Watchful Waiting – A Parent’s View

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Some more UK commentators, and even the Royal College of General Practitioners, have recommended a ‘watchful waiting’ approach for trans children.

I’ve written previously that this UK guidance is out of synch with the medical recommendations in the US, Canada, Spain, New Zealand, Australia. How it is out of synch with experts in other countries who consider watchful waiting, which they more accurately describe as ‘delayed transition’, to be harmful to trans kids.

Here I want to share my own experience, and the experience of other parents, on how watchful waiting plays out in practice. For me watchful waiting is a misleading term – it sounds very benign and sensible. While the term used to describe this elsewhere, ‘delayed transition’, is a more accurate description, the reality for those living through it is that ‘prolonged rejection’ is a better description of what ‘watchful waiting’ means in practice.

From as soon as my child could properly speak, they asserted ‘I am a girl’. For some initial time, in total ignorance about gender diversity, I opted for active rejection: ‘No, you are not a girl you are a boy’.

Months and months of daily (multiple times a day) active rejection followed. My child would insist their gender several times a day. Active rejection was not leading to any change in my child’s insistence (just an increase in my child’s distress and depression). I researched and came across the UK guidance for ‘watchful waiting’, whereby they recommend a supposedly neutral approach where a child is not actively rejected (ie stopping saying ‘no you are not a girl’) but without any active affirmation (without saying, ‘ok we will call you a girl’).

We really tried that watchful waiting approach with our child. This is how it played out in practice with an insistent, consistent, persistent and increasingly distressed trans child (and these are the children who we are talking about, who most obviously benefit from affirmation).

Every single day my child would cry and say ‘I’m a girl’. During watchful waiting we would tell them I loved them and we didn’t need to talk about gender – They were left thinking their mum and dad did not understand or did not care about this thing that was so important to them.

Every day they would cry themselves to sleep saying ‘But I’m a girl’. I would hug them and tell them I loved them, whilst ignoring the thing that was causing their distress. – They were left thinking that one part of them was broken – un-loveable – unacceptable. How shame inducing? How pathologizing?

Every day I would try to actively break down gender stereotypes, try to break down gender roles or restrictions around gender expression without supporting my child’s identity. This only made my child sadder as their mum was missing the point entirely. In one conversation that sticks in my mind:

Child: ‘But mummy I am a girl’

Me: ‘Boys and girls can do all the same things. Would you like a doll?’

Child: ‘I don’t like dolls, I am a girl…. can I have a spiderman’

In another one:

Child: ‘I’m a girl’

Me: (Desperately thinking about what my child might associate as typically ‘girl activities)… Would you like to try out ballet classes?’

Child: ‘I don’t like dancing’

Me: ‘What do you like?’

Child: ‘Climbing trees. Girls can like climbing trees’.

I was not listening to my child. I was rejecting her.

Every day they spent sad, rejected, and fixated on the topic of gender. They were losing out on the carefree fun childhood of their peers. Every day spent sad and depressed and rejected is a lost day of childhood. Every day spent feeling that who they are is unacceptable to their mum, is a day piling on shame, self-hate, low self-esteem.

I watched them get lower, get less happy, get less curious about the world, get less excited about life get sadder, get more isolated and alone. This is what I was watching. What was I waiting for? My child had told me in very consistent, persistent and insistent terms what she needed. She needed to be loved and accepted as a girl. It was the only thing that mattered to her and she felt deeply rejected, deeply broken, deeply unacceptable. Was I waiting for her mental health to crash? Was I waiting for her to snap out of it? Was I waiting for her to reach an arbitrary age? Was I waiting for her to turn 10?

What would waiting until age 8 or age 10 until I stopped passively rejecting her mean for my child? What would be the benefit to her, of keeping her in a state of continued rejection, depression and sadness until age 8 or 10 as the NHS advises?

What are the risks of waiting until age 8 or age 10 until I stop rejecting her?

What is at stake?

For me the biggest stake is her childhood, her happiness, her self-esteem, her self-worth, her curiosity, her interest, her learning, her education. I care about her happiness right here and now.

During our phase of watchful waiting, my child was on pause, she was stuck, she was unable to thrive.

As soon as we moved to affirmation, everything changed.

Affirmation was a much easier thing to do in practice.

She said:

‘I’m a girl’

And we said: ‘ok we will call you a girl’.

We switched pronouns. As far as our family life was concerned, that was a very quick and easy switch. We switched pronouns and our daughter thrived. She has never once cried herself to sleep since that day. She no longer wanted to talk about gender every time we were alone. She started to talk about animals, and space, and nature, and how things work. She started to explore. She started to have a childhood. She became lighter and carefree. A huge burden lifted from her shoulders (and noticeably shifted to ours as we sought to get the wider world to respect her identity).

The price of watchful waiting was very high for my family. The price was very high for my daughter.

Watchful waiting robbed my daughter of a period of her childhood. A period when she could have been happy and loved and accepted and carefree. When instead she was left feeling rejected and broken. For a child like mine, watchful waiting causes harm.

I am thankful that we had access to other sources of information (my next blog will be on the evidence base for affirmation versus watchful waiting).

I am thankful that the period of rejection was not so long, and that the damage to her self-esteem was not deep.

I am thankful that since the day we stopped rejecting her, the simple change of pronoun, she has flourished in every way.

She laughs, she can dream, she can learn, she can play. She is having a carefree happy childhood. This was literally not possible under prolonged rejection (ie watchful waiting).

Many other parents tell the same story. Of trying watchful waiting for months or years and watching their child sink.

People with no experience of living daily with trans kids need to start listening to the impact ‘watchful waiting’ has in practice. They need to start listening and understand that it is neither neutral, nor benign, nor easy. It is hard to passively reject your child daily. It is hard to watch them sink. It is an approach that fundamentally misunderstands insistent, consistent, persistent trans children. It is an approach that fundamentally undervalues the right of a trans child to a happy childhood.

Trans kids only get one childhood. They need to know they are loved as who they are. They need to know their parents and carers have their backs, will listen to them, will accept them, will stand up for them.

Stop rejecting trans kids. Passive rejection can hurt as much as active rejection. Quiet rejection, rejection through silence and omission can hurt as much as loud rejection.

Listen to your trans kids. Love your trans kids.

 

New Zealand Healthcare Guidelines Affirm & Support Trans Children

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New Zealand has produced guidance for trans healthcare: Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand

Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018.

This follows similar guidelines produced in the US (by the world’s largest paediatric medical organisation the American Academy of Pediatics), Australian affirmative healthcare guidance for transgender children and adolescents, and similar practices in place for trans children and adolescents across Canada, Spain, Germany

New Zealand’s gender affirmative healthcare guidelines for transgender children, yet again shows the UK GIDS is stuck in the dark ages, the UK NHS is failing transgender children.

Here’s a ten point summary (written by me) for those disinclined to read further:

  1. New Zealand endorses gender affirmative healthcare for trans children and adolescents.
  2. New Zealand acknowledges that some children are trans at a young age, that some adolescents come to understand their gender identity at or after puberty, and that all are valid and in need of affirmation and support.
  3. New Zealand uses modern, trans positive language and does not problematise trans children, being clear that trans children who are supported should be able to thrive and should be able to be as happy as any other child.
  4. New Zealand supports social transition for trans children, emphasising the important benefits and protective aspects for their well-being.
  5. New Zealand recognises the importance of supportive families, and prioritises educating parents/carers to accept and affirm their trans children, providing clear and reassuring guidance to listen to their child.
  6. New Zealand is clear that gender affirmative healthcare is medically necessary, considering a range of aspects of health including support in dealing with minority stress.
  7. New Zealand supports access puberty blockers, which it emphasises are reversible. It emphasises that withholding timely access to blockers causes harm, and emphasises that not using blockers can lead to irreversible unwanted physical changes.
  8. New Zealand supports individualised access to hormone therapy, acknowledging the compelling reasons why access prior to age 16 is appropriate for some individuals. It provides clear information on the changes that are reversible, partially reversible, not reversible and the time on HRT for these changes to emerge.
  9. New Zealand acknowledges the harm caused by the pathologisation of gender diversity, and commits to depathologisation within the health service. New Zealand acknowledges being gender diverse is not a mental health condition and commits to mental health support being optional and not a mandatory part of accessing affirmative healthcare.
  10. New Zealand acknowledges the negative health impacts of discrimination, and acknowledges the importance of health service providers advocating for trans people, advocating for social and public policy change to reduce the negative effects of minority stress.

This blog summarises the main areas of the New Zealand guidance that are relevant for trans children and adolescents, highlighting areas where New Zealand’s healthcare guidance for trans children is ahead of the UK NHS (I use the word ahead rather than different, as there is a clear trajectory for trans children’s healthcare globally – I have no doubt the UK will eventually make a change in this direction – as have already done Australia, much of USA and Canada, Spain, Germany etc – It just remains to be seen how many years the UK will cling on to outdated practices, and how many children will be harmed in the meantime.

 The New Zealand Guidelines: An Overview

*Note: The guide is written with many references to Maori terms and indigenous approaches. This heavily abridged version aimed at a UK and global readership just includes English terms – the guidance is worth reading in full.

Commits to gender affirming healthcare (UK GIDS does not offer this)

Gender affirming healthcare (definition): “Healthcare that is respectful and affirming of a person’s unique sense of gender and provides support to identify and facilitate gender healthcare goals. These goals may include supporting exploration of gender expression, support around social transition, hormone and/or surgical interventions. This may also involve providing support to family, caregivers or other significant supporting people”.

“Children and young people: For the purposes of this guideline: those aged up to 11 years are considered children; those aged from 12 to 24 years are considered to be young people”

Normalises gender diversity, normalises rise in referrals (UK GIDS describes the rise as ‘unexpected’ & speculates negative reasons for the rise)

“Internationally and within New Zealand there has been a substantial increase in the demand for gender affirming healthcare over the past decade. The Youth secondary school survey, estimated that approximately 1.2% of adolescents in New Zealand identify as transgender. It is likely that this level of referrals to health services will continue in the foreseeable future.”

Prioritises autonomy and avoidance of pathologisation (UK GIDS does not)

“Autonomy: Autonomy in the context of transgender healthcare involves transgender people being able to able to make informed choices for themselves regarding gender affirming care and being free from experiencing harmful pathologisation and other barriers to accessing this care.”

Acknowledges the importance of partnering with trans communities (UK GIDS does not)

“To successfully enhance the health and wellbeing of transgender people, providers need to partner with transgender communities to shape these services.”

Acknowledges that gender affirming healthcare is medically necessary (UK GIDS does not)

“The medical necessity of gender affirming healthcare has been acknowledged by WPATH, the Australian and New Zealand Professional Association for Transgender Health (ANZPATH) and many other international organisations.

The Yogyakarta Principles pull together existing international human rights legal standards which state that transgender people have the right to access the highest attainable standard of gender affirming care.

Acknowledges the impact of social stigmatisation including in the healthcare system (UK GIDS does not)

“Social stigmatisation and discrimination, including within the healthcare system, present additional barriers to accessing health services and contributes to adverse health outcomes”.

Prioritises community leadership (UK GIDS does not)

“Community leadership: This guiding principle informs us that for health promotion to be effective it needs to be led by relevant communities. Health professionals have important roles to play but cannot replace the leadership which exists in communities. An example of this is the partnership between transgender communities and the Northern Region health board from 2014 to present. Transgender people have been involved in the steering of the project, including development of services and these guidelines. The importance of trans community leadership in the development of trans healthcare services is paramount.”

Recognises the importance of different areas of health: (UK GIDS does not)

“Transgender health recognises the equal importance of spiritual health, family health, mental health and physical health.”

Acknowledges legacy of pathologisation of gender diversity and clarifies it is not a mental health illness, acknowledging the importance of avoiding stigmatisation (UK GIDS does not)

“Historically transgender healthcare has suffered from the pathologising of gender diversity and the inappropriate labelling of gender/cultural identity and expression as a diagnosed mental health illness. The resulting legacy of this pathologisation is a tension in health services between the need to avoid further stigmatisation while simultaneously acknowledging the importance of the wider concept of mental health as part of holistic healthcare delivery.”

Prioritises informed consent and self determination (UK GIDS does not)

“The practice of informed consent in relation to gender affirming healthcare is important because it reaffirms the self-determination of the transgender person and their knowledge of their needs, identities, and self. Informed consent enables the health provider to work alongside the transgender person in a flexible and responsive way”.

Recommends involving trans people in development and provision of services. (UK GIDS does not)

“Health services enable the involvement of trans and gender diverse people, including Māori trans people, in decisions that affect them with regard to the development and provision of services.”

Commits to improving based on feedback (UK GIDS does not)

“Health services have a process for receiving feedback and evaluating people’s experience that report on outcomes and commit to acting on the feedback/data received to improve services.”

Recognises impact of colonisation in persecuting gender minorities who were accepted and valued in pre-colonial society (UK GIDS does not)

“It is increasingly apparent that, in Aotearoa pre-colonial Māori society, people of diverse genders and sexualities were both accepted and valued within extended families. The colonisation in the 1800s by the British had a huge impact on Māori culture and society. Any expression of gender or sexual fluidity was strongly discouraged by the missionaries. Recorded histories overlooked or erased stories of takatāpui.

Likewise, Pacific cultures also accepted gender diversity as part of the normal range of human expression. The impact of colonisation of many of the Pacific Island nations through faith-based missions and colonial government administrations has had a negative impact on the acceptance of gender diverse people.”

Recognises the minority stress intrinsic to living in a transphobic society (UK GIDs does not)

“Tangata takatāpui moved from a social and cultural situation where minority stress was simply not a factor in the pre-colonial world of Māori, to one where it has become a key force in the negative health outcomes they experience”.

“Minority stress: Minority stress theory suggests that trans and gender diverse people experience stressors as a result of sociocultural sanctions about being transgender and/or gender nonconforming. These include prejudice, discrimination and violence which negatively impact on physical, social, spiritual, and psychological wellbeing. It is important to note that minority stress results from a multitude of everyday events that trans people experience. Daily stressors for trans people can include not being affirmed by health providers, being asked invasive questions in inappropriate settings, or not having access to a safe public bathroom. Minority stress here includes the economic stressors that many trans and gender diverse people also negotiate.”

Recognises that supporting wellbeing of trans people must include addressing these barriers to health (UK GIDS does not)

“Supporting the wellbeing of transgender people includes recognising that barriers to health, housing and employment will have negative health impacts. Improving health services is part of creating health, education, housing, and employment environments that are accessible, respectful, and inclusive of trans and gender diverse people”.

Recognises the importance of trans positive health services (UK GIDS does not)

“Trans positive health services: Primary and secondary health services that are respectful and affirming of people’s gender identities can have a positive impact on trans people’s well-being. There are many important nonmedical supports that can be useful for health services to be aware of when supporting people who are socially transitioning.”

Supports social transition (UK GIDS does not)

“Social transition: Social transition consists of the steps many transgender people choose to take to alter their presentation in the world to better align with their gender identity. Transition looks different for every individual and it is important to note that neither social or medical transition is required in order to be recognised as a trans or gender diverse person.

Transgender people should be supported through these steps of social transition to allow them to have positive experiences in the world as a truer representation of themselves. Social transition can also start out part-time in known safe environments, such as home or school.”

*Note there is nothing negative here about the psychological impact of social transition (GIDS latest scare story). There is no age-based barrier to support. No references to the discredited and harmful ‘watchful waiting approach’ that UK GIDS still clings to. Watchful waiting sounds benign. It depends what you are watching whilst you wait. For many trans kids, rejection causes immense harm. For many trans kids, affirmation and fully love and support allows our children to breathe, allows them to thrive, allows them to enjoy their childhoods. Why should trans children in New Zealand, Australia, USA, Canada, Spain (including Canary Islands) have happy childhoods whilst UK trans children are left depressed, rejected, ashamed.

Recognises family health (UK GIDS does not)

“Family Health: There are many forms of family support; a parent looking out for their trans child, an adult supporting their trans partner or parent through transition, a family advocating for respectful care of their trans relative in a resthome. In reality it is not just one person who ‘transitions’ but the whole family”.

Highlights that family support is a HIGHLY protective factor (UK GIDS does not)

“Family and young people: Family support is a highly protective factor for trans young people. Research shows that trans young people reporting strong family connectedness have a greatly reduced likelihood of poor mental health, even when experiencing stigma and discrimination elsewhere. Family support provides a place from which takatāpui rangatahi can draw strength and resilience to help deal with the challenges they face outside the family.”

