Gender Dysphoria and puberty blockers

June 28, 2024June 28, 2024 / growinguptransgender / Leave a comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They are criticising puberty blockers for failing to cure transness.

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

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

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

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

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

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

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

We need to reduce gender dysphoria they say.

We need to make children not trans they mean.

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

They just care about making trans kids into cis kids

This is all they ever care about.

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

UK leading the way in transphobic state violence

May 30, 2024May 30, 2024 / growinguptransgender / Leave a comment

Last night we learnt that the failing-fast UK government, in one of its very last actions, did something unprecedented, just to make life more un-liveable for transgender children and adolescents in the UK.

They enacted a very rare government power to block access to the only two remaining routes to doctor-prescribed UK-pharmacy-dispensed puberty blockers.

They used an emergency legal power that as far as I can see has only been used once before. That was in 1999 for a barely-known drug that had caused a number of deaths. Even then they went through several steps to gain medical authority scrutiny and approval of government use of emergency powers to enforce a ban, also considering the likely impacts on existing users of the substance (there was no significant use of the 1999 substance that was considered highly toxic).

Yesterday afternoon the UK government used this same rare power to place an immediate (starts 3^rd June) emergency ban on puberty blockers a) from overseas prescribers and b) from NHS GPs in primary care.

Let’s start with the second one. The UK government has enacted draconian emergency powers to ban the medical prescribing of NHS GPs in primary care. GPs in primary care already only have ever prescribed puberty blockers as a harm minimisation strategy – where they know a trans adolescent is accessing from a source (eg grey market without any monitoring) and they recognise their duty of care to minimise harms and where the threat to that adolescent’s life is considered severe (adolescents who cannot conceive of living through the wrong puberty). The UK government has made this harm reduction care from NHS GPs illegal. This has now closed literally the last route to UK-prescribed puberty blockers.

The UK establishment has systematically closed every single UK route to puberty blockers. The GMC (the UK regulator of medical doctors) has used its powers against a series of trans positive doctors since the early 2000s (thereby deterring any other doctors from stepping forwards). The CQC has denied approval to any UK private practices seeking to support trans adolescents under the age of 16, meaning the UK registered private providers do not offer support to trans adolescents at the point of puberty. The NHS gender clinics maintained a tight monopoly, with one English and one Scottish clinic for under 18s. The former was closed in March 2024, and the latter has currently blocked routes to puberty blockers. The new English service (also covering Wales) has no route to access to puberty blockers. Every door has shut.

The primary target of the draconian emergency ruling is those who currently receive a prescription for puberty blockers from an overseas doctor. Currently, the vast majority (I would guess 98%) of UK trans adolescents on puberty blockers receive them from an overseas doctor’s prescription, that is dispensed in a UK high-street pharmacy. There must be high hundreds or low thousands of trans adolescents currently receiving puberty blockers via this route. This route will now stop working on the 3^rd of June. High hundreds or low thousands of trans adolescents will be without any route to receiving their prescription in a UK pharmacy.

What are those adolescents meant to do? Now they cannot even go to their GP as an emergency and harm-reduction route. Those who cannot or will not consider grey market routes will literally be medically detransitioned, something known to be an actual medical and well-being risk, by the edict of a transphobic government. This will not be safe. This was never about safety.

The power to take this step is based on emergency measures that can only be enacted where there is a critical threat to immediate safety. The government waved this through with the claim “the Cass Review…”.

The Cass Review was a shambles of transphobic medical policy. The Cass review approach to puberty blockers was based on one clever trick.

If the Cass review had asked these two questions, the answers would have been very clear. 1. Are puberty blockers effective at blocking puberty (Yes, very clearly). 2. Are they safe at blocking puberty (Yes, very clearly, used since the 1960s for precocious puberty in children who are 6 or 7, used since the 1980s for trans adolescents, NO EVIDENCE OF HARM).

The trick played by the Cass Review is that they didn’t ask these questions. They instead asked, 1. Are puberty blockers effective at treating gender dysphoria? Shifting to this question allowed them to ignore the very clear evidence that they are extremely effective at blocking puberty. They claimed that effective puberty blockers should improve well-being which has never been the case. Puberty blockers are intended to maintain well-being, in stark comparison to trans adolescents without puberty blockers whose mental health, well-being, wish to live, and ability to succeed at school and socially tends to nose-dive at puberty). Unless you have an unethical study watching the kids who fall off a cliff in mental health without blockers then how do you prove they help prevent a decline in mental health? Shifting the question to whether they ‘treat gender dysphoria’ allowed the Cass Review to state the evidence of effectiveness was ‘inconclusive’.

