Puberty Blockers – Overview of the research

Nicola Sturgeon Opens Glasgow Pride

The UK media is full of scaremongering about puberty blockers (GnRHa) and the evidence or supposed lack thereof in support of their use for trans adolescents. Opinions abound, but few, however, have the opportunity or access to read the academic literature. In this article, a comprehensive overview of the studies and academic literature on puberty blockers are presented, providing improved access to this evidence. Links to the papers are provided throughout, supported by a full bibliography.

Puberty blockers are a recommended intervention for trans youth at the start of puberty (when such interventions are requested), endorsed by the global Endocrine Society and WPATH (the World Professional Association for Transgender Health). Within medical and clinical service provider communities, strong consensus in support of puberty blockers has grown, with endorsement from the world’s largest paediatric health body the American Academy of Pediatrics, providing access to blockers throughout the USA, and national health services around the world including centres in Spain, Australia & New Zealand. Authors from the conservative UK NHS children’s gender service (GIDS), wrote a position paper in 2016 (Costa) stating that “Despite a limited number of studies, the existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence”, with a more recent 2019 UK paediatric endocrinologist authored piece (Joseph) affirming that puberty suppression “is now a recommended treatment option”.

Puberty blockers have been used since the 1970s for children with precocious puberty, with extensive studies for this cohort (Eun Young Kim provides an overview of the literature), on their long-term use “considering evidence of impact on height, reproductive function, obesity and metabolic syndrome, bone mineral density and bone markers, polycystic ovary syndrome, psychosocial problems”. “Long–term studies on the recovery of reproductive function in precocious puberty patients of more than 6–20 years are being reported”. “Puberty was recovered within 1 year after GnRHa treatment discontinuation, and there were no abnormalities in reproductive function”. “Bone mineral density decreases during GnRHa treatment but recovers to normal afterwards, and peak bone mass formation through bone mineral accretion during puberty is not affected”. “Some studies have reported decreases in psychosocial problems after GnRHa treatment. Overall, GnRHa seems effective and safe for CPP patients, based on long-term follow-up studies.”

In trans youth, blockers have been studied since the late 1980s. An early paper published in 1998 (Cohen Kettenis) reported on the protocols followed for a 13 year old trans boy who was treated with puberty blockers, with HRT (Hormone Replacement Therapy) and surgery after turning 18. This was the first longitudinal case study, which documented a successful outcome from using early puberty blockers. As an adult, the subject was happy and satisfied with the outcomes, (though noted the delays between blockers and HRT were overly long).

The longest follow-up study is of a Dutch trans man who started on puberty blockers at age 13 in 1988. His health and well being was monitored\ regularly for over 22 years, when he was last followed up, aged 35 (in 2010) he was well-functioning with no clinical signs of a negative impact of earlier puberty suppression on brain development, metabolic and endocrine parameters, or bone mineral density (Cohen Kettenis, 2011).

Their use in trans adolescents has been well studied in the Netherlands. In 2011 (Kreukels) the then world leaders in what became known as “the Dutch Approach” wrote that they “believe that offering this medical intervention minimizes the harm to the youth while maximizing the opportunity for a good quality of life including social and sexual relationships, and that it respects the wishes of the person involved”. “Because the effects are reversible, this treatment phase could be considered an extended diagnostic phase. Knowing that the treatment will put a halt to the physical puberty development often results in a vast reduction of the distress that the physical feminization or masculinization was producing.”

Another 2011 study (De Vries) collected data from 2000-2008 of 70 trans youth (33 trans feminine, 37 trans masculine) capturing the time period when they were only receiving puberty blockers. Puberty blockers were started at an average age of 14.75 (youngest was 11.3). Youth received puberty blockers alone before starting HRT alongside for an average of 1.88 years (the shortest period on just puberty blockers was 0.42 years, the longest was 5.06 years). Whilst on puberty blockers there were improvements in behavioural and emotional problems, and reduced symptoms of depression, enabling healthy psychological development. There were not improvements in body image and gender dysphoria. “As expected, puberty suppression did not result in an amelioration of gender dysphoria. Previous studies have shown that only gender reassignment consisting of CSH (cross sex hormone) treatment and surgery may end the actual gender dysphoria”. All youths later went onto HRT (which did lead to improvements in body image and gender dysphoria as well as wider improvements to wellbeing (see 2014 study for follow up). In a clinic with a clear route to HRT (all youth in the study were later prescribed HRT) the authors speculate that improvements in wellbeing whilst on puberty blockers may be due to the youths on puberty blockers having confidence that a route to HRT is available.

A summary position statement from Amsterdam in 2011 (Kreukals) outlined their view: “In our opinion, to deny these youngsters GnRHa treatment is unreasonable. Although the physical effects of puberty suppression are reversible, it has been argued that the effects on psychosexual develop ment are not reversible: the adolescents will miss puberty that is a result of their own natal sex hormones. However, in this sense, denying GnRHa treatment is equally irreversible: the adolescents will never know how puberty in accordance with their gender identity will be, because that is made impossible by the effects of their own sex hormones. Transsexual adolescents often consider not experiencing the puberty of their desired sex more harmful than missing their natal puberty. As puberty suppression therapy generally results in a physical appearance that makes it possible to live unobtrusively in the desired gender role, withholding GnRHa treatment is also harmful because of the potential life-long social consequence s (such as stigmatization).”

Hembree (2011) reviewed other studies noting increased suicidal ideation where blockers were not given.

A 2012 paper (Edwards Leeper) from a major paediatric treatment centre in the USA, emphasised a key reason for puberty blockers – “44% of transgender youth presenting for medical intervention had been previously diagnosed with a psychiatric disorder, the most common being depression, anxiety, and bipolar disorder. Thirty-six percent of these patients had been prescribed psychotropic medications and 9% had been hospitalized psychiatrically in the past. These psychological problems often intensify when transgender children reach puberty”. They also note that “it is not uncommon for these symptoms to decrease and even disappear once the adolescent begins a social and physical transition. The previous diagnoses of major psychiatric disorders, especially mood disorders (e.g., major depressive disorder, bipolar disorder) in these patients are often secondary to their gender identity issue and many patients are “cured” of these disorders through medical intervention for the gender issue.” The authors emphasise multiple psychological benefits of pubertal suppression, especially through avoiding needless emotional and psychological suffering, which can be severe for some adolescents (e.g., self-harming behaviors and suicidality). Delamarre , in an earlier 2006 paper, highlights that once trans adolescents are on puberty blockers, their anxiety at physical changes is taken away, enabling them to concentrate on other issues, enabling them to better develop and socially connect with peers.