Prioritises helping parents gain support to understand their loved one (UK GIDS does not)

“Parents report a range of emotions following disclosure from their child that they are transgender, including confusion, the need to have time to process, the need to grieve for the loss of a son/ daughter, fear for the future and acceptance of their child. While the young person is likely to have spent considerable time developing an understanding of who they are, families may perceive the change as being sudden and require time to adjust. Families report that they need information and time to understand their loved one’s journey. It is an important part of the role of health services to support this process. Some families find joining parent support groups helpful.”

Recommends primary and secondary health services provide clear, unambiguous affirmative advice to parents/carers (UK GIDS does not)

“Practice points: Primary and secondary health services need to provide education, promote connection to family and to support family to be able to support gender diverse children and young people through simple advice:

  • Assure your child/young person that they have your unconditional love and support, or at least that you will commit to their journey with them.
  • Encourage exploration of how they express themselves. It is important that young people have spaces in which they feel safe enough to explore their gender.
  • Use the child/young persons preferred gender pronouns (he/him, she/her, they/them etc) and preferred name when they are ready to do so. Support family and friends to do the same, providing it is safe to do so.
  • Provide written/online information for family.”

Is confident and non-pathologising on topic of transgender children (UK GIDS is not)

“Gender diverse children: Many children explore different ways of expressing their gender though play. Most of these children are comfortable with the sex they were assigned at birth, although some are not. Some children will assert themselves as a gender different from the sex assigned at birth. These transgender children are usually insistent, consistent and persistent in their gender identity and may exhibit distress or discomfort with their physical body. Some transgender children are aware of their gender identity from a very early age, while others may take some time to figure it out or find a safe way to express it. Children can be very aware of the disapproval of those around them and may try to hide their feelings about their gender. For gender expansive children, including those who may identify as transgender, no medical intervention is needed pre-puberty.”

*Note the way the language is affirming and reassuring about young trans children as well as affirming and reassuring about children who are aware of their identity later. The UK uses language that is unsupportive and un-reassuring about both.

Is clearly supportive of a gender affirmative approach for trans children, including unambiguous support for social transition (UK GIDS is not)

“Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach which involves assisting children to create an environment where their gender can be affirmed. This might require providing education and support for families and schools to be able to support the gender diverse child to navigate a social transition and helping children to develop the coping skills to address any negative reactions that they might experience for being gender diverse. Family may want support from their primary care health team, a paediatrician, child and adolescent mental health service or parent support group to work out how best to support their child. This is particularly important if there is associated distress related to gender identity.

*note no fear mongering on social transition, no words of concern and caution, no words about regret or desistance, nothing on need to delay, deny or diagnose.

*note the emphasis on providing assistance externally, to make the world a better place for a trans child. The UK focuses their effort internally, onto the trans child themselves, focusing on psychoanalysis of that child, making their gender diversity the problem.

Non-pathologising about trans adolescents who are aware of their identity at puberty (UK GIDS is not)

“Young people: Trans young people may present to a range of health providers requesting support with their gender identity, so all health teams need to be able to provide an inclusive environment where young people will feel safe talking about their gender. Some young people present with longstanding diverse gender identities since childhood, while others find that adolescence was a crucial time for the development of their gender identity. Identity may emerge during or after the onset of the physical changes brought on by puberty and the changing social and romantic interactions with peers.

*note no scaremongering about social contagion. No scaremongering about adolescents confusing gender for sexuality. No scaremongering about social media and the influence of the internet. No undermining of the validity of trans teens who become aware of their identity at or after puberty (all of these have been talked about in the media by UK GIDS).

Non-pathologising understanding of gender fluidity (UK GIDS is not)

“Similarly, some previously gender expansive children may shift along the gender spectrum to find their gender identity more aligned with the sex assigned at birth. In all of these situations, these young people and their families will benefit from supportive healthcare providers who pay attention to how the young person is expressing their gender.”

*Note the guidance sees no trade-off or tension between supporting trans kids and supporting kids who shift gender modality. It argues that both benefit from supportive healthcare. UK GIDS likes to argue that their known harm to trans kids somehow benefits kids who might shift gender modality (despite no evidence of this).

Focuses on co-existing concerns without using co-existing concerns as a pretext for denying identity or delaying affirmation (UK GIDS does not)

“Trans young people need to be assessed routinely for risks around abuse, bullying, drug and alcohol use, nutrition and unhealthy eating behaviours, sexual health and any mental health concerns“

*It would not be surprising to me if youth with co-existing issues are better able to address other co-existing issues, once their gender is affirmed. In the UK adolescents with co-existing concerns are denied affirmation of their gender, on the pretext that their gender issues may be symptoms of a misguided coping strategy for dealing with other issues. There is no evidence for this approach which is rejected elsewhere and causes harm to some of the most vulnerable youth (eg descriptions of children and teens in UK GIDS having their identity invalidated and being forced to discuss trauma as a potential cause of gender ‘confusion’ if they have suffered abuse or bereavement).

Prioritises peer support (UK GIDS does not adequately encourage peer support and some media engagement has encouraged scaremongering on ‘social contagion’, discouraging wary parents from helping their child connect to peer support)

“Trans young people often benefit from being linked into supportive peer groups, including online groups.”

Understands trans kids may find puberty difficult (UK GIDs recent media engagement seemed to suggest that trans kids were finding puberty difficult because of being too supported and affirmed in their childhood – they suggested childhood rejection was the best way to avoid trans kids worrying about puberty)

“Anticipation of and/or experiencing pubertal body changes can be very distressing.”

Is clear and unambiguous on evidence of benefits of puberty blockers and gender affirming care (UK GIDS is not)

“There is good evidence that puberty blocking and gender affirming care for trans young people significantly improves mental health and wellbeing outcomes.”

When parents are unsupportive, unequivocally prioritises the need of trans adolescents, even under age 16 (GIDS does not)

“Decisions regarding medical interventions are ideally made collaboratively between the trans young person, their family and the health team. However, it is not always possible to involve family. Lack of family support does not preclude trans young people from accessing care. While young people aged 16 years and older are considered to be able to make decisions about their medical care younger people are not prohibited from consenting to medical interventions if the young person is deemed to be competent to make an informed choice. To assist this informed consent process, we recommend that gender affirming healthcare for young people is provided within a multi-disciplinary team”.

Prioritises the importance of trans students being in school (UK GIDS does not. In UK, the number of trans children out of school (often due to mental health problems linked to continued rejection, minority stress, violence, bullying) should be a national scandal)

“Schools: Feeling connected to school is also a significant protective factor for trans young people. Schools have an obligation to provide safe environment for their students. The Youth New Zealand school survey found that while 74% of trans young people thought that school was okay, 54% were afraid that someone at school would hurt or bother them. There are a range of support materials available for schools.”

Clearly is on the side of trans students and unambiguously supports the need for records to correctly reflect gender identity (UK GIDS does not)

“However, many students have reported to us that they still experience barriers to updating school records to correctly reflect their gender identity and experience gender-based exclusion from activities such as joining sports teams, choirs and groups”.

Recommends schools provide information on gender affirming healthcare (UK GIDS does not)

“Practice points for school health teams • Have information on gender affirming healthcare services readily available and on display. • Provide training on working with transgender students for the whole student health team”.

*UK language from GIDS to schools can be the opposite of affirming, referring to complex cases, pathologizing and stigmatising gender diversity and discouraging schools from full support.

Is interested in the general wellbeing of trans students (UK GIDS focuses on gender identity, is not proactive on discrimination)

“School health teams should: “• Have information and support available for transgender students who experience discrimination from students or teachers. • Be connected to local health and social services in your area that specialise in working with transgender young people. • Enable students to establish a diversity group or other support for transgender students (if they desire to do so).”

Provides clear affirmative guidance for family members: (UK GIDS does not)

“• Listen first and foremost. Be available to listen to your family member’s experiences. Make an active effort to listen without judgment. Remember that advice isn’t always necessary; sometimes all they need is a kind ear. • Respect trans people’s pronouns  Trust that they are making the right decisions for themselves. • Educate yourself and others”.

Recommends family members listen to and learn from trans people (UK GIDS does not)

“Read and listen to the stories of transgender people. This will give you a better understanding of their experiences and enable you to interact in a positive way with your family member.”

Encourages peer support (UK GIDS does not)

“provide easily accessible information and access to peer support services for trans people of all ages and their family”.

Recommends children receive gender affirming healthcare (UK GIDS does not)

“That gender affirming healthcare services for children and young people are provided by clinicians with expertise in child and youth development.”

*note there is no requirement for psychoanalysis, the foundation of the UK GIDS service.

Non-pathologising approach to mental health of trans people (UK GIDS does not)

“Mental health: Trans and gender diverse people have the same inherent potential to flourish and thrive as other people, but currently experience increased risk of harm because of discrimination, social exclusion, bullying and assault, as well as institutional barriers such as difficulties accessing healthcare, bathrooms, and appropriate legal identification. Trans people from ethnic minority or refugee backgrounds are likely to be at even greater risk of experiencing harm.”

*GIDS does not acknowledge that trans kids have the same inherent potential to flourish and thrive. It does not acknowledge that the mental distress trans kids face is in large part due to cisnormativity and transphobia, including in (and encouraged by) NHS health services.

Acknowledges wider determinants of health (UK GIDS does not)

“It is becoming increasingly accepted that it is the additive effects of minority stress that results in mental health difficulties. It is important that health services acknowledge these wider determinants of health and the potential role they play in leading positive societal change to improve health outcomes”.

*The best things NHS GIDS could do for trans children is to give clear unambiguous affirmative trans positive statements about trans children to schools, to parents, to the UK media. Instead they do the exact opposite, making life so much harder – literally making minority stress and wider determinants of health worse. Where is the commitment to Do No Harm when it comes to the NHS and trans children?

Explicit on benefits of affirmative care on mental health and wellbeing (UK GIDS does not)

Being transgender is often but not always accompanied by gender dysphoria, a person’s discomfort or distress with their body or gender roles associated with their sex assigned at birth. Constant reminders can be experienced when showering or dressing. However, increasing evidence demonstrates that supportive, gender affirming care for trans people significantly improves gender dysphoria and mental health and wellbeing outcomes. International studies consistently show high rates of mental health issues such as anxiety and depression for trans people. In New Zealand the Youth’12 secondary school survey highlighted the mental health disparities experienced by transgender young people compared to their cis gender peers with 41% vs 12% experiencing significant depressive symptoms and 20% vs 4% reporting an attempted suicide, respectively, in the past 12 months. Because of the high prevalence of mental health problems among trans people, health services that are multidisciplinary and include mental health professionals will be more responsive to the on-going needs of trans people accessing gender affirming health care.

Psychotherapy is not mandatory (psychoanalysis is integral to UK GIDS)

The role of mental health professionals: Trans people may seek support from mental health professionals for a range of reasons, including support related to their gender or concerns with their mental health. Mental health professionals should be aware that mental health problems may be related to the effects of minority stress for being transgender or may be due to other causes. While many trans people access psychotherapy for support with living in their affirmed gender, psychotherapy is not a requirement of accessing gender affirming care. Mental health professionals with the appropriate skills and knowledge can assist with the informed consent process for readiness for gender affirming hormones. The WPATH SOC state that it is important for mental health professionals to have open dialogue with prescribing practitioners, and other providers of a trans person’s care and to access regular peer consultation and feedback. These mental health professionals should have the knowledge to provide information to trans people regarding gender affirming care treatment options and community support availability”.

Recognises the duty of health service providers to be an advocate for trans people (UK GIDS absolutely does not)

Finally, an important component of ethical health care provision is for providers to be advocates for the trans people who use their services. This could include educating or working with family members, schools, workplaces, healthcare settings, and other parts of the community on being inclusive and affirming of trans people. Recognising stigma, discrimination, and violence as the source of many issues that trans people face in Aotearoa, New Zealand, all health professionals should work collaboratively with trans people to advocate for social and public policy change to reduce the negative effects of minority stress”.

Mental health issues are not a barrier to gender affirmative care (In UK GIDS they are)

“Practice points • Include mental health issues as part of a holistic psychosocial assessment, for example discussion of anxiety, depression, risk of self-harm, while being clear that having mental health issues is not a barrier to accessing gender affirming services. • With the involvement and consent of the transgender person, plan for provision of on-going support for any mental health issues identified. • Respect the self-determination of each person as being the expert on their experience. This is often referred to as the “informed consent model” of gender affirming healthcare because it counteracts pathologisation and repositions the transgender person as being at the centre of their own life. • Recognise the impact of hostile environments on trans and gender diverse people, (i.e. minority stress) and validate the experiences that people have navigating those environments. • Ensure access to gender affirming health services alongside secondary mental health services: provide clear information about what to expect from secondary mental health services if referrals are appropriate, and work alongside secondary mental health services if they are involved”.

Recognises that trans children/young people may want support with challenges that are not related to gender (UK GIDS forces a prolonged focus on gender as the problem)

“When discussing stressors, follow the transgender person’s lead as to whether their current challenges and health needs are focused on their gender or on something else in their life. • Listen to each transgender person about ways that they would appreciate you advocating for them, which may be on an immediate interpersonal level (for example with family members or other health providers) or on a broader level in relation to other settings such as schools and workplaces”.

Embeds guidance for trans children in guidance for trans people of all ages (UK GIDS keeps trans children separate – using this to maintain a greater degree of pathologisation than would be accepted in adult care). Eg this section on pronouns is written the same for adults or children. Children are not treated worse just because they are young.

“Listen and reflect back the language each person uses about themselves, including gender identity terms, preferred names (even if not legally changed) and correct pronouns”.

Recognises neurodiverse people can also be trans (UK GIDS raises extra barrier to care for neurodiverse children and young people. In the media and to parents UK GIDS emphasises neurodiverse children and young people may be confused about gender identity)

“Neurodiversity and gender diversity It has been increasingly recognised that neurodiversity (autism spectrum) is common among the transgender community. Involving clinicians with the relevant diagnostic skills can be helpful for some people, as being able to identify as being on the autism spectrum can be helpful to understand behaviour and learn strategies to manage any difficulties. It is important to acknowledge that the person presenting is the expert on their own experience. Although some neurodiverse people may have difficulty in articulating their gender identity, this should not create an unnecessary barrier to access any relevant gender affirming services. Some people may express their gender identity non-verbally. The presence of neurodiversity can add complexity and extra time and support may potentially be required to help navigate all stages of the gender health journey including gender exploration, social, medical and surgical transition. Family may need support to understand more about the co-existence of neurodiversity and gender diversity, so that they understand that it is a common overlap and that being on the autism spectrum does not invalidate being transgender or seeking health services as part of transitioning.”

*See how reassuring the language is above. We never hear this from UK GIDS, who encourage allistic parents to reject neurodiverse children’s gender identity (for insistent trans children, the euphemisms that UK GIDS uses to avoid accusations of conversion therapy ie ‘delay’ ‘caution’ ‘watchful waiting’ equals rejection in practice).

“It is recommended that clinicians consider two key questions when working with people on the autism spectrum: • Is the gender identity clear, urgent, pervasive, and persistent over time? • Does the gender dysphoria increase or decrease with interventions?”

Physical Health is dealt with alongside wider health dimensions (UK GIDS focuses on psychoanalysis to test/validate gender identity followed by physical interventions)

“The physical dimension is just one aspect of health and well-being and cannot be separated from the aspect of mind, spirit and family. These guidelines are based on the principle of trans people’s autonomy of their own bodies, represented by healthcare provision based on informed consent.”

Prioritises informed consent (UK GIDS does not)

“Medical treatments such as hormone therapies and surgical interventions may also be an important part of a person’s transition and physical health. While many trans people will benefit from hormone therapies and surgical interventions, some may choose only one of these options and others may decide to have neither. For those who are seeking medical support, access to competent care through an informed consent model is of paramount importance.

In regards to transition goals, it is important to recognize that each person will articulate these differently. It is not helpful to assume that everyone wants to conform to binary gender norms and clinicians need to be aware not to impose a binary view of gender.

The importance of discussing individual transition goals and individualising treatment options is especially true for non-binary people but also applies to those with a more binary gender”.

States unambiguously that withholding gender affirming treatment is not a neutral option (UK GIDS does not)

“Withholding gender affirming treatment is not considered a neutral option.

Avoiding harm is a fundamental ethical consideration for health professionals when considering healthcare. Withholding gender affirming treatment is not considered a neutral option, as this may cause or exacerbate any gender dysphoria or mental health problems. Conversely, access to gender affirming care may reduce the mental health pressures a trans or gender diverse person is experiencing. This does not discount that clinical decisions can be complex, particularly where there is family opposition for young people, the person is neurodiverse or has complex mental health needs. It is best practice that gender affirming healthcare is provided by well-resourced multidisciplinary teams that include mental health professionals and have good links with peer support groups.