Secondly, instead of asking whether the medicine is ‘safe’, they asked a narrower question, is it ‘safe in treating gender dysphoria’? This allowed them to disregard decades of studies that puberty blockers are safe when used in cis children. The drug is very clearly safe. It is still today (and next week) prescribed by the NHS for younger children who are not trans. There are no safety concerns. The medication is clearly safe.

The only way that the Cass Review was able to raise any safety concerns at all, was through transphobic speculation. They speculate, with zero evidence, that perhaps puberty blockers may ‘change the outcome’, keeping a trans child as a trans adolescent, when all they need is a good dose of their endogenous hormone and then they would turn out normal (cis). (See my recent podcast transcript that dives into this). The severe safety risk that the Cass Review speculates about, is the risk of still being trans. There are some other speculations, that are only proposed for trans adolescents (not for cis youth receiving the same medication for any other purpose, including endometriosis or early puberty). None of the speculations are evidenced. The Cass Review also references things like bone density, which is a minor risk that endocrinologists are well aware of and can be easily managed by a) monitoring bone density b) taking vitamin supplements c) not being on blockers without hormones for more than a couple of years. There is no evidence of actual risk or actual harm at all of trans adolescents using puberty blockers.

The actual risk is, of course, the opposite. There is a very real risk to trans adolescents who need puberty blockers and are denied them. In the last week I’ve spoken to two parents whose children no longer wanted to be alive because of starting to be pushed through a puberty that is distressing and humiliating for them. For adolescents who are deeply distressed by puberty, instead of being offered a safe and effective medication that can stop those changes, they are being offered a big pile of nothing. They are being offered the suggestion that perhaps they are not really trans, and perhaps the changes that they find traumatic are just want they really need to grow up cis. That is where we are with trans healthcare in the UK today. Trans children and young teens are being told, ideally you should convert yourself into a cis person, or we literally do not care for you, your life, your safety, your well-being.

High hundreds or low thousands of trans adolescents who are on puberty blockers, happy and healthy, will be forceably detransitioned by government edict, without medical supervision or support, starting on the 3^rd of June. Some of these will turn in desperation to grey market sources, finding every route to UK pharmacy dispensing closed. There are risks to youth who are forced onto grey market sources, both in terms of ensuring the quality of medication that does not come from UK pharmacy, and perhaps even more so in terms of the risks associated with healthcare avoidance. Trans adolescents who are accessing grey market medication, having had every other route banned, will be reluctant to go to their GP for other health issues. There is a real risk of a whole generation of trans adolescents losing out of mainstream healthcare, and becoming at higher risk of the health impacts that occur when a portion of society is afraid of talking to their GP or health service. Communities who are afraid of talking to their healthcare providers (see undocumented immigrants) are likely to go to healthcare providers late when they have a routine health concern, are likely to wait until minor healthcare concerns become major, are likely to have significantly worse general healthcare outcomes. This is where we are heading today for trans adolescents in the UK. It is an absolute oppression. It is not about safety. It was never about safety.

The emergency legislation lasts for only 3 months, as the UK government is enacting an emergency power intended for a new and unexpected threat to life, not a power intended for a medication safely used since the 1960s. This temporality does not reassure me. Let’s look at the Labour Government’s reaction – are they going to condemn this transphobic intervention as dangerous and abusive government overreach into healthcare? I bet they will not. And if they do not, then I have no confidence that they will not extend this if they are in power come September.

In the name of ‘safety’ the UK government is making the UK more unsafe for trans adolescents. Transphobia is the biggest safety threat to trans adolescents, as to trans people of all ages. Trans children and adolescents can have a happy and safe and secure childhood and adolescence. But the UK government and the NHS is trying its utmost to take that happiness and safety and security away. We need to do better for trans young people. #TransRights #TransKidsShouldThrive #TransHappinessMatters

Ten Dangerous Cass Review Recommendations

April 16, 2024April 16, 2024 / growinguptransgender / Leave a comment

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).