A 2014 study (De Vries) of 55 trans youth (22 trans feminine and 33 trans masculine) followed them over an 8 year period from before starting blockers (mean aged 13.6 years), through to start of blockers (average age 14.8, youngest 11.5) through to HRT (mean age 16.7, youngest 13.9) and at least one year after gender reassignment surgery for those who wanted surgery (mean age 20.7). This monitored not only psychological functioning (gender dysphoria, body image, global functioning, depression, anxiety, emotional and behavioural problems) but also tracked wellbeing (social and educational/professional functioning; quality of life, satisfaction with life and happiness). Psychological functioning steadily improved. Well-being improved to similar or better than same age young adults from the general population. “GD (gender dysphoria) and body image difficulties persisted through puberty suppression and remitted after the administration of CSH and GRS (at T2) (significant linear effects in 3 of 4 indicators, and significant quadratic effects in all indicators)“ “None of the participants reported regret during puberty suppression, CSH, treatment, or after GRS. Satisfaction with appearance in the new gender was high, and at T2 no one reported being treated by others as someone of their assigned gender”. “All young adults in this study were generally satisfied with their physical appearance and none regretted treatment. Puberty suppression had caused their bodies to not (further) develop contrary to their experienced gender”. “Psychological functioning improved steadily over time, resulting in rates of clinical problems that are indistinguishable from general population samples (eg, percent in the clinical range dropped from 30% to 7% on the YSR/ASR30) and quality of life, satisfaction with life, and subjective happiness comparable to same-age peers. They note that this support gave “these formerly gender dysphoric youth the opportunity to develop into well-functioning young adults. These individuals, of whom an even higher percentage than the general population were pursuing higher education, seem different from the transgender youth in community samples with high rates of mental health disorders, suicidality and self-harming behaviour”.

Paediatric endocrinologist Rosenthal outlined key endocrine considerations in 2014, highlighting the potential negative impact on bone health of extended pubertal suppression and arguing for earlier introduction of HRT, stating that delaying HRT until age 16 can be “detrimental to bone health”. In addition he stated the negative impacts on emotional well-being of denying trans youth the opportunity to progress through puberty at the same time as their peers, and thereby isolating them. For this reason, gender centres are “studying the impact of cross-sex hormone treatment initiation at 14 years of age (which approximates the upper end of the age range for normal pubertal onset in natal males and 1 year beyond the upper end of the age range in natal females”).

A 2014 paper (Khatchadourian) summarising treatment in a Canadian clinic emphasises the high rates of suicidal ideation before treatment, in a cohort not treated until an average age 16. “Importantly, 10 of the 84 patients (12%) had attempted suicide with a resultant visit to an emergency department before being seen in our clinic”. “The older age of our cohort of patients compared with the Dutch cohort (mean age 16.6 vs 14.6 years, respectively) may also explain differences in frequency of psychiatric comorbidity, as our patients had more time to develop these comorbidities.” They note a decrease in suicide attempts or visits to emergency departments for suicidal ideation once engaged with the clinic (from 10 incidents before treatments, to 4 after). “Although our numbers are quite small, this finding suggests a lessening of emotional problems and suicidality when puberty blockers or cross-sex hormones are started. This is further corroborated by findings in the Dutch cohort, where an improvement in psychological functioning in areas such as depressive symptoms was demonstrated in adolescents with gender dysphoria treated with GnRHa for nearly 2 years.” This study also emphasises youth who do not need to undergo interventions like painful electrolysis or chest surgery, as early treatment prevented unwanted pubertal development. The authors conclude that “most experts in transgender care would agree that initiation of GnRHa therapy at an earlier stage ofpuberty is preferred, because preventing the development of unwanted secondary sexual characteristics can alleviate distress.”.

A 2014 paper (Fisher) outlines the negative consequences in Italy where puberty blockers were not offered – 23 youth, (14 trans feminine, 9 trans masculine, average age 16.3 years old), who had been diagnosed with gender dysphoria but who had not been granted any medical intervention, had low levels of wellbeing, and high levels of emotional and behavioural problems. They also noted that a high proportion, 42%, had dropped out of school early. The authors from Italian clinical services consider ethical implications of prescribing or denying blockers. They discuss fertility, referring to wider studies and concluding “several studies report that fertility potential is not impaired by long-term treatment with GnRHa even when used in younger subjects, before age 7, to treat precocious puberty. In addition, GnRHa treatment seems to have a protective effect on the reproductive outcomes, as fertility problems were more prevalent in subjects with precocious puberty that were not treated when compared with those treated. Professionals should inform patients that sperm production can be satisfactory after cessation of GnRHa or with gonadotropin treatment (both associated with body virilisation. FtM individuals have to be informed that no adverse effects are expected in relation to their fertility when treated with GnRHa” They argue that the current (2014) clinical evidence as well as international clinical guidelines suggests that prompt prescription of puberty blockers provides the best outcome for trans adolescents. They note experience from Italy that later pubertal changes can be unbearable, changes that “are usually profoundly humiliating for transgender youth”. They add that unwanted pubertal changes “often perceived as devastating, may seriously interfere with healthy psychological functioning and well-being”, being associated with worsening gender dysphoria, distress, depression, self-harming behaviour, anxiety, low self-esteem, social isolation and suicidal ideation. They emphasise that “although there are cases of comorbid psychiatric disorders, these psychological symptoms are often a result of the discomfort that Gender dysphoric individuals feel in their own bodies and of the social rejection they experience”. They go on to outline eight reasons to endorse blockers including 1) immediately reducing suffering 2) enable better decision making on further medical intervention 3) the physical effects are fully reversible 4) outcomes for physical transition are enhanced if unwanted secondary sex characteristics are not developed 5) Future surgeries are less likely to be needed 6) Can prevent emotional and psychological suffering that can have short term and longer term risks for well-being 7) provide better psychosocial functioning 8) avoids unsupported youth turning to illicit un-prescribed medication. They conclude that the “current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behaviour, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.”