Practice points: Acknowledge that withholding gender affirming healthcare is not considered a neutral option”.

Being trans and wanted to socially transition is not a mental health condition, mental health support should be optional not mandatory (in UK GIDS it is mandatory and indeed at the heart of their approach)

“Social transition can be a stressful time for some people who may benefit from extra mental health support, but it is important to ensure that they consent to having this support and it is not enforced as a requirement for accessing gender affirming care.”

Emphasises that much can be done in primary health care (UK GIDS continually communicates how specialist and complex everything linked to trans children and young people is)

“Accessible gender affirming care involves people being able to access this care as close to home as possible. There are limited numbers of teams that are specialised in gender affirming care in New Zealand and these are receiving increasing demand. Primary health providers should be aware of the barriers and potential harms with requiring people to travel or wait to access care and might consider assessment and provision of gender affirming hormones within the primary care setting.”

Emphasises clearly and confidently the positive impact of puberty blockers on wellbeing (UK GIDS does not talk in the below terms about puberty blockers)

“Puberty suppression using GnRH agonists: Health teams need to be aware of the positive impact of puberty blockers (GnRH agonists) on future well-being. Be mindful of the need to refer promptly and be aware of referral pathways. Puberty blockers can be prescribed from Tanner stage 2 to suppress the development of secondary sex characteristics, although are still beneficial when prescribed later in puberty to prevent ongoing masculinisation/feminisation. Puberty blockers are considered to be fully reversible and allow the adolescent time prior to making a decision on starting hormone therapy. They do not stop growth or weight gain, and monitoring of height is recommended as adult height may potentially be increased if prolonged puberty suppression delays epiphyseal fusing. A bone age may be helpful to assess whether epiphyseal closure has occurred when considering what rate of hormonal induction to use as this may potentially impact on final height. Puberty blockers halt the continuing development of secondary sexual characteristics, such as breast growth or voice deepening, and relieve distress associated with these bodily changes for trans young people. For trans women and transfeminine people, they will prevent further masculinisation of the face and body that typically occurs into early adulthood.

*Note how confidently New Zealand health guidance talks about puberty blockers. GIDS does not talk in such reassuring ways about puberty blockers. GIDS instead speculate on an unevidenced theory about blockers potentially affecting brain development in mysterious and unstated ways. Brain development! This sounds really scary! But actually it is fully unscientific and vague – the kind of speculation you get from psychoanalysis who are not medically qualified. Do you think paediatricians go around speculating (with zero evidence) to parents about the irreversible impact on brain development of a drug that they have just prescribed to a cis 12 year old? They say ‘we don’t fully know the impact of them on adolescent brain development’. They also say things like ‘they are not reversible, as if you have taken them, you won’t know what it is like to have never taken them’. Well no shit sherlock but that isn’t what we are talking about when we talk about whether or not drugs are reversible. They also basically say to parents ‘there’s no evidence’ and ‘we give these blockers out but we don’t know what we are doing or if maybe it is the wrong thing to do’. Some anti-trans clinicians are known to tell parents that they believe blockers are harmful.  Goodness me – no wonder there is so much hysteria in the UK on trans children’s healthcare when the NHS is telling parents and media that it is prescribing drugs it does not have confidence in. The way in which UK GIDS communicates about puberty blockers is an indication of the systemic transphobia in UK GIDS – it causes real harm and negative health outcomes for trans children and families.

Access to gender affirming hormones on an individualised basis (not possible in UK GIDS)

“Gender affirming hormone treatment. In New Zealand young people aged 16 years and older are considered to be able to consent to medical care (Care of Children Act 2004), however it is increasingly recognised that there may be compelling reasons to initiate hormones prior to the age of 16 years for some individuals, although there is as yet little published evidence to support this. Consideration should be given to the individual circumstances including family support, length of time on blockers, concerns around final height, risks of delaying hormones and most importantly the ability to consent”.

Having mental health concerns is not a barrier to affirming care (It is in UK GIDS – being out of education (eg due to schools being able to tackle transphobic bullying, being depressed etc is a barrier to accessing HRT in UK GIDS)

“The WPATH standards emphasise that the having medical or mental health concerns does not mean gender affirming care cannot be commenced, rather that these need to be responded to alongside gender affirming care.  According to the standards, this readiness can be assessed by a prescribing provider or mental health professional who is experienced and competent at working with trans people.”

*Who gets to decide the definition of ‘competent at working with trans people? Would anyone in UK GIDS pass? I have heard of maybe three clinicians out of 60+ who people have regularly positive feedback on.

Clear, reassuring, easy to understand communication on the effects of masculinising hormones or feminising (GIDS does not provide it so clearly for public understanding)

table 5b

table 6a (2)

Fertility

I’ve not much considered the sections on fertility in this blog as a bit off my main focus. But two bits stood out. There is an Annex B on fertility information. I wasn’t clear whether this leaflet is accurate for those who have had blockers at Tanner stage 2 and never progressed beyond Tanner 2 of the puberty associated with their assigned gender?

Consent for form blocking testosterone is very clear, confident and reassuring, and also includes information on the harms of NOT blocking testosterone

“Annex C: A consent form for blocking ‘male’ hormones”.

Includes clear language on common side effects

“• Hot flushes • Mood swings – mostly in the first few weeks of starting • Possible fatigue. Most side effects should settle within a few days to weeks of starting the medications. Allergic reactions can happen but are rare. Please tell your health team if you have any problems. Potential risks of blockers • Increased height (unlikely if already through puberty) • Decrease future bone density”

Also includes:

Risks of withholding blockers: Withholding the use of blockers may cause additional distress leading to anxiety and depression. Not using blockers can also lead to irreversible unwanted physical changes”.

Interesting mention of need for contraception whilst on blocker, is this included in UK guidance?

Consent for form blocking oestrogen is very clear, confident and reassuring, and also includes information on the harms of NOT blocking oestrogen

“Annex D; A consent form for blocking ‘female’ hormone”.

“Blockers are a reversible medication used to stop the physical changes of puberty. It can be started in early puberty (Tanner stage 2–3). If started then blockers will usually stop significant breast development and further pubertal changes such as starting periods and widening of the hips. Blockers can also be started later in puberty where it may cause breast tissue to soften but not usually to reduce significantly in size. Blockers will stop periods but may take up to 3–6 months to do so

Starting a blocker often improves psychological distress associated with having the unwanted female hormone and allows time to think about whether starting testosterone is right for you.

Common side effects

  • Hot flushes • Mood swings – mostly in the first few weeks of starting • Possible fatigue. Most side effects should settle within a few days to weeks of starting the medications. Allergic reactions can happen but are rare. Please tell your health team if you have any problems. Potential risks of blockers • Increased height (unlikely if already through puberty) • Decrease future bone density”.

Also mentions:

Risks of withholding blockers: Withholding the use of blockers may cause additional distress leading to anxiety and depression. Not using blockers can also lead to irreversible unwanted physical changes”.

Dr Jo Olson-Kennedy on puberty, blockers and hormones

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Dr Jo Olson-Kennedy, world leading expert in support for trans children, recently gave a talk at Gender Odyssey in Seattle. She provided with great clarity a wonderful overview of puberty, blockers and hormones for trans children and adolescents. The talk was recorded, and for the benefit of those interested in best practices in healthcare for trans children, I’ve written a transcript of sections of the second half (any errors in transcription are mine).

This was a talk aimed, in part, at parents of trans kids. Note the level of knowledge and the effort to explain complex topics to parents. We never hear anything like this level of sophistication combined with practical guidance from the ‘experts’ in the UK. In part this is because the UK ‘experts’ do not see their role as one of education, and in part it is because the UK ‘experts’ do not have anywhere near this level of knowledge.

Two other things you’ll note from Jo Olson-Kennedy’s presentation that you never hear from UK GIDS. 1: Respect and 2: Individualised care.

Note how each child is treated with respect and dignity. Note how each child is provided with individualised care intended to meet that child’s need. No rigid, harmful, one-size fits all protocols. No defensive or transphobic practices either.

The UK children’s gender service is run by psychologists, psychotherapists and psychoanalysts with a few psychiatrists and social workers on the team. Not one paediatrician. Jo Olson-Kennedy, on the other hand, is a paediatric Medical Doctor. Similarly, the head of the Australian Children’s Gender Service, Michelle Telfler is a paediatrician.

It is time to move UK trans children’s healthcare out of the hands of psychologists, psychiatrists and psychoanalysts. Being trans is not a mental health condition. We need medical doctors and affirmative counsellors to build resilience, along with family therapists, the latter as much to support and educate parents, as to support the child. Mental health specialists only getting involved to support either where there is a mental health issue, noting that gender identity is not in itself a mental health condition, or where a client expresses a desire for psychotherapy.

Supported trans children have good levels of mental health and do not need engagement with a mental health service. Instead, they need knowledgeable experts with empathy, ability to build resilience and confidence, and paediatric medical doctors with the ability to treat trans children with dignity, care and respect. Moving trans healthcare from specialist mental health facilities to medical doctors (eg in primary care) is common place in other countries (including parts of Canada) and could easily be introduced here.

On to Jo Olson-Kennedy’s presentation, first on puberty tanner stages:

“Everyone is born at tanner 1, there is no zero. For people with overies tanner 2 is the differentiation of the nipple areola complex from the rest of the chest and there are palpable buds that feel like buttons, that is tanner stage 2 of chest development. Tanner 3 is actual chest tissue that is different from the fat chest wall. For people with testes T2 is testicular enlargement to 4 ccs, we use an orchiometer to assess testes size, 1 inch long half an inch wide.

Pubertal timeslines are different in overian and testicular puberty. For trans masculine kids we’re talking about 9, 10, 11 (these estimates are for white kids, people of colour go through puberty at earlier ages). Preventing puberty is needed earlier for trans masculine kids.

Peak growth velocity is also different and happens at different stages of puberty. For people with ovaries the greatest changes are in stages 2 and 3 of puberty. For people with testes the greatest changes are at tanner 3 or 4. When we think of the timelines for preventing pubertal changes we have to pay more attention to our trans masculine kids than our trans feminine kids because the changes that are really horrible for trans girls are later, you don’t go to tanner 2 and get a moustache or facial hair, your voice doesn’t even drop, those are all later.

What precedes gonadal puberty is adrenal gland development. This is critical. Because 6 to 18 months before your gonads started chugging away, your adrenal glands start, in all bodies, putting out a hormone (DHEA?) which is an androgen like hormone. This causes pubic hair, axillary hair, body odour, and parents who have kids who have transitioned at 5 will have body odour panic, pubic hair panic ad I want you to know that if this is happening at 7 or 8 years old it is probably not gonadal puberty it is probably adrenal gland development, and there is no way to block that and we would not want to, the adrenal glands are super critical to life.

What happens when puberty starts?

When puberty starts your hypothalamus talks to your pituitary gland through a hormone called gonadotropin releasing hormone (GNRH), and gonadotropin releasing hormone is called that because it causes the pituitary gland to release gonadotropins, which are lutinising hormone (LH) and follicle stimulating hormone (FSH). This is true of everybodies body. This stimulates your gonads to release their sex steroids. Early in puberty and throughout puberty you secrete gonadatrophin releasing hormone in pulses, it is diurnal, once in the morning, once in the evening, LH and FSH come out in pulses, and sex steroids come out in pulses, all these things are on a feedback loop, when there is a lot of sex steroid it feeds back to reduce production.

If you have ovaries you get oestrogen and progesterone and breast development, wider hips, periods. If you have testes you get facial hair, adams apple, broadening of shoulders etc.

Case study: 10 year old assigned female at birth, socially transitioned at 5. 5 months before I got the phone call the kid’s chest development had started and they would not come out from under their bed and go to school. 10 years old. Horrific anxiety. These kind of cases. There’s really no challenge to them. They are not complicated. This kid needs blockers.

How do blockers work?

We give a biosynthetic or analogue version of gonadotrophin releasing hormone. It is called a blocker but really that is an erroneous term, it is actually an analogue, instead of getting it in pulses, instead the body gets it in a steady state, the receptors get down regulated and now no signal to the gonads to make sex steroids. It is specific to this particular pattern of development. Does not impact your thyroid. Does not impact your growth hormone. Does not impact your social development or your cognitive development. We mimic the action of GNRH and down regulate those receptors and you do not now have a message from your brain to your gonads. When you go onto continuous GNRH you get a giant pulse and then it comes down after those receptors are down regulated. That is really important because if your kid is going to go on to a blocker, they may have 4 or 5 weeks of crappy. They may have 4 or 5 weeks of emotional lability because they are getting a strong message to release their endogenous hormone and that can be really upsetting to people.

How do we know they are reversible?

Because we use GNRH analogues for a whole load of other medical conditions, we use GNRH analogues for people who start puberty at 6, 7, or 5, we don’t want them to go into puberty at 5 for a whole host of reasons. We use GNRH analogues whenever we want to shut down the hypothalamus pituitary gonad axis, so if you have a hormone dependent tumour, we want to stop the production of hormones eg prostate cancer. Also for endometriosis.

Kids have puberty panic when they are trans ‘oh no I’m going to wake up with a beard’ – so it’s real important to talk to kids and say puberty is a process, you don’t go from tanner 1 to tanner 4 in a day, that’s not how that happens. But they are very vigilant and I have a lot of trans girls in my practice who are ‘I’m pretty sure I have facial hair’ and their voice is super high and I’m like ‘no, that’s not the order of that, that’s not how it goes’, so it’s important to have those conversations. But if you’re that panicked you actually can’t participate in your life, because this is taking up a lot of bandwidth.

So how do we do this? One is injectable and the most common one we use in the USA is Lupron. There is a subcutaneous one but doesn’t have an intermediate dose so can be challenging, then there is an implant that has a medication called Histrellin which is also a GNRH analogue, Histrellin is a really small implant, goes under the arm, lasts for 2-3 years, we take them out at 2 years as our surgeons find they become more embedded after 2 years and are harder to get out.

No blockers are FDA approved for trans care, not because we haven’t been using hormones for one hundred years because we have, but because there are levels of discrimination at our highest places.

Histrellin implants are sold as two brands, one has a pediatric indication in precocious puberty – 50mg histrellin secretes 65 micrograms a day. The other one has an adult indication, it has 50 mg histrellin secretes 50 mg a day. Both are equally efficacious in suppressing puberty in kids with gender dysphoria, there is a significant difference in cost. None of these are FDA approved so you may as well get the cheaper one which is $4,000, the other one is $35,000. Equally effective. I’m about to publish a study on this.

We have a discrepancy between the Endocrine Guidelines recommendations about blockers and what actually happens on the ground. So the Endocrine Guidelines recommends puberty blockers early to avoid development of secondary sex characteristics that are undesirable at tanner 2, tanner 3. But then they also recommend hormones at 16. The newest Endocrine Guidelines address this and says there are compelling reasons to start earlier than 16.

What happens is a lot of 13 and 14 year old trans masculine kids come (to the service), they are already through puberty, because they started at 10. When they go on to GNRH analogues, because that is what the guidelines guide you to do, they go in to menopause. They are in chemically inducted menopause, which means they have hot flashes, they will have insomnia, they will have short term memory problems, they will have exacerbation of depression. This is not really addressed and I wish more people, as they do this clinical work, are going to understand that this is 100% true. So we in my practice we actually add in low dose testosterone for kids who are around 13, 14 or so, because it helps mitigate those symptoms and I think that is really important.

Weight gain. Super common in kids going on blockers because of the complicated interaction of all of the hormones of puberty. Emotional lability – some kids just do not do well and I will tell you that I have more people having challenges with injections than implant. I just think it has to do with not getting a steady dose and getting blocker wearing off towards the end of the 3 months. Also, your kid does not need to go to the OR for an implant, it is a ten minute out patient procedure to numb the kid’s arm and put it in.

Transfeminine folks on GNRH analogues and small doses of oestrogen. Argh! I feel like in some ways we suspend those kids in the worst part of female puberty. It’s like ‘hey sit here for 6 months – none of your friends will be but here you go’ and it’s really hard on them, so the dosing can be problematic. I’m going to talk about that in hormones 201 this afternoon.

