs. Nor are standard protocols for lowering cholesterol using statins, one of the most widely-prescribed drugs in the United States.

It is thus simply a mistake – and a mischaracterization of medical research across fields of medicine – to conclude that the absence of RCTs means that there is “no evidence” for the efficacy of medical treatment for gender dysphoria. Medical research requires, instead, that researchers evaluate the design and conduct of specific observational studies and do so with an awareness of clinical context.

In sharp contrast to BPW, this is precisely what the authors of the Endocrine Society did in their 2017 clinical guidelines, which use the GRADE system but, in addition, carefully discuss the characteristics of the studies supporting each treatment guideline. The Endocrine Society discloses the GRADE rankings for each treatment recommendation in order to be transparent about the evidence base for each of its recommendations. Then, following National Academy of Medicine (formerly, Institute of Medicine) standards for clinical practice guidelines, they proceed to a qualitative review of the evidence, place the evidence in clinical context, and discuss openly the values at stake in making a clinical practice recommendation.

The June 2 Report repeatedly and erroneously dismisses solid studies as “low quality.” If Florida’s Medicaid program applied the June 2 Report’s approach to all medical procedures equally, it would have to deny coverage for widely-used medications like statins (cholesterol-lowering drugs taken by millions of older Americans) and common medical procedures like mammograms and routine surgeries.

In its opening words, the June 2 Report makes an error that is repeated throughout the document: “Studies presenting the benefits to mental health, including those claiming that the services prevent suicide, are either low or very low quality and rely on unreliable methods such as surveys and retrospective analyses, both of which are cross-sectional and highly biased.” As we document in Section II.B., above, it is an outright mistake to conclude that a study in the technical category of “low quality” is unreliable or poor evidence for clinical practice. Thus, it is frank error for the June 2 Report to dismiss well-done, scientifically important studies because they rank as “low quality” using specialized, technical terms.

Like the BPW document, the June 2 Report thus relies on a deceptive use of technical terminology that is at odds with the standards used in medical research. It simply is not – and cannot be – the case that all clinical recommendations must be based on RCTs. Many areas of medicine do not lend themselves to ethical and practical RCTs. It is unethical to conduct an RCT when randomizing a patient to a control group would cause harm by denying treatments of known efficacy. For example, it would be unethical to conduct an RCT on the treatment of juvenile diabetes by randomizing some participants to receive insulin and others to receive no treatment.

It is quite common for the medical community to adopt important, consensus clinical practices supported by observational studies alone. For example, observational studies, notably the famous Framingham Heart Study, provided the framework for clinical practice guidelines in prevention and treatment of cardiovascular disease. In 2013, the American College of Cardiology and the American Heart Association issued updated clinical practice guidelines on the treatment of cholesterol to reduce heart disease risk in adults (the “Cholesterol Guidelines”). These authoritative guidelines have been widely used in clinical practice but are based not only on RCTs but on a great deal of observational evidence, including studies technically ranked as “low quality.” Concretely, many of the original treatment recommendations regarding statins are based on observational studies, not RCTs. The authors of the Cholesterol Guidelines, very much like the Endocrine Society authors, are quite careful to grade their evidence. But they do not rest their treatment guidelines on a mechanical assessment of technical quality. Instead, they (like the Endocrine Society) carefully explain why particular bodies of evidence should be given weight in clinical decision-making.

The cholesterol example shows that the June 2 Report rests on a fundamental misunderstanding of medical research and clinical practice. If the Florida Medicaid program actually adopted the standard of evidence urged by the June 2 report, the program would not cover statins (drugs to lower cholesterol) for many patients, which are prescribed to 28% of adults over the age of 40 and are one of the most effective ways to prevent cardiovascular death. Other common practices that would have to be reconsidered under this logic include: post-menopausal hormone replacement therapy (which reduces lifetime risk of heart attacks and stroke) and mammography screening for breast cancer.

The same point is true of the technically “low quality” evidence base for many surgical procedures, including minimally invasive gall bladder surgery, which have long since had a foundational grounding in observational studies. We think it unlikely that Florida’s Medicaid program will begin to refuse to pay for statins, mammograms, and routine surgeries. If not, then the June 2 Report reflects an untenable and discriminatory double standard.

(I’ll emphasise in case of confusion – all the above text in italics is not my work, but a direct quote from the Yale report – the authors of which are listed here)

Relevance for the NHS

The text above prompts several important questions for the NHS:

  1. Does the NHS (NICE report and Cass review) reflect a similar “discriminatory double standard” in its characterisation of the evidence base as ‘low quality’? Does NICE use the same approach across other areas of healthcare (including e.g. abortion)?
  2. Should the NHS (NICE and the Cass review) be more careful when using technical terms like “low quality evidence” in an already polarised and politicised area of healthcare, knowing how such terms are reported in the media and knowing how such terms inflame and undermine support for healthcare?
  3. Why has the NHS (NICE and the Cass review) failed to grapple with the very well established reasons why “high quality evidence” like RCTs are infeasible and unethical? Given the known ethical and practical impossibility of RCTs, why on earth did the NICE review recommend collection of such “high quality evidence”?

I’m also left with some bigger questions for the UK:

4. The above intervention from an esteemed team of establishment professors across different disciplines is likely to hold some weight in challenging and holding to account poor healthcare sector practices. Here in the UK we do not have paediatricians, law professors, experts in effective approaches to experience-informed healthcare speaking up on the clear flaws in the NHS approach to trans adolescent healthcare. Why not?

5. Are there lessons we can learn from experts in other areas of healthcare who have challenged commitment a narrow definition of ‘evidence’ within healthcare policy?

(post-script: I’d normally include a link to the NICE report, but it appears to have disappeared from the NICE website – if someone has a functioning link please let me know so I can update it).