A 2015 UK study (Costa) compared adolescents supported with puberty blockers to those denied access to blockers. 201 Adolescents with gender dysphoria aged 12-17 (average age 15) were assessed for psychosocial functioning, using an assessment called CGAS. All the youth in the study registered low levels of psychosocial functioning at baseline (CGAS = 57). One group of 61 youth were not granted puberty blockers, instead having 18 months of just psychological support. Their psychosocial functioning improved after 6 months of psychological support (to CGAS = 60) but then plateaued and stayed significantly below the levels of children without psychological symptoms (staying at CGAS = 62). Another group of 60 youth were allocated blockers after 6 months of just psychological support. Like the untreated group, their psychosocial functioning improved when just receiving psychological support (to CGAS = 60). Their psychosocial functioning then improved more significantly at each six monthly check up whilst on puberty blockers. The psychosocial functioning of youth after 12 months of puberty blockers had improved to match that of children without psychological symptoms (CGAS = 67). Trans youth with puberty blockers were able to reach levels of psychosocial functioning the same as their peers.

Another 2015 study (Staphorsius) looked at the impact of puberty suppression on executive functioning in trans adolescents, using a well-established task called ‘Tower of London’ and comparing trans adolescents on blockers to trans adolescents not on blockers. They found no significant effect of blockers on performance scores (reaction times and accuracy) when comparing trans girls on blockers (8) to those not on blockers (10), or when comparing trans boys on blockers (12) with those not on blockers (10). “In conclusion, our results suggest that there are no detrimental effects of GnRHa on Executive Function.

A 2015 study (Klink) followed 34 trans youth through adolescence and into adulthood. 15 trans girls/women and 19 trans boys/men were followed from starting blockers at an average age of 15.0, through to starting HRT at an average age of 16.5, through to final follow up at an average age of 22.0. The paper analyses data on bone mineral density.
A 2017 study (Vlot) looked at the impact of puberty blockers and HRT on bone health. 34 trans boys and 22 trans girls were studied, providing data on impacts on different bone health related measures. These studies are followed up by a 2019 study (Joseph) below.

Very few studies focus on asking what trans youth themselves think about puberty blockers. One exception is a 2016 study (Vrouenraets) of 13 adolescents (5 trans girls and 8 trans boys), 12 of whom received puberty blockers, at an age range between 13 and 18, with median age 17. Asked about a lack of data on the long-term effects of puberty suppression the majority said that being happy in life was more important for them than any possible negative long-term consequence of puberty suppression “The possible long-term consequences are incomparable with the unhappy feeling that you have and will keep having if you don’t receive treatment with puberty suppression” (trans youth age 18)”. “It isn’t a choice, even though a lot of people think that. Well, actually it is a choice: living a happy life or living an unhappy life. (trans girl, age 14). Interviewed youth also understood that treatment has to be given in order to obtain long-term data, and were more than willing to be the person to test it.

A 2016 study (Schagen) aimed to evaluate the efficacy and safety of GnRHa treatment in trans adolescents, evaluating the extent to which (early) pubertal physical changes can be reversed, the need for monitoring of gonadotropins and sex steroid levels, and the need for screening of liver and renal function. Forty-nine trans feminine adolescents (average age 13.6, range 11.6-17.9) and 67 trans masculine adolescents (average age 14.2, range 11.1 – 18.6, 77% had started menarche) treated between 1998 and 2009 were included in the analysis. “None of the adolescents discontinued GnRHa treatment because of side effects. This is in agreement with the finding that GnRHa treatment is well tolerated by children and adolescents”. “Gonadotropins and sex steroid levels were suppressed within 3 months. Treatment did not have to be adjusted because of insufficient suppression in any subject”. “We did not identify any renal or hepatic complications of the treatment, and previous studies on GnRHa treatment in children with precocious puberty did not find such adverse effects. Therefore, it does not seem necessary to routinely monitor these parameters”.

A 2017 paper (Schneider) provided a case study of the brain of a single trans youth during pubertal suppression. “Brain white matter fractional anisotropy remained unchanged in a GD girl during pubertal suppression with GnRHa treatment for 28 months, which may be related to reduced serum testosterone levels. The global performance in the Weschler scale was slightly lower during pubertal suppression compared with baseline, predominantly due to the reduction in operational memory. Either a baseline of a low average cognition or the hormonal status could play a role in cognitive performance during pubertal suppression”. A major limitation is a sample size of one, and comparing white matter in a trans girl to post pubertal cis boys. Also, the adolescent in the case study suffered conversion therapy and associated depression at a young age, and studies show the link between memory and childhood trauma. A 2020 paper (Chen) conducted a brain study on a larger sample of 18 girls with precocious puberty – the study did not provide any clear recommendations, but simple concluded that this is adding to the body of research on the effects of GnRHa on brain function.

A 2018 paper (Wiepjes) summarised overall data on all people treated in Amsterdam up to 2015. Out of those referred to the clinic in before the age of 18 and treated with puberty blockers, they found that 4 out of 207 trans girls (2%) stopped puberty suppression without proceeding to HRT and 2 out of 370 trans boys (less than 1%) stopped puberty suppression without proceeding to HRT. Reasons for discontinuation of GnRHa were not reported. In addition to these youth, a further 112 trans girls and 148 trans boys referred in adolescence went straight to CSH without taking blockers.

A 2019 study (Joseph) of the impact of puberty suppression on bone mass  followed 70 adolescents, referred to the UK GIDS between 2011-2016. The sample included 31 trans girls and 39 trans boys aged 12-14 years, and all but two of the trans boys (95%) were postmenarchal. Two analyses were performed, a complete longitudinal analysis (n = 31) where patients had scans over a 2-year treatment period, and a larger cohort over the first treatment year (n = 70). All youth were required to stay without addition of HRT until age 16. At baseline trans boys had lower bone mineral density (BMD) measures than trans girls. There was no significant change in the absolute values of hip or spine BMD or lumbar spine BMAD after 1 year on GnRHa. BMD-Z scores were low, but the authors highlight the debatable utility of measuring and contrasting Z scores (which compares BMD to same age youth who are not on puberty blockers). Bone mineral density rises due to sex hormones at puberty, so those with delayed puberty will automatically not gain this rise at the same age as un-suppressed cis adolescents of the gender they were assigned at birth, and will automatically score low when compared to such Z scores. The authors highlight that their observations mirror the observations in studies by Klink 2015 and Vlot 2016 which also demonstrate no significant change in absolute BMD under pubertal suppression. They “propose that it may be clinically inappropriate to compare these subjects’ BMD with that of contemporaries who have not had pubertal blockade as the bone development in the GD subjects has been halted in comparison to those of their age group”. They suggest developing expected-BMD charts for pubertally suppressed adolescents, as a more useful way of tracking BMD. The authors note that there are no international guidelines for the surveillance of bone health in young people with gender dysphoria, that reference ranges may need to be redefined for this patient cohort, and that there needs to be clarity on treatment options where an adolescent is found to have low bone mineral density (BMD). More important than tracking bone health whilst on blockers, is understanding the long term impact on BMD once sex hormones are added. They conclude that absolute BMD and BMAD scores do not change substantially over a 3 year period in trans adolescents on GnRHa treatment and recommend that yearly bone scans while on puberty blockers may be unnecessary.