Bone density is important to keep an eye on. Bones density is the amount of bone material inside the bone – it starts going up much more rapidly at puberty, so when you go on blockers you now do not have that rapid increase so getting bone density scans at baseline to make sure someone isn’t starting with really low bone density is important, but also every year. Some people think we don’t need to do that, but there hasn’t been an awful lot published on this so we do it from a safety perspective.

Growth velocity slows down when you’re on blockers and here’s why. Kids still grow on blockers but don’t grow as rapidly as they would if they had not gone on blockers. This was a study which came out of the Netherlands which showed when you add in cross sex hormones there is a jump in bone density.

It is really hard to predict linear growth. I can show you my growth charts which have only increased my consternation about this. For trans masculine kids remember, most people with ovaries get to their final adult height 18 months after their first period, so in general if you are making mostly oestrogen in your body you are going to close your growth plates faster. Most people who have a testosterone driven puberty grow well on into adolescence.

Here’s an example growth chart for a trans masculine kid, they had their period here, and would have stopped growing 18 months later. But they went on to blockers and grew slowly and then went on to low dose Testosterone and that growth velocity picked back up again. This is a boy’s growth chart because that is what we are looking at, the growth of a trans boy on a boy’s growth chart.

Here is a trans girl’s growth chart. Here she is growing at a pretty rapid growth. Goes on a blocker, it slows down. Goes on a low dose oestrogen, look at this – holy moly! So that kid was completely panicked, the kid by this point was 15 and a half and some folks would be like ‘you can’t put that kid on an adult dose of oestrogen’ but yes you can and so I did, and it flattened out, I don’t yet know if this kid’s growth plates have closed or not.

When you measure growth velocity per year, pre-puberty 9 cm a year, on the blocker moves down to 7, then moves up to 13 cm (on low dose oestrogen), so that’s really fast for oestrogen. Oestrogen, both for oestrogen and testosterone driven puberty is what accelerates growth but then is also what closes the growth plates. Complicated.

Here’s another case study: This kid started blockers – most of my trans girls start blockers around 11 and a half or 12. On blockers growth slows down, put this kid on an escalating oestrogen and then growth goes up really high, then I said we need to up the dose of oestrogen to flatten out the growth curve, which it looks like we have.

In assigned females peak growth velocity occurs in tanner 2 in 40% individuals and 30% in tanner 3.

In assigned males peak growth velocity occurs in tanner 3.

Also growth isn’t stopped in all parts of the body simultaneously. Hands and feet fuse first, then arms and legs, followed by spine. When we do a bone age we do a hand scan and that might be premature for our trans boys.

Can we use blockers in later pubertal adolescents and young adults? Absolutely. Especially if parents or kids are not ready for hormones yet, if they are like ‘no I don’t want to do that yet’ or if the parents are (not on board), so there can be a role for blockers in kids who are not in tanner 2 or 3. But you have to be careful, especially about menopause.

You can use blockers alongside gender affirming hormones. This is important, because trans girls always have to be blocked, somehow, until they have no testes. But if someone is not planning to have that surgery, they will always need to be blocked, because they always have the potential for producing testosterone.

Non-binary. So many of my non-binary are ‘can I be on blockers forever?’ No. you cannot. Hormones are sadly binary. I am cool with non-binary kids being on blockers for maybe 2 years, around, but then I get nervous about bone density so we have to have that conversation.

Here are two case examples. Both 14 year olds, showing everyone needs an individualised approach. 14 year old assigned female had period year before I saw them, came out a year ago as male, some menstrual and chest dysphoria, no suicidal attempts, was socially transitioned living as himself. Same week, 14 year old assigned female. Happy childhood. Typical very common story for transmasculine kids, tom boy, sporty, at age 11 tanked, when puberty hit multiple suicide attempts, multiple hospitalisations, also socially transitioned living as male, kid felt very strongly about needing peer concordance, was already at tanner 5. First kid said ‘I want to be on blockers’. Second kid said ‘I want nothing to do with blockers I want to be on testosterone’. And that was right for him and he’s done great.

[Editor’s Note: earlier in the talk Jo Olson Kennedy makes reference to a WPATH presentation last year, where an unnamed person, said that almost all the kids they see who go on blockers continue in the service and they have no idea why. Jo Olson-Kennedy said she does know why those kids continue in the service – because they are trans! In the final section Jo Olson-Kennedy provides two case studies of examples she has come across when kids have decided to come off blockers.]

Let me tell you about 2 kids who went on blockers and chose to stop.

This kid, assigned female, started saying ‘I a boy’ at 18 months. At 3 years old the kid was in an enormous amount of distress saying I’m a boy. At three kid socially transitioned, started living as a boy. Lived as a boy – also liked dolls and sparkly shoes. Asked ‘if I’m a boy and I like girl’s clothes, am I cross-dressing?’ Said ‘I will live as a boy at elementary school, as a girl at middle school, and by high school I’ll know what’s right for me’. The kid decided to live as a girl at 9. 2 months later called me saying I have breast buds, I need a blocker. Said didn’t want breasts and wanted time to think. Went on blockers for 2 years. 2 years later came in and said I want blocker removed, I want to go through female puberty. I said ‘what is happening with your gender?’ They said ‘well, I don’t know yet’. I said ‘well what if it lands on boy’. The kid said ‘It’s 2017, who says boys can’t have boobs’. Touche small child, I will take your blocker out. So I took the blocker out and the kid continues to live as a girl. A year later calls to say ‘do you know where I can get a binder’. And I was like ‘oh your mum wants to pole her eyes out right now’. So this kid is extraordinary and their gender is still happening. And I asked them, do you think your parents should have supported you to live as a boy for so long, and they said, ‘I wouldn’t be here now if they hadn’t’. So that is testament to what it means to socially transition, go on blockers, come off blockers.

Another kid, assigned female, got blocked at 9, started testosterone at 13, discontinued both a year later, went through their endogenous puberty identifying as non-binary and a year later came back to start testosterone again.

So all of this is ok, and it’s all good and everyone’s going to go on their journey whether we want them to or not and we can make it easier”.

 

 

UK GIDS Failing Publicly

The heads of the UK Children’s Gender Identity Service (GIDS) have just published a new journal article, featured in the British Medical Journal ‘Archives of Disease in Childhood’:

“Assessment and support of children and adolescents with gender dysphoria” Gary Butler (Consultant Paediatric Endocrinologist), Nastasja De Graaf (GIDS researcher), Bernadette Wren (Head of Psychology at GIDS), Polly Carmichael (GIDS Director).

This latest article from the heads of the UK children’s gender service (GIDS) sets out the UK service’s position and deserves close scrutiny. Here goes:

Introduction

The article is intended for “professionals” who:

“may be unsure how best to provide supportive care, how to access the national Gender Identity Development Service (GIDS) for children and adolescents, or how to deal with a transgender young person presenting with another clinical problem unrelated to their gender transition”

Referencing fringe figures

The first reference they have chosen to include is co-authored by Ray Blanchard and Kenneth Zucker, two controversial figures, the former whose theories have been rejected by mainstream practitioners and who is known for speaking about trans people with disrespect, and the latter who was sacked from his clinic in Canada for work that could not be distinguished from conversion therapy and who has compared trans children to animals.

Conflating behaviour with identity

For a guide intended for non-specialists, the publication from the very start confuses and conflates behaviour, expression and identity:

Gender atypical behaviour is common among young children and can be part of general development”.

They omit any publications (e.g. Hidalgo et al 2013Olson et al 2015, Ehrensaft 2016Fast & Olson 2017)  that evidence the existence of trans children at a young age – with an insistent, consistent, persistent gender identity different from the one assigned at birth. They also omit to mention that trans children may or may not have non-traditional behaviour or expression. Gender identity and behaviour/expression are different things, and any publication intending to educate, should be clear on this. This omission is a fundamental failing.

Focus on exponential rate of rise, not on actual numbers compared to population prevalence

The first paragraph focuses on the ‘exponential’ rise in referrals since 2011. The language is alarmist, with the focus only on the rate of increase, with no discussion of the actual numbers. The actual numbers are extremely low and as with all low numbers, can easily show exponential growth.

The section on prevalence contains no discussion on how these low actual numbers compare to estimates of prevalence across the population. There is an alarmist focus on the growth rate without mentioning the numbers for 2011 were only 200 children a year (from the UK population of 60 million) and in 2016 were only 2,000 children a year. 2,000 children a year from a under 18 population of about 14 million children in the UK is still a very small percentage. So yes from 200 to 2000 is an exponential rise, but it is still only a tiny fraction of the under 18s in the UK.

This section does not mention that recent population prevalence surveys have put the trans population at around 1%, which would mean up to 140,000 of those currently under 18 might identify as trans. Referral numbers rising from 200 a year to 2,000 a year should not be a surprise in this context.

There is also zero discussion of the wider context, not only the rise in visibility and awareness of trans people in general, but the specific context in the UK – GIDS mentions a rise in referrals since 2011 with no mention of the arrival of the Equality Act in 2010, legislation that protected trans children and enabled families like mine to feel safe enough to get support at school and in other areas – protection that allowed families to be more open, protection that enabled families to support their child.

Australian gender specialists describe a rise in referrals in a completely different manner:

“Spurred on by increasing acceptance of transgender individuals in society (and normalisation of the right for anyone to question their gender identity), the number of young people seeking support is likely to increase further”

UK GIDS cannot seriously claim the rise in referrals is unexpected – a rise in referrals was predicted by GIRES back in 2009.

Focus on rise in ‘birth registered females’ 

GIDS continue:

“A striking feature of this increase is the large proportion of birth-registered females from 2011 onwards. This increase and the change in sex ratio is also seen in other countries. 

Let’s break this down. Again the focus on rise in referrals. From 57% assigned female in 2011 to 69% assigned female in 2016. From about 100 assigned females in 2011 to about 1,400 in 2016, from a population of 64 million people in the UK. Any analysis of trans prevalence would acknowledge that the 100 referrals of assigned females under 18 years old in 2011 was a gross under-representation. A rise in assigned female referrals was predicted by GIRES in 2011. A less transphobic service would celebrate the fact that more assigned females are getting listened to, getting referrals and getting support.

The Fig for the accompanying graph states “referrals by birth-registered gender”. In the UK birth certificates state ‘sex’ not ‘gender’. GIDS should be aware of this.

Here appears the second academic reference in their paper. The first was co-authored by Zucker and Blanchard. Who is their chosen second reference? Oh, of course, it is another paper co-authored by Zucker.

Inclusion of unsubstantiated speculation

“The reasons (for rise in assigned females) are not fully explicable and a number of questions arise. Is this increase due mostly to the greater tolerance of gender-diverse expression in westernised society? Is male status still regarded as preferable?

We are still in the paper’s first proper paragraph, in a paper intended to educate professionals, who are not gender specialists, in evidence based medical consensus. At this point in the paper, GIDS decides it is appropriate to engage in unevidenced speculation about the reason for a rise in assigned females. It chooses to include unevidenced speculation that matches a fringe theory proffered by transphobic lobby groups: “Is male status still regarded as preferable?”.

This unqualified speculation implies that children and adolescents are choosing to be trans. That trans boys choose to be trans to benefit from the enhanced status that comes with being seen as a trans boy. This suggestion woefully minimises the very real challenges facing trans boys and trans masculine children in a transphobic UK. But most importantly it is not supported by evidence. This is a GIDS publication in a medical journal. Do NHS professionals in medical journals routinely apply speculation on medical care eg. for reasons for a rise in asthma? Why are professional standards for trans children’s medical professionals so dire?

And more:

“What are the benefits, as well as the possible harms, in supporting and helping these young people at different stages of development?”

GIDS are not talking about the nuances of different treatment pathways here – they are saying that ‘supporting and helping’ young people has the potential to cause harm. Implying that there are circumstances when it is better to not ‘support’ and not ‘help’ young people.

Noticeably, despite extensive evidence of the harms of withholding care to trans adolescents (See Giordano and here ), they choose not to include any reference to the known harms associated with not helping young people. The then Chair of the NHS Clinical Reference Group for Gender stated that “not treating people is not a neutral act. IT WILL DO HARM”.

“Not treating people is not a neutral act. It will do harm: there are a number of studies that report evidence of suicide and self-harm among trans people who are unable to access care.”
John Dean, MBBS, FRCGP, Chair, National Clinical Reference Group for Gender
Identity Services, England

Here is the 2017 Australian Standards of Care for trans children (now also published in the Lancet) on withholding treatment:

“Avoiding harm is an important ethical consideration for health professionals when
considering different options for medical and surgical intervention. Withholding of
gender affirming treatment is not considered a neutral option, and may exacerbate
distress in a number of ways including increasing depression, anxiety and suicidality,
social withdrawal, as well as possibly increasing chances of young people illegally
accessing medications”.

GIDS omits any reference to evidence that withholding care causes harm.

Criteria for the diagnosis of Gender Dysphoria

GIDS describe the diagnosis of Gender Dysphoria (from the 2013 DSM-5) and focus on descriptions of behaviour.

There are many problems with the DSM-5 diagnostic criteria that GIDS are either unaware of, or choose not to discuss.

Contrast this with the astute approach Johanna Olson-Kennedy takes to DSM-5 gender dysphoria diagnostic criteria.

Dr. Olson-Kennedy critiques the adult Gender Dyspohria diagnosis that requires a trans person to have “a strong conviction that one has the typical feelings and reactions of the other gender”.  Olson-Kennedy ridicules this describing her “big book of typical feelings and reactions, the blue pages are male and the pink female”.

The DSM-5 gender dysphoria diagnostic criteria for children is even more absurd. In order for a child to be diagnosed with gender dysphoria, they HAVE to say yes to at least one of these three outdated, stereotyped criteria:

  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.

  • A strong preference for playmates of the other gender.

  • A strong rejection of toys, games and activities typical of one’s assigned gender.

If a trans child such as mine, likes a wide variety of toys and plays with all children (and how can that possibly be a bad thing?) then that child CANNOT be diagnosed as gender dysphoric according to DSM-5. The diagnosis is obviously nonsensical.

It is a stereotyped and confused mess of a diagnostic tool, yet the GIDS paper presents this without critique, qualification, or apology, instead accepting and endorsing its focus on behaviour rather than identity. Perhaps this endorsement is because GIDS are content with a confusion between gender identity and behaviour – confusion that is consistently used by vocal transphobic lobbyists to argue against support for trans children.

The GIDS article states: “for children, cross-gender behaviours may start between the ages 2 and 4, the same age at which most typically developing children begin showing gendered behaviours and interests”.

Why are they focusing on behaviour and interests? If the authors had any understanding of gender, they would examine how and why behaviour and interest do not equal identity. This omission is astonishing.

Again, no mention of Olson 2015 or Fast 2017 that found: “Transgender children do indeed exist and their identity is a deeply held one” providing evidence that “early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.” This research literature from the US is completely omitted from the GIDS paper.

Do GIDS feel it is appropriate to disregard academic literature that challenges their (unevidenced) beliefs?

The language contrasting trans children with ‘typically developing children’ is also cisnormative and pathologizing. My child is developing typically. She just happens to be trans.

Cisnormative and outdated terminology

GIDS include a glossary of ‘useful terminology’. The definitions they have chosen to use, and those that are missing, evidence their cisnormativity and lack of sensitivity or awareness of trans inclusive language and risk alienating their service users.

“Transgender: Transgender refers to the broad spectrum of individuals who identify with a gender other than that associated with their birth sex”.

The phrase ‘birth sex’ is outdated – ‘assigned sex’ is used for a reason. Especially given the 2017 Endocrine Society guidelines has a whole section on the substantial evidence of a biological underpinning to gender identity (something GIDS do not reference in their paper).

Here’s a better definition, from the Australian Standards of Care: “Trans/Transgender: A term for someone whose gender identity is not congruent with their sex assigned at birth”

“Non-binary: Non-binary is a lack of identification with conventional maleness or femaleness. Non-binary people may express features of both genders or neither.”

This muddled definition places more emphasis on gender expression than on identity. It is also ironic, in a definition of non-binary, to use the phrase ‘both genders’. A better definition would focus on identity not expression: “Non-binary: A term to describe someone who doesn’t identify exclusively as male or female”.

“Transman/transboy: A person born phenotypically female (natal female), registered (assigned) female at birth, who identifies as male. Also known as female to male.”

Many trans people consider the lack of space between trans and man or boy offensive. Trans is an adjective. ‘Transman’ is a term frequently used by those who wish to other trans people. It is used by those who argue that trans men are not men. The definition is also cisnormative – the phrase ‘identifies as‘ would never be used for a cis man.

The GIDS definition of a ‘transman’ states ‘a …female….female….female who identifies as male’. The term ‘female’ appears three times in their definition before the word male.