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 17^th 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

April 10, 2024April 10, 2024 / growinguptransgender / 1 Comment

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

April 9, 2024April 9, 2024 / growinguptransgender / Leave a comment

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

January 30, 2024January 30, 2024 / growinguptransgender / Leave a comment

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

1. Bachman C, Gooch B. LGBT in Britain: Health Report [Internet]. London, UK: Stonewall; 2018 [cited 2021 Jun 6]. Available from: https://www.stonewall.org.uk/system/files/lgbt_in_britain_health.pdf

2. Government Equalities Office. National LGBT Survey: Research Report. Manchester: Government Equalities Office; 2018.

3. Pearce R. Understanding Trans Health: Discourse, Power and Possibility. Bristol: Policy Press; 2018.

4. LGBT Foundation. Primary Care Survey Report [Internet]. Manchester: LGBT Foundation; 2017 [cited 2021 Jun 6]. Available from: https://s3-eu-west-1.amazonaws.com/lgbt-website-media/Files/f7a0343c-67ee-4777-8882-739a44d41a70/LGBT%2520FOUNDATION%25202016-17%2520Primary%2520Care%2520Survey%2520Report.pdf

5. Vincent B. Non-Binary Genders – Navigating Communities, Identities, and Healthcare [Internet]. Policy Press; 2020 [cited 2021 Aug 21]. Available from: https://policy.bristoluniversitypress.co.uk/non-binary-genders

6. Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med 1982. 2013 May;84:22–9.

7. General Medical Council. LGBT Patient Guide [Internet]. General Medical Council; 2021 [cited 2021 Jun 6]. Available from: https://www.gmc-uk.org/Ethical-guidance/Patient-guides-and-materials/LGBT-patient-guide?utm_source=press&utm_medium=press%20release&utm_campaign=LGBT

8. Crowley D, Cullen W, Hout MCV. Transgender health care in primary care. Br J Gen Pract. 2021 Aug 1;71(709):377–8.

9. General Medical Council. Trans Healthcare Hub. [cited 2023 Aug 22]. Trans healthcare. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare

10. Mikulak M, Ryan S, Ma R, Martin S, Stewart J, Davidson S, et al. Health professionals’ identified barriers to trans health care: a qualitative interview study. Br J Gen Pract. 2021 Dec;71(713):e941–7.

11. Guss C, Woolverton GA, Borus J, Austin SB, Reisner S, Katz-Wise S. Transgender Adolescents’ Experiences in Primary Care: A Qualitative Study. J Adolesc Health. 2019 Jun 1;65.

12. Davy Z, Benson J, Barras A. Shared care and gender identity support in Primary Care: The perspectives and experiences of parents/carers of young trans people. Health (N Y). 2022 Nov 26;13634593221138616.

13. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan;3(2):77–101.

14. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021 Jul 3;18(3):328–52.

15. Vincent B. Studying trans: recommendations for ethical recruitment and collaboration with transgender participants in academic research. Psychol Sex. 2018 Apr 3;9(2):102–16.

16. Brown S, Kucharska J, Marczak M. Mental health practitioners’ attitudes towards transgender people: A systematic review of the literature. Int J Transgenderism. 2018;19(1):4–24.

17. Riggs DW, Sion R. Gender differences in cisgender psychologists’ and trainees’ attitudes toward transgender people. Psychol Men Masculinity. 2017;18(2):187–90.

18. Stroumsa D, Shires DA, Richardson CR, Jaffee KD, Woodford MR. Transphobia rather than education predicts provider knowledge of transgender health care. Med Educ. 2019;53(4):398–407.

19. Turban JL, Winer J, Boulware S, VanDeusen T, Encandela J. Knowledge and attitudes toward transgender health. Clin Teach. 2018;15(3):203–7.

20. Mikulak M. For whom is ignorance bliss? Ignorance, its functions and transformative potential in trans health. J Gend Stud. 2021 Feb 3;0(0):1–11.

21. Carlile A. The experiences of transgender and non-binary children and young people and their parents in healthcare settings in England, UK: Interviews with members of a family support group. Int J Transgender Health. 2020 Jan 2;21(1):16–32.

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.

26. Hidalgo MA, Chen D. Experiences of Gender Minority Stress in Cisgender Parents of Transgender/Gender-Expansive Prepubertal Children: A Qualitative Study. 2019 [cited 2020 Jul 12]; Available from: https://journals.sagepub.com/doi/abs/10.1177/0192513X19829502

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.

30. Matsuno E, McConnell E, Dolan CV, Israel T. “I Am Fortunate to Have a Transgender Child”: An Investigation into the Barriers and Facilitators to Support among Parents of Trans and Nonbinary Youth. J GLBT Fam Stud. 2021 Oct 20;0(0):1–19.

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

December 30, 2023December 30, 2023 / growinguptransgender / Leave a comment

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 14^th 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

Featured

Trans kids in 2023: Optimism and defiance

March 3, 2023March 3, 2023 / growinguptransgender / 1 Comment

Image from She-Ra and the Princess of Power (2018) by ND Stevenson

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

December 9, 2022December 9, 2022 / growinguptransgender / Leave a comment

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

November 25, 2022November 25, 2022 / growinguptransgender / Leave a comment

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.

Growing Up Transgender

Raising our trans child

Author: growinguptransgender