In a 2019 letter to the BMJ (Ferguson) Australian clinicians reviewed existing datasets of impact of puberty suppression on bone health. They outlined heterogeneity in the outcomes, and recommended identifying and tracking individuals who are more significantly affected in terms of bone mineral density, rather than reporting on the average. They note that regardless of the positive impacts of puberty blockers, clinicians have a duty to maximise bone health of trans youth on puberty blockers.

A 2020 study (Achille) tracked 50 youth (mean age 16.2) over one year of endocrine intervention (data captured between 2013 and 2018). 4 trans masculine youth were just on blockers, 8 trans feminine youth were just on blockers, 24 trans masculine youth were just on testosterone, 7 trans feminine youth were on oestrogen and blockers, and 4 trans masculine youth were on testosterone and blockers. Four different measures of wellbeing (depression, quality of life, suicidal ideation) were tracked, controlling for engagement in counselling, and all measures of wellbeing showed improvements with treatment. A key measure of depression showed a reduction from levels indicating clinical depression to below the threshold for clinical depression. (Mean baseline CESD-R score was 21.4 and decreased to 13.9 – A score less than 16 implies no clinical depression)”. The study concludes that endocrine intervention may improve mental health in transgender youth.

A 2020 cross-sectional survey (Turban) of 20,619 trans adults (aged 18-36) used multivariable logistic regression to examine associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality. 3,494 adults (16.9%) reported that they had wanted pubertal suppression, but only 89 (2.5%) had received it. After controlling for other variables, pubertal suppression was associated with decreased odds of lifetime suicidal ideation – 90% of those who had not received blockers had experienced suicidal ideation, compared to 75% in those who had had blockers at an average age of 15. The study adds to evidence on the relationship between pubertal suppression and positive mental health outcomes. It avoids the physical changes known to cause significant distress, and when provided in affirmative care may also protect against minority stress.

A 2020 study (Miesen) compared three groups for emotional and behavioural problems (internalizing, externalizing, peer relations, and suicidality), assessed by youth self-report. They compared 272 adolescents (mean age 14.5 years) who had been referred to a specialised gender identity clinic and were undergoing assessment but had not yet received puberty blockers, with 178 transgender adolescents (mean age 16.8 years) who were on puberty blockers and about to receive HRT – the two trans groups did not differ in scores at baseline (when first assessed in the gender clinic). These two groups were compared with a comparison sample of 651 Dutch high school cisgender adolescents from the general population (mean age 15.4 years). Results: Before medical treatment, clinic-referred adolescents showed more internalising problems and reported increased self-harm/suicidality and poorer peer relations compared with their age-equivalent peers. Transgender adolescents receiving puberty suppression had fewer emotional and behavioural problems than the group that had just been referred to transgender care and had similar or fewer problems than their same-age cisgender peers. Before treatment 31.3% of trans youth had clinical levels of internalising problems, whereas amongst trans youth receiving puberty blocker treatment and about to start HRT only 16.3 % had clinical levels of internalising problems, lower than in the cisgender sample (22.9%). Before treatment 17.3% of trans youth had clinical levels of externalising problems, whereas amongst trans youth receiving puberty blockers and about to start HRT 14% had clinical levels of externalising problems, similar to the cisgender sample (13.8%). In suicidality, this was reported by 27.2% of trans youth before treatment, whereas in the sample of trans youth receiving puberty blockers and about to start HRT it was 12.4% – similar to the cisgender sample (11.9%). Conclusions: Transgender adolescents show poorer psychological well-being before treatment but show similar or better psychological functioning compared with cisgender peers from the general population after the start of specialized transgender care involving puberty suppression. The study provides further evidence that trans youth could benefit from gender affirmative care. “A clinical implication of these findings is the need for worldwide availability of gender-affirmative care, including puberty suppression for transgender adolescents to alleviate mental health problems of transgender adolescents”. “This first study comparing a group of transgender adolescents just referred for gender-affirmative care, a group of transgender adolescents receiving treatment with puberty suppression, and a group of cisgender adolescents, from the general population showed that when affirmative care involving puberty suppression is provided, transgender adolescents may have comparable mental health levels to their cisgender peers. This type of gender-affirmative care seems thus extremely important for this group”.

A 2020 study from the Netherland (Brik) examined the trajectories of trans and gender questioning adolescents after initiation of blockers. Prior to 2016 the clinic protocol required adolescents to be 16, and on blockers for at least 6 months, before they could start HRT. From 2016 youth could progress to HRT at age 15 if they had been on blockers for 3 years, and from 2017 the protocol shifted again to allow progression to HRT at age 15 if they had been on blockers for 2 years. The study looked at 143 adolescents who were deemed eligible for puberty blockers, all of whom started blocker treatment between November 2010 and January 2018. This included 38 trans girls, median age for starting blockers was age 15 (range 11.1-18.6) and 105 trans boys, median age for starting blockers 16.1 years (range, 10.1–17.9). Treatment status as of July 2019 was reviewed.

From the sample of 143 adolescents, 11 were too young to be eligible for HRT at the point of the study (having been on blockers for a maximum of 2.8 years). One of these 11 had stopped blockers as his parents were unable to regularly take him to collect medication and get it injected and had instead switched to other medication to stop periods, being too young to be eligible for HRT).