Further, the term ‘natal female’ is widely considered outdated and offensive by trans people. The Endocrine Society states there is clear evidence of a biological underpinning to gender identity. Trans boys are not ‘natal females’. Many medical professionals already use gender affirming terminology, with even the Endocrine Society using the term transgender male to refer to trans men – there is simply no justifiable reason to use the term ‘natal female’ when talking about trans men.

“Transwoman/transgirl: A person born phenotypically male (natal male), registered (assigned) male at birth, who identifies as female. Also known as male to female.”

As above – where is the space between trans and woman or ‘girl’?  ‘Transwoman’ is a term used by those with deep seated hostility to trans women to attack and discriminate. It is considered by many to be deeply offensive. Are the authors so unaware that this language is deprecated?

Again, in their definition of a trans woman (transwoman), they repeat the word male three times before saying ‘who identifies as female’.

The text suggests that the term ‘male to female’ is a noun and a synonym for trans girl. Not helpful.

Cisgender

GIDS do not include a definition of the word cis or cisgender. The words cis or cisgender are not used ONCE in their paper. Through these definitions and omission GIDS erase and ‘other’ trans people and their service users.

Appropriate assessments prior to referral

“The GIDS is an unusual multidisciplinary service in that the initial assessment … is aimed at understanding the young person’s development and gender identification in the context of their family background and life experiences It takes account of how they feel about their gender and their body now and in the past, the context in which the gender dysphoric feelings arose and intensified, how these feelings are being managed in everyday life, and what hopes are held for proceeding in the future”.

GIDS focus is on ‘the context in which the gender dysphoric feelings arose’. They place causation at the centre (a later section of the paper discusses their quest for a diagnostic test for ‘transness’ – asking a child their identity apparently didn’t occur to them.

There is no discussion of the 2016 Lancet publication which states that parenting has no impact on gender identity. There is no mention that gender identity is resilient to external influence, and no mention that past attempts to externally change a gender identity are considered unethical and ineffective. These omissions are damning.

Compare the Australian standards of care which  explicitly covers those issues which are ignored by GIDS:

 “In the past, psychological practices attempting to change a person’s gender identity to be more aligned with their sex assigned at birth were used. Such practices, typically known as conversion or reparative therapies, lack efficacy, are considered unethical and may cause lasting damage to a child or adolescent’s social and emotional health and wellbeing”.

Autism

“Around 35% of referred young people present with moderate to severe autistic traits”.

GIDS provide no published detail, nothing of their methodology and no discussion of the number of children who have ‘moderate’ versus ‘severe’.

This sentence also smacks of ableism. The statistic about autism is given without any discussion of how their service supports and cares for neuro-diverse trans children. For a brief summary of current literature on the intersections of gender diversity and autism see this 2017 review by Gender Analysis.

Assessment

“The assessment period usually takes 6 months or more over a minimum of four to six sessions”.

Earlier in this paper GIDS have already confirmed that they follow the NHS service specification. Their own service specification clearly states on page 13:

“an initial assessment process which will be specific to the person in terms of duration and will typically be over three to six meetings depending on the individual”.

GIDS’ own service specification commits to individualised care, yet here they are stating a minimum of four sessions regardless of circumstance. In a service where waiting lists for a first appointment (once a family manage to secure a referral from a GP) have risen to 18 months!

These illegal and unethical waiting periods have a direct negative impact on young people and their families.  There are reports of families re-mortgaging homes to afford private care outside of the UK. There is a growing practice of (dangerous) self-medication. These problems are entirely avoidable and are a direct consequence of a lack of individualised care and the appalling waiting lists created as a result.

Trans teens are a highly vulnerable group – making a highly distressed trans teen entering puberty wait 18 months for a first appointment and then inflict an inflexible protocol requiring a minimum 4 sessions, spread months apart, before any consideration of a referral (with further assessment and delay) to the endocrine service, for fully reversible, safe, puberty blockers, is both unnecessarily CRUEL, and a gross dereliction of duty of care.

“At the end of the assessment, it may be possible to confirm or exclude a diagnosis of GD”.

Note the arrogance and where the power lies. The clinician can ‘exclude’ a diagnosis of Gender Dysphoria. There is no practical recourse, no appeal, and no power to challenge the monopoly service authority over trans children.

Rates of referral to pediatric endocrine clinic

For several years GIDS have been talking about rates of continuation to medical intervention, without ever providing any published data.

Head of service Polly Carmichael spoke on the Victoria Derbyshire Show on the 7th August 2017:

Polly was asked by the presenter Victoria Derbyshire:

“How often might you see a child at a young age, 3 or 4 or 5 who as they grow or mature eventually change their mind?”

Polly answered:

“Those that are referred to the service at 5 years old it will only be 6% of those who ultimately go on to seek physical interventions to change their body”

Following this national media appearance parents asked GIDS to SHOW US THE DATA.

Radio silence. GIDS confidently, publicly, state a statistic about a specific group (only 6% of 5 year olds will go on..) on national television, ignoring the negative impacts this may have on families with trans children, and then fail to publish anything to support their claim.

This is a gross abuse of their power.

For years parents have been asking GIDS to publish data to support claims that they have been stating on national television morning breakfast shows, in newspapers, at medical conferences. These claims that are interpreted by viewers and readers as exceedingly high rates of children ‘changing their minds’.

Finally, in this paper, GIDS have included data, and within the respected British Medical Journal. How exciting! Let’s take a look!

What does their data actually show?

“Following psychosocial assessment at the GIDS, on average 38%–40% of all clients attend the joint endocrine clinics, although this varies across the age range.”

That seems a clear statistic. It appears that 38% of children go to endocrine. It is strange that they have chosen to provide an average percentage across all age ranges, when they are only taking data over a 4-7 year time window. They acknowledge, straight up, that the 38% figure is an underestimate as the older cohort (who are more numerous) proceed to adult services for endocrinology. They do not however, acknowledge that the youngest cohort are too young to be eligible for endocrinology making the 38% figure even more of an underestimate. It is strange then for them to have chosen to lead with this largely meaningless average percentage number.

GIDS do not provide all the data, but do provide a graph which will assist with testing this 38% figure.

figure 2 Butler paper

The blue bars track the age at initial referral. The mean age of referral to GIDS was age 14.4 years (the mode would be a more useful statistic in this graph).

The orange line tracks the proportion who had been referred to endocrinology by 2017.

While the underpinning evidence is unfortunately missing, we can use the data visually presented in the graph in order to test the accuracy of the 38% figure for different age groups.

In the graph we are given a single combined data set for the period 2010-2013. For the sake of a simple calculation, we’ll take a single yaer within this (2012) and assume that everyone has been referred in 2012 (rather than 2010-2013 – taking the latter of the mode numbers, as referrals have risen each year).

4 year olds (age of referral) in this data set

4 year olds referred in 2012 are 9 years old in 2017. Unsurprisingly zero out of approximately 10 of these children have been referred by 2017 (they are too young to be at tanner stage two, especially as those children referred at age 4 were more likely to be assigned males who typically start puberty later than assigned females).

6 year olds in this data set

For 6 years olds referred in 2012, who are age 11 in 2017, roughly 3 out of 20 have been referred to endocrinology. Again, this is not surprising. The majority of referrals at 6 are assigned males and most assigned males have not started tanner 2 at age 11.

9 year olds in this data set

For 9 year olds in 2012, who are 14 years old in 2017, we can see around 50% have been referred (20 out of 40 children).

12 year olds in this data set

Children referred at age 12 are age 17 in 2017, and we can estimate about 80% of them have had a referral. Similar for those referred at 13 and 14 years old,

15 year olds in this data set

For children referred at 15 years old, 50% have had a referral to endocrinology a drop compared to 14 year olds at referral.

For 16 and 17 year olds  the referral rate drops further. As GIDS explains in their paper, many 15, 16, 17 year olds will have limited benefit from blockers, and many prefer to wait until adult services (transfer at 17) where they are allowed to go on to HRT without the children’s service mandatory year on just blockers.

Some assigned females presenting to gender services at age 16 choose to go on the pill through GP rather than blockers through GIDs and go direct to adult services as they know those being referred at 16 will not get referred for Testosterone in the children’s services. Adolescents presenting in late puberty have less benefit from blockers and service users reports indicate a greater reluctance of GIDs to prescribe for those entering the service at ages 15-17.

Wait just one moment here!

Let’s look again at exactly what head of service Polly Carmichael, co-author of this paper, said on national media on the 7th July 2017 [10:20 am]:

When asked by the presenter Victoria Derbyshire

“How often might you see a child at a young age, 3 or 4 or 5 who as they grow or mature eventually change their mind?”

Polly responded:

“Those that are referred to the service at 5 years old it will only be 6% of those who ultimately go on to seek physical interventions to change their body”

We are now able to check Dr Carmichael’s statement against this newly published data:

For 5 year olds referred in 2010-2013, we are not given the number who have received referral to endocrinology by 2017, but from looking at this graph it is a very low number, it may  well be as low as the 6% stated by Dr Carmichael. What does this 6% mean? Let’s dig deeper into this exact issue, using both the above graph and GIDS own referral statistics from their website:

Year  Number of 5 year olds referred

 Age in 2017

2010 3 12
2011 3 11
2012 8 10
2013 10 9
Total: 24
Average age: 9.95

The entire data set for 5 year olds is 24 children. The average age of their sample in 2017 is age 9.95 years old.

If we were to make the assumption that 100% of these children would wish to access puberty blockers, how many of those 9.95 year olds would reasonably be expected to have accessed puberty blockers in 2017?

GIDs own figures suggest younger children (including 5 year olds) are by far more likely to be assigned males – with 4 times as many assigned males as assigned females at this age.

What then, is a common age for assigned males to start puberty? This 1980 publication states that puberty for assigned males begins at age ranges 9.7 to 14.1 years.

We would therefore expect a very small number of our 24 children to have started puberty. So we would expect a very small number of our children to have reached the stage of being eligible for puberty blockers. The figure of 6% having been referred to endocrinology after the start of puberty sounds a reasonable figure given most will not yet have reached tanner stage 2 of puberty.

This data TELLS US NOTHING about how many 5 year olds referred in 2010-2013 will end up needing medical interventions.

This data DOES NOT justify the Head of GIDS going on national television and, in response to a question on whether young children ‘change their minds’ answering that ‘only 6%’ of 5 year old continue. It is dismissive and damaging.

This dismissive and damaging rhetoric from GIDS directly feeds into (and is a contributor to) the moral panic that we are facing in the UK today around trans children.

This dismissal and erasure of trans children feeds into the situation in the UK where transphobic groups hold meetings stating on camera ‘trans children do not exist’. Where transphobic groups write damaging schools guidance that has been compared to conversion therapy.

GIDS and their anti-fact media messaging is complicit in the harm that is being caused to trans children across the UK.

Misleading manipulation of data 

A person who reads this article quickly, glancing at the headline statistic and taking a cursory look at the graph will likely take away two things 1) that only 38% of children go on to endocrine treatment, and 2) that those most likely to go on to endocrine are those referred at age 15 (due to the authors decision to present a graph appearing to show a peak at age 15). These two conclusions would both be wrong. GIDS either lack basic competence at data communication, or are actively intending to misrepresent the data.

On a similar note, they are using their Fig 2 graph to discuss the percentage of children who have been referred to endocrinology. Why then are they showing us a bar chart of numbers entering the service and a line graph of numbers referred, and expecting the reader to guess the percentage. It would be far easier to simply provide a graph of the percentages. The apparent hump on their graph at age 15, fits their mantra that ‘almost all trans children desist at puberty’, whereas a graph showing percentages would have a peak at about age 11. This is manipulation of data to fit a misleading narrative.

‘Desistance’ during early puberty

Head of service Polly Carmichael has talked about the Dutch ‘evidence’ that nearly all trans children will change their mind and not go down a medical intervention path. This ‘evidence’ has been shown to be false multiple times and is now even rejected by the Dutch authors themselves who claim to have been wrongly interpreted. Polly Carmichael claims that GIDS’ own data corroborates the (now withdrawn) findings of the Dutch. She describes a ‘paradox’ that the vast majority of trans children stop being trans at puberty, whereas the vast majority of children referred after puberty do continue being trans. She has a ‘hypothesis’ that early puberty natal hormones are responsible for a change of heart in those referred pre puberty. On the basis of this ‘hypothesis’, the hypothesis that the majority of trans children ‘desist’ during early natal puberty, GIDS delays provision of hormones blockers, and tells service users that prompt provision of hormone blockers may ‘change the outcome’ and solidify a trans outcome.

We can now test this hypothesis using this new GIDS data. How can we test it? We focus on children who were referred before the start of puberty, selecting the older pre-pubescents for maximum age at time of sampling. We therefore focus on children referred at age 9. The majority of 9 year olds have not yet started puberty.

If the GIDS hypothesis is correct, and the vast majority of pre-pubertal children do not go on to medical intervention, we should spot this trend in those referred at age 9. We should see less than 20% of those referred at age 9 going on to referral to endocrinology.

Let’s look at the data. Children aged 9 in 2010 are 16 in 2017. Children aged 9 in 2013 are aged 13 in 2017. Looking at their referrals data, the average age of this group in 2017 is 14.2 What percent of 9 year olds (at referral) in this data set have been referred to endocrinology by 2017? 50%. Fifty percent.

THEIR OWN DATA CONTRADICTS THEIR HYPOTHESIS!

Their own data contradicts their hypothesis that the vast majority of children referred pre-puberty do not go on to endocrinology. Their own data shows that 50% have gone on to endocrinology by the time they are (on average) aged 14.

We know that 50% (20 out of 40 – estimate from looking at graph – actual data is not provided) have had a referral to endocrinology by 2017. Of the other 50% (20) GIDS tell us nothing (despite proposing their percentage as a noteworthy finding). Many questions are left unanswered. How many of those 20 who have not been referred to NHS endocrinology have skipped GIDS gatekeeping and gone to private healthcare services in the UK? How many of those 20 have gone to the USA? We do not know. How many of those not (yet) referred will go on to a referral to endocrinology but have not yet reached tanner stage 2 of puberty (remember, nearly half of this sample are aged 13 or under in 2017). How many are wanting a referral but have not been approved by GIDS, having not yet jumped through the right hoops in their answers or cooperation. How many are denied  due to co-existing challenges or circumstances that allows GIDS to deny or delay referral (eg being out of school, being neuro diverse, being too depressed or suicidal, being insufficiently binary, or having a presentation that doesn’t match with GIDS expectation of what a child who is trans will look or act like). How many are wanting a referral but have not had the support of their parents for referral to endocrinology? We must remember that the majority of parents of children at the GIDS are unsupportive, and unsupportive parents can block (and certainly delay) a referral to endocrinology. How many are of these ‘desisters’ are *still trans* but have decided against taking puberty blockers at this point in time due to other life factors, such as exams, travel, other medication. None of this is explored in this paper.

A reflection on data reliability: GIDS data doesn’t appear to be reliable. There is a discrepancy between the total referral figures shown on their website, and their assigned-gender disaggregated figures released through a 2017 Freedom of Information Disclosure. For the year 2012-2013 the former states 3 five year olds (the FOI lists 0 five year olds). For the year 2013-2014 the former states 10 five year olds (the FOI lists 6 five year olds). These discrepancies bring into question GIDS data management.

Pubertal status

On the timing of puberty blockers, GIDS states:

“It is a requirement, according to the Endocrine Society and WPATH guidelines and UK service specifications, that a young person has commenced puberty before any intervention is agreed, as the GD may resolve once puberty commences.

First, Endocrine and WPATH guidelines (SOC7) do of course require puberty to start before prescribing blockers (blockers serve no purpose pre puberty). However, the endocrine society’s position is misrepresented. The Endocrine society says:

“We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage 2”.

“At” tanner stage 2. The Australian SOC is even more clear:

“Puberty suppression is most effective in preventing the development of secondary
sexual characteristics when commenced at Tanner stage 2″

“At” Tanner stage 2. The difference between recommending blockers at tanner stage 2 and a requirement that a young person has commenced puberty before any intervention is agreed may sound inconsequential, but this emphasis has profound implications for UK trans children. GIDS have no urgency about prescribing at tanner 2 – indeed they actively encourage delays, believing that a longer period of ‘natal’ puberty is a good thing.

“It is a requirement, according to the Endocrine Society and WPATH guidelines and UK service specifications, that a young person has commenced puberty before any intervention is agreed, as the GD may resolve once puberty commences.

The GIDS statement ‘GD may resolve when puberty starts’ does not appear in either the endocrine guidelines or WPATH (SOC7).

GIDS is fraudulently linking their pet theory (GD resolving when puberty starts) with the more respected evidence from the Endocrine Society / WPATH. This is misrepresentation. No evidence is provided for this claim.

This aligns with Polly Carmichael’s pet theory of natal pubertal hormones making trans children turn cis. A theory she has been speculating about for over a decade. A theory she has never provided a shred of evidence for.  Here she is a decade ago saying the same non-evidenced theories she clings to to this day:

“if you halt your own sex hormones so that your brain is not experiencing puberty, are you in some way altering the course of nature?”

A decade ago she was saying the same thing that she says to the media today, that there is not enough long term data on the outcomes of puberty blockers:

“The Dutch data looks promising. But they have not been doing it for so many years that you have long-term follow-up. The data is not over a long enough period of time and that concerns endocrinologists.”

<https://www.theguardian.com/society/2008/aug/14/children.youngpeople>

Her position has not changed in one decade. Her position has not changed because she is not listening to trans people, she is not listening to parents of trans children, and she is ignoring medical experts who disagree with her.

In both psychiatry and social work the term “defensive practice” is used to describe a deliberate practice of risk averse decisions, strict adherence to protocols and lack of learning. Defensive practice is also associated with an organisational culture in which leaders are not challenged (Whittikar & Havard 2016).

This term accurately describes how the GIDS leadership have become stuck in defending their (outdated, pathologising, harmful, non evidence-based) ways of working. They have become defensive, and in defending, have failed to evolve, failed to adapt and failed to remember their primary responsibility – ensuring the best possible outcomes for their clients (trans children and families). Alongside defensive practices they bring an inherent cisnormativity and transphobia – in which their model actively aspires towards and prioritises a cis or ‘not trans’ outcome, above the well being and happiness of their service users.

Persistence

The GIDS paper moves on to talk about persistence (the problematic history of this term, and implication that ‘persistence’ is undesirable, is not explored in the paper):

“Fig 2 demonstrates the low absolute numbers and proportion of prepubertal children with persistent GD.”

FIG 2 DOES NOT SHOW THIS.

Fig 2 shows the percent of children referred to GIDS between 2010 and 2013 who by 2017 had been granted by GIDS a referral to the paediatric endocrine service.

It shows about 80% of those referred at 10 years old are granted a referral to endocrine. For the younger children, those aged 5 in 2012 are only aged 9.95 in 2017 and most of them have not yet started puberty. This study tells us nothing about how many of those 5 year olds will receive a referral to endocrine at some point during their adolescence.

Importantly, this study does not tell us anything about how any of these children identify. It tells us nothing about their dysphoria.

FIG 2 does not tell us the proportion of prepubertal children who have ‘persistent’ Gender Dysphoria. THIS IS FALSE.

By conflating a referral rate with a ‘persistence’ rate, it also equates requirement for endocrine interventions with identity – ignoring the diversity of needs amongst trans children, including those who absolutely ‘persist’ in an identity different to the one presumed at birth, but do not need/choose to take hormone blockers/medical transition.

By conflating a referral rate for persistence, it also overlooks (as far as we can tell from the limited information they publish), those who seek private treatment or pursue treatment overseas.

The data completely ignores the issue of gate-keeping. GIDS are extremely conservative about referrals to endocrinology, and known to discriminate against children with mental health issues, those who are neurodiverse, those who present later, those who are non-binary. We do not know how many of those who have not been referred to endocrine desperately want a referral, but have not yet been granted one.

Finally, we know that two thirds of teens in the service are not supported by their parents. Teens who are unsupported are much less likely to get a referral to endocrinology. How many of those counted as not having been referred to endocrinology have had their referral blocked or delayed by unsupportive parents.

None of these factors are acknowledged in the article.

The article overall conjures up the unsubstantiated claim that ‘GD may resolve’, falsely creates an untrue 38% referral rate (which GIDS themselves clarify in the text is an underestimate of the reality), and mis-describes their referral rate as a ‘persistence’ rate. They use this to dismiss the existence of and undermine the rights of trans children.

Pathologising language continues

The next section provides an overview of the many tests they have carried out on trans children to look for reasons for being trans.

“Endocrine assessment of the reproductive axis of the birth-registered phenotypic male….”

The phrase ‘the birth registered phenotypic male’ is extremely pathologizing and othering language for trans girls. The phrase trans girl, trans feminine people, or people assigned male at birth would be a less offensive replacement.

“A search for sources of hyperandrogenism in adolescent birth-registered phenotypic females in an attempt to explain the dysphoria has not elucidated any differences from a control population”

“It therefore appears that GD is not associated with excess androgen production in postpubertal phenotypic female”

“our search for genetic, endocrine and radiological diagnostic markers of a dysphoria-related state has proven negative”.

How many of these children gave informed and voluntary consent to these unrequested, unwanted, pieces of research, with little relation to their care? Why have UK researchers been focused on a quest to find a diagnostic test for transness, and not on the key challenges, how can we help trans children to have good mental health and wellbeing?

GIDS are so detached from seeing trans children as important individuals with hopes and dreams and high potential. They fail our trans children time and time again.

Fertility preservation

“Various medical options are considered in case of a desire to revert to their birth gender in subsequent years after irreversible treatments have occurred, or in case assisted conception techniques might be called on in adult life to assist with starting a family”

This paragraph is strange. There is no information here. No evidence on what they are talking about re ‘revertion’ after irreversible treatment. No information on numbers.

Talking about a desire to revert after irreversible treatment is a subject that needs handling sensitively with careful context. Everyone working in this field is aware that a tiny number of examples of adults with ‘regret’ are used by anti trans lobbyists to undermine and deny care to trans children.

This report is not however, by anti trans lobbyists, but advice to non-specialists focused on working with children.

Partially irreversible treatment in the form of cross sex hormones is only available from around age 16, and GIDS only permits the children with the most straight forward diagnosis and a long history of gender dysphoria, who have already been on blockers for at least a year, to access HRT at age 16. The gatekeeping is extensive. How many children can they really have seen in the youth service who have had a clear enough history and presentation to receive blockers before 15 and HRT at 16, have had HRT long enough for irreversible changes, and have sought to reverse changes by age 17 before leaving children’s services. Knowing their conservative interpretation of the protocols, I do not believe this has happened in any significant numbers, certainly no evidence is presented in this paper or any other publications from GIDS that I am aware of.

If they are talking about data on regret from other services – they need to be providing a published reference for this statement. The fact that they do not provide a reference, suggests to a reader that they are talking from their own experience. They are scaremongering without providing any data.

Blockers

“In those whose GD is clearly established and long-standing and who have participated fully in the multidisciplinary assessment process at the GIDS, GnRHa is the recommended first-stage medical intervention”.

This shows how conservative they are at offering blockers. Adolescents need ‘established and long standing’ GD. These are subjective quantities. How many months or years is enough? How does an adolescent prove this? It seems like only the most straight forward (insistent, consistent, persistent, though they avoid these terms) are eligible. Yet blockers are intended to provide thinking time for those who are distressed about puberty and need thinking time to explore their identity. Children with the longest history and clearest presentation arguably do not have any reason to go onto (just) blockers, with practitioners in the US increasingly bypassing blockers to go straight to HRT for the simplest cases. It is those children who are less sure, who are questioning, who started to question (or vocalise) their gender at the onset of puberty, who need time to think and would most benefit from blockers. This is the very group who are ineligible.

Note also the requirement to have ‘FULLY participated in the multi-disciplinary assessment process’. There is a vast and unacknowledged power dynamic here. This evidences how GIDS wield their power and absolute authority. Adolescents and families are afraid to advocate for their rights, afraid to challenge clinicians who ask inappropriate questions, afraid to not complete pathologising  questionnaires that themselves induce dysphoria and have subsequent negative impacts on the mental health of adolescents. There is no service user autonomy. The powerlessness of children and families adds to stress and feelings of having no control over the future – a powerlessness that greatly harms the mental health of trans and gender questioning children and adolescents.

“The fact that between 73% and 88% of children attending gender identity clinics who present prepubertally, whether they have socially transitioned or not, are likely not to continue with their intention of changing their gender once puberty has started”.

They are listing the 2008 Wallien and Cohen-Kettenis study as their reference. We have discussed this at length in a previous blog.

Even if we just accept their data and overlook the methodological flaws in the Wallien and Cohen-Kettenis study, from the children initially classified as GD who were later re-assessed,  21/36 were ‘persisters’ and 15/36 were ‘desisters’. So even the data in this study shows a 58% persistence rate not the 27% rate that GIDS have quoted using this very reference.

Those who have been paying attention to the current discourse, will be aware that several articles have been recently published criticising the desistance rate myth (the myth that such enormous percentages of children desist from a trans identity). Ehrensaft published on this topic months before this paper came out (notably omitted from GIDS’s references). Since GIDS’ paper was in print, there have been three consecutive publications by a team including Kelley Winters, making clear that these high desistance statistics are simply false. Steensma and Cohen-Kettenis, the latter, one of the authors of the paper GIDS quotes, have also published a new article stating that their work has been misrepresented and does not support high desistance rates.

Here’s Steensma and Cohen-Kettenis in their recent paper (2018):

“The classification of GD [Gender Dysphoria] in the Wallien and Cohen-Kettenis (2008) was indeed based on diagnostic criteria prior to DSM-5, with the possibility that some children were only gender variant in behaviour. We have clearly described the characteristics of the included children (clinically referred and fulfilling childhood DSM criteria) and did not draw conclusions beyond this group, as has wrongly been done by others”.

Cohen-kettenis is here, the very author of the paper that GIDS quotes, stating clearly that others have been wrongly misrepresenting her own work (she is one of the two co-authors of the 2008 Wallien and Cohen-Kettenis study). Cohen-kettenis here, provides final clarity that her 2008 study includes children who are not trans and merely non-conforming.

Yet GIDS have taken this study and wrongly interpret as “The fact that between 73% and 88% of children attending gender identity clinics who present prepubertally, whether they have socially transitioned or not, are likely not to continue with their intention of changing their gender once puberty has started”

The study they use as the reference included children who were just non-conforming and not trans. It did not consider which children were socially transitioned. And it most certainly does not say that children who have socially transitioned (a group much less likely to include children who are just non-conforming ) have the same ‘persistence’ rates as children who have not socially transitioned.

Butler, De Graaf, Wren and Carmichael  HAVE FABRICATED THE STATEMENT ‘whether they have socially transitioned or not’.

They have not provided a single reference for this claim.

This is unprofessional, unethical and OUTRAGEOUS.

The ‘desistance’ myth (the myth that the majority of trans children become cis at puberty) has been propagated by Zucker and by the Dutch school, which includes Steensma and Cohen-Kettenis. The Dutch have now publicly distancing themselves from association with this myth, claiming to have been misunderstood and misquoted. Zucker clings to this myth, but is now disregarded as totally out of touch with modern evidence based practice.

GIDS, meanwhile, are clinging desperately to this myth. They need this myth to justify their pathologizing and cisgenderist approaches. If they acknowledge that they are badly mistaken on the assumption that trans children end up cis at puberty, they would have to start asking what else they have got wrong.

The leadership at GIDS, the authors of this paper, are not capable of this mental step – if they acknowledge how badly they have got this wrong they would also have to acknowledge the harm they have caused their whole career.

“Some may ‘desist’ completely, with their initially perceived dysphoric feelings pointing towards developing homosexuality”.

This statement is drawn from the thoroughly discredited ‘desistance’ literature. Furthermore, there is a lot of confusion (and hysteria) in the UK media about the difference between gender identity and sexual orientation. Credible clinicians would in this section state that transgender individuals have a variety of sexual orientations and that gender identity and sexuality are different things.

“GnRHa is prescribed in standard doses for a minimum of a year before additional medical interventions can be considered”.

This requirement to have a minimum one year on blockers, regardless of age or stage of puberty, is not supported by WPATH SOC 7, nor by the Endocrine Society, nor is it in the NHS Service Specification which GIDS are committed to work within. Parents who have complained of the health impacts of forcing 17 year olds to spend a year on just blockers before HRT are reassured that minimum one year is not an official policy. Yet here it is again in writing. This one year minimum on blockers without HRT for late puberty adolescents is not evidence based and is not an approach followed in other countries – not even in neighbouring Scotland. GIDS are here applying a rigid protocol, against their own service specification, unsupported by evidence. 18 year olds in adult services would not be required to have any time on blockers before HRT. 17 and a half year olds in GIDS are forced to have a year on just blockers, regardless of side effects, regardless of not wanting to take blockers.

GIDS uses their monopoly to wield absolute power over trans children and adolescents.

Psychological benefits of GnRHa treatment

“Most young people welcome the ‘blocker’ intervention as helping them to feel more comfortable in their bodies while holding future gender options open. However, our psychometric data suggest that although it permits further time for exploration, the impact on reducing psychological difficulties is limited. Further research is needed to determine whether GnRHa treatment is beneficial for young people of all ages, or whether some age groups may benefit more from this particular treatment than others, perhaps younger rather than older adolescents?”

The evidence is clear that medical intervention for distressed trans youth is the best way of securing improved mental health. It is not surprising that blockers alone do not provide an improvement – HRT (or surgery) are the treatments that distressed trans youth (trans youth who seek a medical transition) need – blockers are simply a delaying method, to ‘buy time’. While they mitigate the fear of future changes, blockers are not in themselves a treatment which treats dysphoria. They simply delay a decision.

Eligibility for cross-sex hormone/gender-affirming hormone treatment

“Cross-sex hormone treatment, currently referred to as gender-affirming hormone treatment (namely the induction of the opposite-biological sex puberty using testosterone in a phenotypic female and oestradiol in a phenotypic male)”

There is a reason why the term ‘gender affirming’ hormone treatment is used. There is a reason why ‘opposite biological sex puberty in a phenotopic female’ is not used. Stop pathologizing trans people!

“(HRT) may be considered once full commitment to the preferred gender has been confirmed”

It is not a ‘preferred’ gender. My child would ‘prefer’ to have her gender match her assigned sex.

“At the GIDS there are psychosocial criteria that need to be met, including that the young person shows some evidence of presenting coherently in the gender role with which they identify and that mental health difficulties are not escalating.

Coherent gender role! This sounds like some 1950s housewife stereotyping. It is 2018 GIDS!

“At the GIDS there are psychosocial criteria that need to be met, including that the young person shows some evidence of presenting coherently in the gender role with which they identify and that mental health difficulties are not escalating.”

Trans youth have to demonstrate distress to be eligible for HRT. But not too much distress. Just exactly the right amount of distress.

“The capacity to give informed consent is an absolute requirement prior to commencing sex hormone treatment… It is acknowledged by the Endocrine Society that a young person under the age of 16 may not have sufficient psychological maturity to commit to such a lifelong and life-changing decision”.

Here’s what the Endocrine Society actually says:

“Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old.”

The Endocrine Society states that most adolescents have maturity by the age of 16. GIDS changes this to “the Endocrine Society” says “under 16s may not have sufficient psychological maturity to commit to such a lifelong and life-changing decision”. GIDS has changed the emphasis and padded with additional spin. This introduces a focus on “life-changing” that is not in the Endocrine guidance. This is misleading.

The GIDS paper attributes to the Endocrine Society and to WPATH SOC 7 the statement:

“no evidence is available to understand the effects of giving gender-affirming hormone treatment before 16 years”

They do not include any reference to a key part of the Endocrine Society’s guidance:

“We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years”

And they have misconstrued what the Endocrine Society has actually said which is:

“there is minimal published experience treating prior to 13.5 to 14 years of age”

GIDS have completely changed the Endocrine Society’s position on age of eligibility for sex hormones and have claimed the Endocrine Society says there is no evidence for under 16s, when in fact the Endocrine Society says there is no evidence under 14.

Further the GIDS paper fails to mention that the WPATH SOC7 states:

“Adolescents may be eligible to begin feminizing/masculinizing hormone therapy, preferably with parental consent. In many countries, 16-year-olds are legal adults for medical decision-making and do not require parental consent”

“Refusing timely medical interventions for adolescents might prolong gender dysphoria”

“withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents”

Gender affirming hormones and height

“The dose increase schedule is conducted more slowly in those who have never completed puberty in their birth sex to allow emotional and social maturation, as well as the completion of the adolescent growth spurt in height”.

Some trans girls are dysphoric about their height and fear further height will make their lives harder. They are nevertheless kept on a low HRT dose, and keep gaining height, without being told that an increase to their HRT dose could stop further height.