132 adolescents were old enough to be eligible for HRT. 123/132 (93%) had gone from just blockers onto HRT. Median age at the start of gender-affirming hormones was 16.2 years (range, 14.5–18.6 years) in trans girls and 17.1 years (range, 14.9–18.8 years) in trans boys. The majority of these (103/132) had proceeded to HRT as soon as they were eligible. 19/132 had what the clinic called an extended amount of time on just blockers before going on to HRT. This extended time on blockers ranged from 0.8 years to a maximum of 2.4 years, with a median duration of 1 year. Reasons for spending an extended time on just blockers included i) lack of family support (n=6) ii) lack of safe home/school absenteeism n=5) iii) what the authors call a ‘comorbidity’ like autism or depression (n = 8) or iv) logistical issues (n=8). One adolescent was kept on blockers for an extended period for additional assessment due to being non-binary. Only one adolescent had additional time on blockers to allow the adolescent more time for decision-making about gender-affirming hormone treatment. Those delayed because of mental health or psycho-social issues had monthly mental health appointments during the extended period on just blockers. 1 youth had moved clinic and at age 17 had decided to stay on just blockers for a while longer, delaying initiation of testosterone until after exams, having been on blockers for 2.5 years.

From the 132 adolescents old enough to be eligible for HRT, 3 (2%) stopped taking blockers but later went on to HRT. 1 of these, a trans boy, experienced hot flushes, an increase in migraine and fear of injections in addition to problems and school and unrelated medical issues and wished to temporarily discontinue blockers. He restarted blockers after 5 months and later proceeded on to HRT.  One of these, a trans boy, interviewed at age 19, reported an increase in mood problems and suicidal thoughts and confusion attributed to GnRHa treatment and stated: “I was already fully matured when I started GnRHa, menstruations were already suppressed by contraceptives. For me, it had no added value”. The third case, a transboy, experienced mood swings starting 4 months after he had begun GnRHa treatment. A year later, he started to frequently feel unwell and miss school. After 2.2 years, he developed severe nausea and rapid weight loss for which no cause was identified. Because of this deterioration of his general condition, he wished to discontinue GnRHa treatment after 2.4 years. He gradually recovered over the next 2 years and subsequently started HRT.

From the 132 adolescents old enough to be eligible for HRT, 5 (4%) stopped blockers and reported no wish for gender affirming treatment at this time. Their identities and stories were individual. Two described non-binary identities. One had psycho-social problems. One found the period on blockers helpful in understanding a cisgender identity. One described falling in love and questioning his gender identity before identifying with his assigned gender.

In conclusion: Out of the 132 adolescents old enough for HRT, 126 (95%) were on HRT at the time of the study, 1 had chosen to extend their time on blockers before HRT, and 5 (4%) had decided not to have gender affirming treatment. The adolescents and parents were asked their views on GnRHa. All felt free to stop GnRHa.  Some stated it gave them time to think and feel who they were and what they wanted in the future and felt that without GnRHa treatment they would not have been able to make these decisions. Others stated that GnRHa should not be routinely offered before the start of gender-affirming hormones when adolescents are already fully matured, because of the lack of physical benefits. Instead, a consideration time of 6 months with psychological follow-up was suggested.

Continued questions

Despite the decades of studies, critics of blockers continue to claim they are new and experimental, a claim refuted by  Giordano and Holm in a 2020 paper. Critics also point to low quality evidence, especially lack of randomised control trials. However, a wide number of studies comment on the impossibility of conducting randomised control trials on this cohort. A 2011 paper (De Vries) by the leading practitioners at the time from the Netherlands states “Finally, this study was a longitudinal observational descriptive cohort study. Ideally, a blinded randomized controlled trial design should have been performed. However, it is highly unlikely that adolescents would be motivated to participate. Also, disallowing puberty suppression, resulting in irreversible development of secondary sex characteristics, may be considered unethical.” Giordano and Holm (2020) are stronger, being clear this “particular use cannot be investigated by a RCT ”. Rosenthal (2014) agrees “Furthermore, randomized controlled trials for hormonal interventions in gender-dysphoric youth have not been considered feasible or ethical ”.

The latest 2020 paper (Brik) similarly states: “A randomized controlled trial in adolescents presenting with gender dysphoria, comparing groups with and without GnRHa treatment, could theoretically shed light on the effect of GnRHa treatment on gender identity development. However, many would consider a trial where the control group is withheld treatment unethical, as the treatment has been used since the nineties and outcome studies although limited have been positive. In addition, it is likely that adolescents will not want to participate in such a trial if this means they will not receive treatment that is available at other centers. Mul et al. (2001) experienced this problem and were unable to include a control group in their study on GnRHa treatment in adopted girls with early puberty because all that were randomized to the control group refused further participation“.

Although global consensus for puberty blockers is strong, a variety of different views remain. A 2015 study (Vrouenraets) interviewed psychiatrists, psychologists and endocrinologists from 17 treatment teams worldwide, gaining insights into the views underpinning different attitudes towards treatment. Those opposed to treatment diverged from those who supported treatment in their view on whether gender dysphoria is natural variation or mental illness; the potential role of puberty in developing identity; the role of comorbidity; and the physical or psychological effects of enabling or denying intervention.

Ethics are discussed in a number of articles. Giordano reviewed the ethics for and against puberty blockers over a decade ago, in 2007 and 2008, noting the high risk outcomes in trans children who could not access medical intervention. They concluded that “suspension of puberty is not only not unethical: if it is likely to improve the child’s quality of life and even save his or her life, then it is indeed unethical to defer treatment”. Giordano and Holm followed up in 2020 with a review of the latest studies, highlighting the evidence of benefits and reinforcing the earlier conclusion on the ethical prerogative to provide treatment.

A 2017 article (Giovanardi) on ethics from a fly-by-night unrated journal is discredited for misrepresenting key literature (as discussed here, the researcher whose research is misrepresented made a complaint but the journal had folded before the paper could be retracted or corrected).

Lopez (2018) examines data on puberty blocker implants for precocious puberty as compared to trans adolescents. In a 2016 dataset blockers were used in 512 cases for precocious puberty at average age 8.9 years olds, whereas they were only used in 62 cases for trans adolescents at an average age of 14 years old. The age-based arguments against trans adolescents accessing blockers do not seem to apply for the much younger cohort in precocious puberty, suggesting it is not the medication or the age of use that people have a problem with, but rather its use for gender dysphoric adolescents.

A 2020 article (Pang) examines the ethics of extended puberty blocker treatment for an agender teen – a teen who started blockers at 12, is now 15 and wants to continue on just blockers till 18. One commentator contrasts the two main risks; impaired fertility in the future and low bone density, with the one key benefit: continued alleviation of gender dysphoria and anxiety. They quantify the bone density related risks: with a bone density in the lowest 2.5 percentile a person “has a 0.2% to 0.3% risk of sustaining a hip fracture and a 1% to 2% risk of other fractures in the next 5 to 10 years compared with a control with normal bone density (0% risk of hip fracture and 0.7%–1% risk of other fractures in the next 5–10 years).” They highlight that the adolescent and/or their parents may still decide that these risks are outweighed by the potential psychosocial benefits from relieved gender dysphoria. Another commentator, whilst recognising the clear benefits of puberty blocker usage, highlights that with shorter term use (2 years), bone density increases significantly once sex hormones are introduced, and recommends a shorter time on blockers to promote optimal bone density.


Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., et al. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. Int J Pediatr Endocrinol 2020, 8. doi:10.1186/s13633-020-00078-2.

Brik, T., Vrouenraets, L. J. J. J., de Vries, M. C., and Hannema, S. E. (2020). Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch Sex Behav. doi:10.1007/s10508-020-01660-8.

Chen, T., Yu, W., Xie, X., Ge, H., Fu, Y., Yang, D., et al. (2020). Influence of Gonadotropin Hormone Releasing Hormone Agonists on Interhemispheric Functional Connectivity in Girls With Idiopathic Central Precocious Puberty. Front Neurol 11, 17. doi:10.3389/fneur.2020.00017.

Cohen-Kettenis, P. T., Schagen, S. E. E., Steensma, T. D., de Vries, A. L. C., and Delemarre-van de Waal, H. A. (2011). Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up. Arch Sex Behav 40, 843–847. doi:10.1007/s10508-011-9758-9.

Cohen-Kettenis, P. T., and van Goozen, S. H. M. (1998). Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. European Child & Adolescent Psychiatry 7, 246–248. doi:10.1007/s007870050073.

Costa, R., Carmichael, P., and Colizzi, M. (2016). To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nat Rev Urol 13, 456–462. doi:10.1038/nrurol.2016.128.

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., and Colizzi, M. (2015). Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine 12, 2206–2214. doi:10.1111/jsm.13034.

de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., and Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 8, 2276–2283. doi:10.1111/j.1743-6109.2010.01943.x.

Delemarre-van de Waal, H. A., and Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology 155, S131–S137. doi:10.1530/eje.1.02231.

Edwards-Leeper, L., and Spack, N. P. (2012). Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center. J Homosex 59, 321–336. doi:10.1080/00918369.2012.653302.

Ferguson, G., Simm, P., O’Connell, M., and Pang, K. C. (2019). Gender dysphoria: puberty blockers and loss of bone mineral density. BMJ 367. doi:10.1136/bmj.l6471.

Fisher, A. D., Ristori, J., Bandini, E., Giordano, S., Mosconi, M., Jannini, E. A., et al. (2014). Medical treatment in gender dysphoric adolescents endorsed by SIAMS-SIE-SIEDP-ONIG. J. Endocrinol. Invest. 37, 675–687. doi:10.1007/s40618-014-0077-6.

Giordano, S. (2007). Gender Atypical Organisation in Children and Adolescents: Ethico-legal Issues and a Proposal for New Guidelines. Int J Child Rights 15, 365–390. doi:10.1163/092755607X262793.

Giordano, S. (2008). Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder? Journal of Medical Ethics 34, 580–584. doi:10.1136/jme.2007.021097.

Giordano, S., and Holm, S. (2020). Is puberty delaying treatment ‘experimental treatment’? International Journal of Transgender Health 21, 113–121. doi:10.1080/26895269.2020.1747768.

Hembree, W. C. (2011). Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child and Adolescent Psychiatric Clinics of North America 20, 725–732. doi:10.1016/j.chc.2011.08.004.

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 102, 3869–3903. doi:10.1210/jc.2017-01658.

Joseph, T., Ting, J., and Butler, G. (2019). The effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria: findings from a large national cohort. J. Pediatr. Endocrinol. Metab. 32, 1077–1081. doi:10.1515/jpem-2019-0046.

Khatchadourian, K., Amed, S., and Metzger, D. L. (2014). Clinical management of youth with gender dysphoria in Vancouver. J. Pediatr. 164, 906–911. doi:10.1016/j.jpeds.2013.10.068.

Kim, E. Y. (2015). Long-term effects of gonadotropin-releasing hormone analogs in girls with central precocious puberty. Korean J Pediatr 58, 1–7. doi:10.3345/kjp.2015.58.1.1.

Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., and Rotteveel, J. (2015). Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J. Clin. Endocrinol. Metab. 100, E270-275. doi:10.1210/jc.2014-2439.

Kreukels, B. P. C., and Cohen-Kettenis, P. T. (2011). Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol 7, 466–472. doi:10.1038/nrendo.2011.78.

Lopez, C. M., Solomon, D., Boulware, S. D., and Christison-Lagay, E. R. (2018). Trends in the use of puberty blockers among transgender children in the United States. J. Pediatr. Endocrinol. Metab. 31, 665–670. doi:10.1515/jpem-2018-0048.

Miesen, A. I. R. van der, Steensma, T. D., Vries, A. L. C. de, Bos, H., and Popma, A. (2020). Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. Journal of Adolescent Health 66, 699–704. doi:10.1016/j.jadohealth.2019.12.018.

Murchison, G., Adkins, D., Conard, L. A., Ph, R., Ehrensaft, D., Elliott, T., et al. (2016). Supporting & Caring for Transgender Children’. Human Rights Campaign Available at: [Accessed October 3, 2019].

Oliphant, J., Veale, J., Macdonald, J., Carroll, R., Johnson, R., Harte, M., et al. (2018). Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand. Available at: [Accessed October 3, 2019].

Pang, K. C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., et al. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics 145. doi:10.1542/peds.2019-1606.

Rosenthal, S. M. (2014). Approach to the patient: transgender youth: endocrine considerations. J. Clin. Endocrinol. Metab. 99, 4379–4389. doi:10.1210/jc.2014-1919.

Schagen, S. E. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., and Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. J Sex Med 13, 1125–1132. doi:10.1016/j.jsxm.2016.05.004.

Schneider, M. A., Spritzer, P. M., Soll, B. M. B., Fontanari, A. M. V., Carneiro, M., Tovar-Moll, F., et al. (2017). Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression. Front Hum Neurosci 11, 528. doi:10.3389/fnhum.2017.00528.

Staphorsius, A. S., Kreukels, B. P. C., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E. E., et al. (2015). Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology 56, 190–199. doi:10.1016/j.psyneuen.2015.03.007.

Telfer, M.M., Tollit, M.A., Pace, C.C., & Pang, K.C. (2018). Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Chil-dren and Adolescents. Melbourne: The Royal Children’s Hospital Available at: [Accessed October 4, 2019].