Over 90% go to adult services

“over 90% of those attending endocrinology clinics request further support from adult gender identity clinics”.

 

Surgery for adults

It is questionable why there is any discussion of surgery in a paper which is focused on children and adolescents, who are, by definition, ineligible for surgical interventions. A critical reflection leads to a conclusion this is included simply to provide further opportunity for scare mongering.

“Male-to-female feminising genitoplasty is a well-established procedure where the penoscrotal skin is refashioned to produce the vagina and labia with preservation of the glans and neurovascular bundle to form a clitoris capable of orgasm. Concern now exists that the early blockade of puberty may result in insufficient genital skin being available for this procedure”.

This statement fails to mention well established alternative surgical techniques being used for those who received early puberty blockers. Puberty blockers have been used since the mid 1990s, and hundreds of young adults around the world who received blockers have gone on to access successful gender confirmation surgeries with extremely high rates of satisfaction and extremely low rates of regret. Stating the concern without mentioning that trans adults who received early puberty blockers have already had successful surgeries, is unnecessary, un-evidenced scaremongering.

“In full male genital reconstruction, a penis can be formed from either abdominal, thigh or forearm skin flaps. A hydraulic implant is inserted in a newly fashioned scrotum to provide controllable erectile function. This approach requires several surgical procedures and leaves extensive scarring”.

The focus on scarring without any mention on levels of satisfaction with surgery, is unhelpful.

There is a brief mention that “the few longitudinal follow-up studies that have been published in the Netherlands have generally shown a high satisfaction outcome, particularly from those who have gone through surgical affirmation of their identified gender. It is useful here to also note a recent Dutch paper from Wiepjes et al (2018)

“6,793 people visited our gender identity clinic from 1972 through 2015 .. Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret” [note the Dutch, like GIDS, offensively use transwoman as a noun]:

Long-term outcomes

“In the UK, as yet there is little evidence of the longitudinal outcome from the GIDS”.

So do some proper research! Focus on topics that will inform clinical decisions. Design research in collaboration with service users and their families. Design research in collaboration with those already undertaking well-funded, large cohort, longitudinal studies in the USA and Canada.

Conclusion

“The UK, along with other developed countries, is seeing an increase in the number of young people who are questioning their gender and taking the decision to pursue social and medical transition in line with their identified gender which may be non-binary. While professionals need to treat young people with respect and to acknowledge the intensity of their gender identification, much is still to be ascertained about the impact of medical intervention. The best practice in this field currently involves close collaborative working in multidisciplinary teams”.

So the key conclusions they want their readers to take away are …. er…No. nope. Nothing clear or useful here.

We need to acknowledge that the vast majority of professionals, raised in a cisnormative and transphobic society, start with negative and sceptical views of trans children. How does this conclusion in any way helping educate and advocate for trans children?

References – hold on, this is interesting

The references are perhaps the worst part.

Some references are core texts that have to be referenced (DSM, Endocrine guidelines, WPATH SOC 7 and the NHS’s service specification)

Several are references from figures with a controversial history of transphobia (eg Blanchard and Zucker).

Most references are from their colleagues in the Netherlands.

There is an interesting article (not referenced by GIDS of course) called ‘Cisgenderism in psychology: pathologising and misgendering children from 1999 to 2008′. It talks of an ‘invisible college’ of gender specialists who often collaborate on joint publications, comprising those who worked most closely with Kenneth Zucker, and who until recently held enormous power over trans children worldwide. This collection of clinicians work was reviewed, and it was found that they held significantly more cisgenderist and pathologizing approaches to trans children than other professionals in this field.

I thought it would be interesting to check how many of the references that GIDS have selected include those clinicians know for cisgenderist and pathologising approaches to trans children.

I excluded the references that are core texts (DSM, Endocrine guidelines, WPATH SOC 7 and the NHS’s service specification)– and excluded those publications that are not about trans or gender diverse children).

No of references where one of the authors is from the  ‘invisible college’ ie Zucker or those who have published with Zucker – those who have cisgenderist and pathologizing tendencies 10
No of other references where one of the authors has worked at GIDS (including self-citations 2
No of references from other people in the Netherlands 4
No of references from other sources 2. (Both on fertility)

What references are not included

More interesting than what references are included is what references are excluded:

  • Almost all publications from experts in the US are excluded from this GIDS article.
  • Almost all publications from experts in Canada, Australia, are excluded.
  • Almost all publications from clinicians who support affirmative approaches are excluded

GIDS erase through omission any peer reviewed evidence that they instinctively disagree with.

This is not how science and evidence works. The authors completely omit an entire body of evidence from the USA which supports a gender affirmative approach helps trans children. Further, they omit any of the growing consensus of publications which criticise the UK’s delayed transition approach as harmful.

Peer review

The article was “Commissioned; internally peer reviewed”.

It is not clear who internally peer reviewed this paper. It is shocking that this has been accepted for publication. More shocking still is that this poor article is the ‘best practice’ that our children can expect from the heads of the UK children’s gender service.

This week a far better article was published in the Lancet. The Lancet article criticises as harmful many of the practices that are still core to the systematically transphobic UK children’s service. UK clinicians are well advised to learn from this new Lancet publication.

Instead of reading and learning from credible material published by those who are trying to help trans children to thrive, GIDS are choosing to look inward, reading and citing work by discredited members of their ‘invisible college’.

Caught in a defensive practice model, left behind by their international peers who support a gender affirmative model of care, GIDS are in an increasingly desperate state.

It is perhaps not surprising therefore that some GIDS clinicians are emboldened to publicly align themselves to the cause of anti transgender lobbyists who believe that transgender children both do not, and should not exist.  A ‘pay to publish’ book with the central premise of denying the very existence of trans children, recently received a glowing endorsement from a serving GIDS clinician.  The GIDS library later publicly announced the purchase of the same book via its official twitter account.

This book received a scathing review by the Times Educational Supplement who utterly discredited the “masquerade of a scholarly text”. Review quoted at some length below.

The messages of the book are bold. The first is that “transgender children do not exist”. Having dismissed the perspectives of youth, parents, charities, medicine, social policy and the law as “unproven” and “intellectually incoherent”, it suggests that trans youth are a discursive invention. “Transgenderism”, it contends, reinforces traditional gender binaries, propping up the patriarchy. This framework remains undeveloped and the chapters are inconsistent, offering a hotchpotch of pet clichés that sidestep the evidence-base. Trans youth are variously explained by tribal belonging; restrictive femininity; the distressing human condition; childhood trauma; male transvestites’ sexual desires; and really being gay.

Perhaps hopes were pinned on the highest-profile contributor, whose activism is currently aimed at blocking schools from accepting that children may be transgender. But of 57 sources cited in Stephanie Davies-Arai’s chapter, only seven are peer-reviewed research and these are cherry-picked and distort the wider medical and sociological evidence. Meanwhile, editor Michele Moore’s account of transgender theory leans on dated and inaccurate stereotypes of trans identities that make tiresome reappearances throughout. Nowhere is it acknowledged that many trans people experience binary gender norms as tyrannical, or that many (if not all) trans identities actively queer these binaries.

The second message is that children are “transgendered” by adults and that this is “abusive”. The book constructs an artifice of a society teeming with over-eager parents, whereas research consistently shows that trans youth are often rejected by their families and peers. While claiming that they are motivated by children’s well-being, the authors frequently misuse or ignore recent international studies that unequivocally show both high rates of depression, self-harm and suicide among trans adolescents and the safeguarding effects of gender-affirming support. Indefensibly, the book is almost silent on widely substantiated hate crime against trans youth.

Masquerading as scholarly text, this is epistemological chicanery, with the contributors adopting an already vocal repositioning as the silenced minority. In labelling “transgenderism” abusive, they don’t listen to the supposedly abused; in claiming to challenge “the seemingly unstoppable celebration of transgender ideology”, they present arguments neatly aligned with much recent media coverage. The irony is complete, the consequences no less serious.

In GIDS’ journal paper, Butler, De Graaf, Wren and Carmichael are guilty of many of the same techniques of misinformation, distortion, and cherry-picking literature.

This detailed analysis of the GIDS paper has revealed intentional or incompetent manipulation of data, entirely false claims, misquotations, use of pathologising language, and significant omissions of swathes of recent literature.

GIDS is a failing service stuck in defensive practice.

Our children deserve so much better.

Why does a biological underpinning to gender identity matter?

science

Biological essentialism vs social constructivism

Biological essentialism (or biological determinism), is the idea that behaviours, interests or abilities are biologically pre-determined, rather than shaped by society. In an essentialist interpretation, innate differences between men and women result in  ‘natural’ gender divisions  – with men inherently (innately) better at decision making and women better at nurturing.

Feminists, Freudians, and queer theorists have all challenged biological essentialism. Second wave feminists argued that gender-based inequalities and differences were not natural, and were instead socially constructed. Girls are not inherently worse than boys at physics (due to having pink and fluffy brains) but rather, are often denied the opportunities offered to boys. Social constructivists demonstrated the many ways in which observed gender differences between men and women are socially engineered. Some went a step further, arguing that gender is purely a learned behaviour or a performance.

Brains are complex, and social constructivists, like the popular science writer Cordelia Fine, have rightly debunked the simplified and shoddy science that underpins essentialist claims that men are from Mars with their manly brains, and women are from Venus, with feminine brains.

Gender identity and the neurology of ‘trans brains’

Where then does gender identity fit in?

Some scientists have conducted neurological imaging studies on trans people, exploring whether there are specific, sexually dimorphic areas of the brain in which trans people differ from their assigned sex (the sex they were presumed to have at birth).

Published research findings, often with low sample sizes, have been interpreted as indicating that trans women have a brain more similar to a cis (not trans) woman’s brain than to a cis man’s brain. Such findings have been publicised in newspaper headlines as proof of the existence of trans people.

Such scientific studies, and their shallow interpretation and presentation in the media, have received strong criticism from a wide number of transgender commentators. There are a range of extremely valid reasons for criticism:

  • The suggestion that one specific variable can define ‘transness’ is reductive and overlooks the ways in which society, culture and experience impact on every individual including on the structure of the brain.
  • The reliance on any study as legitimacy for human rights is extremely dangerous – if the study results are later rejected, what happens to these rights?
  • The idea that any brain can be easily classified as male or female is simplistic and overly binary.
  • The suggestion (made by inaccurate media representation of the studies) that one specific variable can be used as a diagnostic test for transness also fills people with fear that any such test could be used by gatekeepers to judge who is accepted as trans and who can be denied support and denied rights. Any such diagnostic test would be entirely at odds with autonomy, with respecting people’s lived experience, with self-identification and dignity.

These reasons for fearing how science will be politically used, or for criticising simplified interpretations of scientific data, make total sense and have historical antecedents – I understand the fear and upset.

Rejection of biology

However, such comments very often seem to take one step further, rejecting not only biological essentialism and the unhelpful simplified, ‘soundbite’ biology loved by the media, but also moving into a sweeping rejection of any mention of a link between biology and gender identity. A culture in which the very mention of biology is discouraged.

This is where as a cisgender (not trans) parent of a transgender child I feel uneasy. I’ll attempt here to explore this from my cis parent’s perspective.

Pathologisation of diversity

For many decades, psychologists and psychiatrists have been aware of trans children expressing distinct gender identities at an early age – 2 or 3 years old.

Across the twentieth century mainstream medical convention, with some exceptions, rejected out of hand any possibility of a biological underpinning to gender identity. The consensus then was that a trans gender identity was a delusion, a mental illness that could, and should, be ‘cured’.

For young trans children, misogynist male psychologists and psychiatrists, frequently working in the field of sexology, focused their attention on the mother.

Therapy and treatment for young trans children focused on presumed maternal abuse or maternal failings.

Does it even matter why trans adults are trans?

When I hear people say ‘does it even matter why people are trans’ – when I hear people dismiss as offensive and unnecessary any consideration of any biological influence on gender identity, I have an emotional response. I also see this reaction in some other parents of trans children (though certainly not in all).

The denial of any possibility of a ‘biological underpinning to gender identity’ is historically tied up with the denial of the existence of younger trans children. The erasure of the existence of younger trans children has caused untold suffering.

As a parent of a trans child who is loving life, it makes me think of the trans children from decades past (and present in too many places in the world) who were traumatised and institutionally abused by medical systems designed to prevent or convert their gender identity. Neither the genitals = sex = gender approach of simplified biology, nor the feminist ‘gender is a social construct’ mantra, left any space for younger children to be trans. Trans children did not fit with either theory so therefore could not exist.

Impact of denial on families

Denial of the possibility of some young children being trans makes me think of the consequences of this denial. It makes me think of the mums who were coerced into distancing themselves from their trans daughters, based on some unsubstantiated theory that an overly close mother-‘son’ bond might lead to a child ‘misidentifying’ as female. How unbelievably cruel to do that to a family.

Shon Faye, whose work I greatly admire, recently wrote that she disagrees with anyone who suggests gender identity is innate and that it should not matter why people are trans. CN Lester, another writer whose work, and excellent book, I’ve learnt a lot from, critiqued the reporting of the research study under discussion  and recommended reading work by Cordelia Fine, author of ‘Delusions of Gender’.

This particular recommendation makes me want to cry.

Delusions of gender as a book has real merits in its debunking of simplified biology,  in its understanding that gender-based inequalities are not natural, and that men are not inherently better at parking. So far so commendable.

However, Cordelia Fine replaces the simplified biology of biological essentialism not with nuanced and complex biology, but a nod to social constructivism. Her work is routinely used by those who argue that gender is merely a ‘performance’ and that trans identities do not exist, except perhaps as a non-conforming person’s misguided response to gender norms.

The view that gender is purely a construct and therefore not ‘real’ is pervasive and extremely dangerous. Adherents of this view may well tolerate trans adults – with a patronising assumption that trans adults made a ‘choice’ to ‘change gender’ as a response to their non-conformity. But whilst adherents of social constructivism may begrudgingly  tolerate the existence of trans adults to some degree, they allow no such tolerance for younger trans children.

The gender as purely a social construct contingent see social influence and gender stereotyping as the only reason for trans identities. They see no valid reason for the existence of young trans children.

Some of the more fringe, actively transphobic, elements of this group, throw their hate and bile at parents of trans children, accusing us of child abuse, demanding that the state take our children away, demanding that children be protected from ‘transing’.

The recommendation to read Cordelia Fine hit a particular nerve as ‘Delusions of Gender’ had a direct impact on my family. We had a family friend who was unable ‘ideologically’ to accept the possibility of the existence of a trans child. They rejected our child and through that rejection, our family entirely. In a parting gesture, they pleaded for us to read ‘Delusions of Gender’. This very book had been the germ of our now former friend’s belief that any trans identity is a delusion, and that pandering to childhood delusion is parental abuse.

Through my shock and upset, I was struck at the time by the unbelievable arrogance. The recommendation that instead of loving my daughter, I should ‘read up on Fine’ and learn that gender isn’t real. This was not to be the first such recommendation.

Fine’s work is populist and best selling, and over the years I’ve had countless similar comments from ‘well meaning’ individuals. It is not that I am ignorant or closed minded, far from it, I’d hazard I know more of Fine’s exploration of gender than those dabblers. I have read, considered, understood the theoretical position being proffered. The same cannot however be said of the Fine pushers. Their position is based on an assumption (from those who have no first hand experience of trans children) that trans children do not, indeed cannot, exist.

The recommendation to read Cordelia Fine is also, depressingly, front and centre in the advice that the UK Children’s Gender Service’s website provides for parents of trans kids. No space here for a clear and much needed message that ‘some kids are trans – get over it, try to be kind’. Instead they present a false dichotomy between simplified biological essentialism reduced to mention of “a boy’s brain in a girl’s body” and “academic psychologist Dr Cordelia Fine” and “gender as a social construct”, with differences based on experiences rather than biology. Parents wondering whether to accept and love their trans child are instead advised to read about the delusion of gender.

When parents and their children reach the children’s gender service in the UK, if they are allocated one of several apparently deeply transphobic clinicians (clinicians who hold so much power over trans children and families), they may then endure literally years of probing and questioning on parental views on gender, as the clinicians probe for the ‘root cause’ of gender diversity.

The social constructivist view also makes me think of the school teachers and class parents and wider community who argue that a child is too young to make a ‘choice’ to be trans and should wait until adolescence or adulthood. Who don’t see the harm of denying a child a happy childhood.

It makes me think of the people who look at us with suspicion, hostility, scrutiny, when I mention I have a trans child. Of the parents who steer their child away from ours, in case being trans is socially contagious.

It makes me think of the people who are no longer in our family’s life, who are unable to see a trans child as anything other than ‘social conditioning gone wrong’.

It makes me think of the people online and in person who target parents of trans children and accuse them of child abuse for loving their child. It makes me think of the haters who want trans children erased from our schools and communities. Who want trans children to be marginalised, made invisible, kept apart from other children.

The existence of trans children poses a challenge both to the simplified biology of biological essentialism and to social constructivism (the idea that gender is merely a performance).

Who cares whether or not biology has any role?

Many people argue that it should not matter whether being trans is partly influenced by biology or fully shaped by culture, society and upbringing. They argue that acceptance will not come through identifying a ‘cause’ for transness, but through people getting to know trans people.

I imagine and hope that acceptance will gradually emerge for trans adults. I think things are slowly moving forward.

What about trans children though? How do we ensure that gains in acceptance and visibility and legislative rights do not leave out trans children, the most vulnerable, those without a voice.

Too many advocates for the rights of trans adults are silent on the topic of young trans children. Many have no understanding or awareness that trans children exist. Others, consider trans children too controversial, too divisive to stick up for.

Trans children are nearly completely invisible. And whilst there remains a default assumption that gender identity is shaped not at all by biology but purely by culture and upbringing, then there will remain a reluctance to support younger transgender children.

Those who believe that gender is purely a performance, who believe that trans identities are socially constructed, do not believe in the existence of young trans children.

The erasure of trans children allows haters to paint themselves as crusaders saving children from being socially influenced or indoctrinated into being trans.

With no openness to the possibility of a trans child being part of natural diversity, they look for a reason. With young children it is blame the parents. With older children it is social contagion. In the first scenario they advocate removing children from abusive parents. With the second scenario they ask that trans identities never be mentioned, embraced or supported at school. For parents who are afraid and unsure how to react to a trans child, they advise conversion therapy.

Another way

Yet, as soon as people open their minds to the idea that there might be a (complex, messy, unattributable) biological underpinning to trans identities, that trans children exist, and have in fact, always existed, the whole deck of cards upon which the transphobes build their hate comes crashing down.

This opening of minds is possible. This opening of minds and shifting of world view happened to me.

Growing up as a gender non-conforming feminist, tired of sexist societal restrictions and expectations, I was instinctively drawn to a social constructivist view point. I had never met a trans person, but had subconscious, lazy, uneducated assumptions about trans people being enthralled to gender stereotypes. I have former friends who are still tied to this world view.

My world view was shaken when I had the good fortune to have a child who opened my eyes. An assigned male child who was insistent, consistent and persistent that she was a girl from the youngest age.

Learning to reset my assumptions

At first, I really struggled to accept my child as a girl. I told her she was wrong. Mistaken.

I did not believe it was possible for a young child to be trans.

I was certain that this child was too young to understand or reject gender norms or sexism or heteronormativity. I knew they were not making a choice, and certainly weren’t being influenced to be trans (she had never come across any representation of a trans person and I was unconsciously transphobic). She wasn’t even gender non-conforming in her interests. A suggestion I sometimes hear (from people who have barely met a trans person) that she was repressing internalised homophobia in infancy is absurd.

She had a persistent, consistent, insistent knowledge that she was a girl that withstood all forms of persuasion.

Like hundreds of parents all around the world who have experienced the same, I had to learn to reset my assumptions about gender identity. I learnt to love and accept my child for who she is. I have never looked back. She is happy and thriving.

I see how people who emphasise ‘gender as a social construct’ utilise that simplistic maxim to make my daughter’s life impossible. How they use it to argue against her rights. How they use it to accuse parents of abuse.

I see how people who claim genitals = sex = gender similarly use simplified biological essentialism to argue that my child is defined and invalidated by parts of her anatomy.

Neither the simplified biology of essentialism, nor simplistic social constructivism, leaves space for my daughter to exist.

Is there an alternative paradigm?

Holistic views of gender

I recently had a short email exchange with Julia Serano and she kindly shared a chapter she wrote on this topic back in 2013 (Excluded: Making Feminist and Queer Movements More Inclusive – chapter 13: Homogenizing Versus Holistic Views of Gender and Sexuality). What follows is what I took away from her chapter, adapted into my own words – I recommend reading her chapter first hand.

In this chapter, Julia critiques the failings of both simplified biology, (gender determinism) and social constructivism, which she terms gender artifactualism.

She outlines how biological essentialists and biological determinists, (often genital obsessed religious conservatist non-scientists), misrepresent and misunderstand biology and science. They present a simplistic last century school child’s version of human biology, assuming that a simple gene or hormone or chromosome works unilaterally triggering a domino rally of binary outcomes.

She also outlines the failings in social constructivism. For decades children’s gender services were dominated by social constructivists who believed that children could not really be trans and that such children could be engineered into accepting their assigned gender. Yet these efforts failed. Medical consensus is now absolutely clear that conversion therapy is unethical and ineffective – conversion therapy did not change a person’s gender identity, merely produced shame, self-hate and depression. Julia notes that gender identities are often ‘profound, deeply felt and resistant to change’. She notes that some people have a fluid gender identity, and that some people do experience a shift in their identity over time, but that such shifts do not result from external pressure and are ‘almost always inexplicable, unexpected’.

She advocates rejection of both simplified biology (biological determinism) and social constructivism (gender artifactualism). In its place she presents a holistic model of gender.

This holistic model of gender acknowledges that biology is complicated. Human biology is not the simplistic yes/no on/off approach that non-scientists and biological essentialists like to pretend. Real biology is complex, multi-faceted, interactive. Just because some people misuse (simplified) biology, does not mean biology itself is essentialist, deterministic, reductionist or sexist.

Julia notes that ‘the human genome has 20,000-25,000 genes. Any given gene or hormone is affected by countless different interacting factors. Because genes and other biological factors act within intricate networks, any given factor will push a system in a particular direction, but will not single-handedly determine a particular outcome’.

Julia argues that ‘while our brains are shaped by learning and socialisation, they are not infinitely plastic ie they are not blank slates. Some traits have a strong intrinsic component’. She notes that though ‘socialisation has a significant impact on brains and behaviours’ it ‘cannot fully override certain intrinsic inclinations’.

She makes a comparison with left-handedness, which is observed in utero before any socialisation. Even with societal pressure to conform to right-handedness some individuals maintain a preference for using their left-hand.

A holistic model of gender allows space for a biological underpinning to gender identity. A holistic model of gender considers the complex interactions between biology, society, experience.

Biological underpinning to gender identity

A wide number of scientific studies have concluded that there is a durable biological underpinning to gender identity.

This supports what other parents with experience like mine have been saying for decades from their lived experience. This backs up what some trans adults remember from their earliest childhood memories.

There is increasing evidence of trans children who have clear gender identities at a very young age. This evidence of young trans children is present in diverse countries and cultures across the world.

The growing scientific consensus of a biological underpinning to gender identity led to the global endocrine society publishing a position statement last year:

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

(for the full position statement and more on the studies see here)

I welcome this consensus. I view it with hope that it will help open eyes and minds and hearts to the existence of trans children like my daughter.

I would happily share this scientific consensus on a biological underpinning to gender identity with a wider audience – I see in it hope of greater acceptance and support for trans children.

However I note that since the publication of this evidence based position statement from the medical establishment, I cannot recall having seen this printed in the media or even referenced in the few articles commissioned by trans authors. Indeed quite the opposite – more often there is a strong resistance to any mention of biology.

Do we have to reject biology?

I understand the scepticism around how biology can be misused, but surely that does not mean this should be rejected outright?

Whilst supporters of trans rights shy away from biology and science, it allows transphobic groups to present themselves as champions of science and rationality. Claims that couldn’t be farther from the truth.

Transphobes focus on gender as performance, as fake, as a delusion. Whilst a huge part of what we call gender is socially constructed, my child’s gender identity is not a choice, is not a delusion, is not a product of societal or parental persuasion.

Transphobic groups like to focus on what they simplistically call biological sex. They describe biological sex as a simple binary reality, with gender identity operating on some parallel dimension outside of biology. My daughter is 100% biological. She does not have a magic gender identity spirit disconnected to her biological body. Her biology is no less real or valid than the biology of cis girls. It is not essentialist to claim that her identity is an integral aspect of her biological reality. The true essentialists are those trying to present a simplified and fraudulent version of biological science, utilising distorted, cherry picked and biased pseudo-science to support a transphobic position.

Acknowledging biology without essentialism

The argument that we should avoid science in case it is essentialist or in case it is used against trans rights is a false logic.

  • It is possible to acknowledge the biological underpinnings of gender identity whilst acknowledging that a person’s felt and expressed gender identity is a complex interplay of biology, culture, socialisation and experience.
  • It is possible to acknowledge the biological underpinnings of gender identity whilst simultaneously recognising that identity is neither fixed, nor binary.
  • It is possible to acknowledge the biological underpinnings of gender identity whilst arguing very strongly against diagnostic testing for ‘transness’ or biological gate-keeping and identity policing.
  • It is possible to acknowledge the biological underpinnings of gender identity whilst maintaining that the only way to know someone’s gender identity is to ask them, and that a right to self-identification is a basic part of dignity

My daughter is real and valid and deserving of rights, equality, respect and dignity regardless of our current understanding of science.

But science already has plenty of evidence that trans children exist and that there is a biological underpinning to gender identity and I see no reason not to talk about this. Having a trans child (or being a trans child) does not mean rejecting science.

We should embrace science

My daughter is growing up with a love of science. A thirst for knowledge. I’ll teach her all the science I know, on microbiology, on chemical reactions, on photosynthesis, on plate tectonics. On neurology, on genes, on hormones and gender identity. On sample sizes, on causality, on peer review, on rigour, on interpretation and data manipulation.

Biology is rich and complex and we have so much still to learn. If she carries on with a love of science she will learn things far beyond my knowledge. Science (high quality science) is full of wonder and excitement and discovery.

We should not be afraid of saying loud and proud that we support science. We should be clear that those attempting to attack or dismiss transgender children and adults not only lack empathy and kindness, they also lack sophisticated understanding of science, of biology, of complexity.

Trans children exist.

They know it.

Parents know it.

Science knows (a bit about) it.

Stand up for trans children

 

 

I am (and always will be) learning. Friendly feedback is welcomed.

 

 

Australia Presents a Gold Standard of Care for Trans and Gender Diverse Children

Part 1. The Guidelines for Trans and Gender Diverse Children and Adolescents

Introduction

This week Australia’s Royal Children’s Hospital Gender Service has launched the “Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents”. These guidelines are compiled by the leading Australian experts, based on the best and most current evidence from around the world. These guidelines are endorsed by ANZPATH (the Australian and New Zealand Professional Association for Transgender Health) and were launched at the recent ANZPATH conference. They are now the official guidelines for all health professionals working with transgender children in Australia.

The standard is clearly written and concise and it is definitely worth reading in full. Here,  for convenience, please find below a brief synopsis of selected key extracts from the document. In Part 2 we will look at Why this standard matters, and why it should be adopted in the UK NHS.

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents (pdf)

 aus standard care

Key extracts from the document:

Evidence Based:

“Recommendations are made based on available empirical evidence and clinician consensus”, “developed in consultation with professionals….from multiple disciplines, trans and gender diverse support organisations, as well as trans children and adolescents and their families”.

Numbers expected to increase:

“with increasing visibility and social acceptance of gender diversity in Australia, more children and adolescents are presenting ….requesting support, advice, and gender affirmative psychological and medical treatment”. with “approximately 1.2% of adolescents identifying as trans” “it is likely that referrals. ….will continue to rise in the future”.

Natural:

“being trans or gender diverse is now largely viewed as being part of the natural spectrum of human diversity”.

(This Australian guidance was completed before the latest Endocrinology guidelines, stating that “there is a durable biological underpinning to gender identity”.

Affirmative care:

“increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved”.

General principles for supporting trans and gender diverse children and adolescents

  • Individualise care”. Emphasises the “importance of tailoring interventions”, recognising each individual’s “unique clinical presentation” and “individual needs”.

  • Decision making should be driven by the child or adolescent wherever possible, this applies to options regarding not only medical interventions but also social transition”.

  • “Use respectful and affirming language”.

  • Avoid causing harm”. “withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications”

  • “consider legal requirements” outlines legal requirements that are barriers to “obtaining identity documents that accurately reflects their gender”. Considers “implications for young people’s right to privacy and confidentiality when enrolling in school or applying for work”.

Children vs adolescents:

“the clinical needs (of children vs adolescents) are inherently different, and consequently we provide separate guidelines for trans and gender diverse children and adolescents”

Psychological Support for a younger child:

  • “Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach”.

  • “for children, family support is associated with more optimal mental health outcomes”

  • “trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”.

  • “others may benefit from a skilled clinician working together with family members to help develop a common understanding of the child’s experience”.

  • “when a child’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, learning or behavioural difficulties …. a more intensive approach with input from a mental health professional will be required”.

Social Transition for a younger child:

  • “social transition should be led by the child and does not have to take an all or nothing approach”.

  • “provision of education about social transition to the child’s kindergarten or school is often necessary to support a child who is socially transitioning to help facilitate the transition and minimise …bullying or discrimination”.

  • “social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers”.

  • “The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

Key roles for a clinician of younger child:

  • Supportive exploration of gender identity over time

  • Work with family to ensure a supportive home environment

  • Advocacy to ensure gender affirming support at school

  • Education (to child and family) on gender identity and signposting to support organisations for child and for parents

  • If child is expressing desire to live in a role consistent with their gender identity, provision of psycho-social support and practical assistance to the child and family to facilitate social transition

  • Referral to endocrinologist ideally prior to onset of puberty

Supporting Adolescents:

[For] “adolescents with insistent, persistent and consistent gender diverse expression, a supportive family, affirming educational environment and an absence of co-existing mental health difficulties, the adolescent and parents may benefit from an initial assessment followed by intermittent consultations with a mental health clinician”

Supporting Parents of Adolescents:

“adolescents often encounter resistance from their parents when their trans or gender diverse identity is first disclosed during adolescence”. “For the clinician, investing time for parent support… will assist in creating a shared understanding….and enable optimisation of clinical outcomes and family functioning”

Fertility Counselling for Adolescents:

“Although puberty suppression medication is reversible and should not in itself affect long term fertility, it is very rare for an adolescent to want to cease this treatment to conduct fertility preserving interventions prior to commencing gender affirming hormones. It is therefore necessary for counselling to be conducted prior to commencement of puberty suppression or gender affirming hormones”

Commencement of puberty suppression

“Puberty suppression is most effective in preventing the development of secondary sexual characteristics when commenced at Tanner stage 2”. ”reduction in the duration of use of puberty suppression by earlier commencement of stage 2 treatment must be considered in adolescents with reduced bone density to minimise negative effects.”

Commencement of gender affirming hormone treatment

  • “The ideal time for commencement of stage 2 treatment in trans adolescents will depend on the individual seeking treatment and their unique circumstances” “adolescents vary in the age at which they become competent to make decisions that have complex risk-benefit ratios”. “The timing…will also depend on the nature of the history and presentation of the person’s gender dysphoria, duration of time on puberty suppression for those undertaking stage 1 treatment, co-existing mental health and medical issues and existing family support”

  • “While later commencement of hormone treatment during adolescence provides time for further emotional maturation and potentially lessens the risk that the adolescent will regret their decision, this should be carefully balanced by the biological, psychological and social costs to the adolescent of delaying treatment”.  “Biological implications of delaying hormones include ….relative osteopenia, and (for) trans females …linear growth…” “Psychological costs may include the negative contribution treatment delay may have on an adolescent’s sense of autonomy and agency, and may contribute to, or exacerbate, distress, anxiety or depression with subsequent increase in self-harm or suicide risk”. “Social costs of delayed treatment include peer group and relationship difficulties with pubertal development occurring significantly behind expected norms”

Surgical interventions

  • “Chest reconstructive surgery may be appropriate in the care of trans males during adolescence”.

  •  “delaying genital surgery until adulthood is advised”

Transition of care to adult care providers

“the young person’s GP is vital in facilitating a smooth process and many GPS continue as the primary doctor involved in hormone prescribing and monitoring of mental health after engaging in a shared care agreement during paediatric treatment”.

 

In Australian Standard of Care Part 2. (Below) we discuss:

  • Why this standard matters, 
  • Why it should be adopted in the UK NHS
  • A comparison between the Australian Standard and UK Service Specification
  • A comparative analysis of the evidence base underpinning the Australian and UK approaches