Turban, J. L., King, D., Carswell, J. M., and Keuroghlian, A. S. (2020). Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics 145. doi:10.1542/peds.2019-1725.

Vlot, M. C., Klink, D. T., den Heijer, M., Blankenstein, M. A., Rotteveel, J., and Heijboer, A. C. (2017). Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone 95, 11–19. doi:10.1016/j.bone.2016.11.008.

Vries, A. L. C. de, McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., and Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics 134, 696–704. doi:10.1542/peds.2013-2958.

Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., and de Vries, M. C. (2015). Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study. J Adolesc Health 57, 367–373. doi:10.1016/j.jadohealth.2015.04.004.

Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., and de Vries, M. C. (2016). Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth. Arch Sex Behav 45, 1697–1703. doi:10.1007/s10508-016-0764-9.

Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., et al. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med 15, 582–590. doi:10.1016/j.jsxm.2018.01.016.

World Professional Association for Transgender Health (WPATH). (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.

Australia Supports Trans Children


Following months of Australian (Murdoch) media scaremongering about trans children, and anti-trans lobbying by right wing groups, Australian politicians asked a leading  Australian medical body (RACP). to review the Australian healthcare approach to supporting transgender youth.

Today brought two important announcements, from the RACP and from AusPATH.

The RACP is the Royal College of Australian Physicians, representing 25,000 Australian medical professionals. The RACP today provided the following announcement:

The RACP has recommended against a national inquiry into gender dysphoria and made suggestions to improve care to young trans people.

In August 2019, the Federal Minister for Health Greg Hunt wrote to the College seeking advice on the treatment of gender dysphoria in children and adolescents. The RACP has now provided that advice to the Minister. The full advice is linked below.

The RACP strongly supports expert clinical care that is non-judgemental, supportive and welcoming for children, adolescents and their families experiencing gender dysphoria. Children and adolescents with gender dysphoria are a very vulnerable population, experiencing stigma and extremely high rates of depression, self-harm, attempted suicide and suicide.

Ensuring children and adolescents with gender dysphoria can access appropriate care and treatment regardless of where they live, should be a national priority. Withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people. 

The RACP notes that there are substantial dangers posed by some of the proposals that have been put forward during the recent public debate on this issue, such as holding a national inquiry into the issue. A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention.

Today, the Australian Professional Association for Trans Health released the following response:

The Australian Professional Association for Trans Health (AusPATH), established in 2009 as the Australian and New Zealand Professional Association for Transgender Health, is Australia’s peak body for professionals involved in the health, rights and wellbeing of trans people, including those who are gender diverse and non-binary (TGDNB). The AusPATH membership comprises approximately 300 experienced professionals working across Australia.

AusPATH welcomes the Royal Australasian College of Physicians (RACP) advice to Minister Greg Hunt, Federal Minister for Health, regarding the care and treatment of TGDNB children and adolescents, and seeking medical intervention. This advice is based on the available scientific evidence and the expertise of those with relevant clinical experience across sub-speciality areas of medicine and bioethics.

 AusPATH agrees with the RACP that ensuring children and adolescents who are trans, including those who are gender diverse and non-binary “can access appropriate care and treatment regardless of where they live, should be a national priority”, and that “withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people.”

As stated by the RACP, “clinical care needs to be “non-judgemental, supportive and welcoming for children, adolescents and their families”.

AusPATH also supports the RACP recommendation that the Australian Government provide funding for research, especially in relation to the long-term health and wellbeing outcomes for trans, including gender diverse and non-binary young people. Increased investment in research and expansion of the knowledge base, for young people and adults, will be vital in improving the current and disturbing high rates of depression, anxiety, suicide attempts and suicide amongst this cohort.

Improving outcomes can only be achieved by reducing the stigma, discrimination, bullying and harassment that trans people, including those who are gender diverse and non-binary, are subjected to on a daily basis. Negative, hateful media campaigns aimed at invalidating the experiences and strength of this community, and those who provide care for them, is reprehensible, harmful and must stop.

There is much work for us to do to improve the lives of all trans people in Australia. AusPATH looks forward to assisting the clinicians, researchers, educators and advocates across Australia to continue the provision of high quality, patient-centred, human rights-focused and comprehensive gender affirming care and treatment.

Best Practice

The Australian guidelines for healthcare for trans youth represent world best practice. These guidelines are summarised in this blog here

I want to highlight a couple of things about the approach that the overall Australian health service has taken to the transphobic pressure it has come under.

  1. The Australian healthcare service overall has centred the needs, rights and wellbeing of transgender children, both in their healthcare, in their engagements with the media, and in their response to political and media pressure.
  2. They have emphasised the importance of patient centred, human rights focused and comprehensive gender affirming care.
  3. They clearly and unambiguously state “withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people.” This clarity in messaging is vitally important in a context of media misinformation and transphobic scaremongering.
  4. They acknowledge, highlight and condemn the negative impact that media and societal transphobia has on the wellbeing of trans children.
  5. The RACP “strongly supports expert clinical care that is non-judgemental, supportive and welcoming”. This strong support, combined with positive and non-pathologising language is really important in this media communication.
  6. The RACP takes a clear public position, backing up the needs and wellbeing of vulnerable trans children and their families. They state “the RACP notes that there are substantial dangers posed by some of the proposals that have been put forward during the recent public debate on this issue, such as holding a national inquiry into the issue. A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention”.

I want highlight the absurd contrast between the way the health service in Australia has tackled this and the current UK NHS approach.

The UK NHS service for transgender children (GIDS) is hugely behind global best practices for transgender youth healthcare – see here for a comparison between the GIDS approach and the Australian approach

The UK is out of touch with gender affirmative best practices as endorsed by Auspath, the Endocrine Society, the American Academy of Pediatrics – and is behind healthcare practices across the US, Canada, Spain, New Zealand, Australia. New global guidelines from the World Professional Association for Transgender Health (WPATH) are due out this year, and are expected to endorse an affirmative approach to support for transgender children. The UK GIDS service, with its pathologising approaches, three year wait for first appointments, psychoanalytic approach (without one single paediatrician) and refusal to embrace evidence based gender affirmative healthcare, is a disgrace.

When faced by the same media and right wing funded transphobic pressure that doctors in the US and Australia have faced, the UK NHS has responded very differently.

Here in the UK we have a court case to investigate whether trans teens are somehow uniquely unable to give informed consent to safe and reversible puberty blocker treatment that has been studied in trans youth for 32 years.

There is a NICE evidence review into puberty blockers and hormones (despite the Endocrine Society having released global guidance in 2016 on this, despite no evidence of harm and much evidence of benefits, and despite WPATH global standards of care producing new global guidelines on this that are due out this year (Standards of Care Version 8). The ToR for this review will be critical, as recent reviews by the BMJ and the evidence review informing the GIDS 2016 service specification were both heavily flawed, bringing ideological biases to the evidence review, and omitting key evidence. The team involved in the heavily flawed 2016 service specification review completely ignored submissions from those advocating for the rights and wellbeing of transgender children – how do we ensure this doesn’t happen this time round? There is very little community faith that this NICE review will be effective – we know there is a lack of the type of RCT evidence NICE normally prioritises, the question is, what do we do based on the level of evidence currently in existence. In Australia and the US (and elsewhere) healthcare providers are very clear that affirmative care is the only way to support trans youth. Parents such as myself are very clear on this. Trans adults are very clear on this. Trans youth are very clear on this – but is NICE interested in these perspectives? We know and experience the harm of inadequate care – we see it daily in our families.

There is also an NHS panel being formed to review the NICE evidence and provide NHS recommendations on trans youth healthcare. Will important questions like the NHS’ failure to offer timely non-pathologising affirmative care led by paediatricians rather than psychoanalysts even be on the agenda? Who is shaping the agenda for these reviews and investigations – they certainly don’t match with the issues that matter to those of us supporting transgender children – they seem to match the agenda of those wishing to ban healthcare for transgender children. Why is there no acknowledgement, that publicity about these reviews, in a context of minority stress and transphobia, adds to the harm, adds to discrimination, makes life worse for transgender children and families?

Who on this panel will be speaking up for the rights of transgender children? Families of trans children, trans healthcare experts and trans communities have little faith in this process centring the rights and wellbeing of trans children. A very significant concern is the question of who will be on that panel. There will be no voice representing trans children on that panel. No voice representing trans adults. No voice representing supportive parents of trans children.

We know there are strong transphobic voices in the UK, including in the NHS, who deny the existence of transgender children like my daughter. Voices who, like in Australia and the US, are actively campaigning to withdraw healthcare for transgender children. Some of these voices are clear in their transphobia – others are subtler in crouching their views in descriptions of ‘concern’ and ‘lack of RCTs’. Many of these opponents advocate stopping all trans youth healthcare, increasing the access barriers, and taking us back to reparative and talk therapy based approaches of rejection and stigma. Approaches that are known to cause harm.

If anyone who has publicly condemned healthcare for transgender children, including those who argue against healthcare until the age of 24 (!) is on the panel, this panel will lack all credibility with families of transgender children. There would be no place for anti-vaccine voices on a review of vaccine safety – there would be no place for anti-climate change fringe voices on a review of climate change policy – there absolutely is no place for anyone who has spoken out against the rights and wellbeing of transgender children in a NHS panel reviewing this healthcare.

The biggest concern – There will likely not be one single paediatrician with experience supporting trans children on that NHS review panel. In other countries like Australia, trans youth healthcare is led by paediatricians. Here in the UK there is not one single paediatrician with this experience and specialism. Our NHS service is led by psychoanalysts who are not medically qualified. This is a huge knowledge gap for this NHS review panel. The panel absolutely has to have on it a paediatrician with experience in leading the care of transgender children. If there is not one such experienced and qualified paediatrician in the UK (which there is not), the panel needs to fill this knowledge gap by inviting experienced paediatricians from the US or Australia to join this panel. Someone like Michelle Tefler, the paediatrician in charge of the Australian trans youth healthcare system would be ideal.

And as we wait, families and transgender children are already being harmed by the UK NHS approach – by the media messaging about reviewing the evidence base on puberty blockers. Already children are experiencing additional trauma, scrutiny and disbelief from NHS health professionals like GPs, from school teachers, from social services, from family members, as a direct result of this inquiry. Direct harm due to the NHS’s chosen approach.

Again, I will compare this to the Australian RACP approach which stated today:
“the RACP notes that there are substantial dangers posed by some of the proposals that have been put forward during the recent public debate on this issue, such as holding a national inquiry into the issue. A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention”.

Why does the NHS continue to fail transgender children so badly, in so many different ways?

Why can’t we learn from the Australian healthcare system?

Who is speaking up for trans children’s rights and wellbeing within the decision making circles of the NHS?



PhD starts here


Throughout the past years of trying to secure the rights of my child, I’ve been frustrated at the substantial barriers trans children face.

The many ways in which their rights are infringed.

The systemic obstacles they need to jump over, hoping for equality of opportunity.

Their very existence is challenged.

Lack of data is part of the problem – time and again trans kids are left out of surveys or research – they aren’t even considered.

With these challenges in mind, I’ve applied for, and been accepted onto a PhD at Goldsmiths Education department.

My topic: Cisnormativity and the rights, equality and well-being of socially transitioned transgender children under the age of 12. I’ll be supervised by Dr Anna Carlile.

I’ll have a focus on trans children in education, as well as considering families, healthcare and wider rights.

I’m doing it part-time, and aim to publish as I go. Watch this space.

I’m very interested in connecting with trans positive researchers, as well as with researchers specialising in child rights / child participation.

I can be reached on twitter @fiercemum

Wish me luck!

New Zealand Healthcare Guidelines Affirm & Support Trans Children


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)


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”.

Trans Rights are Human Rights – Interview with Ed Miliband

In November 2017,  (@DadTrans) was interviewed by Ed Miliband and Geoff Lloyd for their Reasons to be Cheerful Podcast.

The episode went on to jointly win broadcast of the year at the 2018 Pink News Awards

Receiving the award, ex-Labour leader Miliband joked: “This makes up for the general election in 2015.”

He then made an emotional tribute to “Joe” (@DadTrans). Miliband said that “the podcast worked because of Joe’s testimony,  “I learned a lot by listening to him”.

Take a listen here:


Offensive, dated, harmful: 2019 research from the UK Children’s Gender Service


Last year GIDS (UK Children’s Gender Identity Service) published two poor cisnormative and pathologising research articles. One was reviewed in detail here.

This week a new article came out:

Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties’ by Anna Churcher Clarke and Anastassis Spiliadis in ‘Clinical Child Psychology and Psychiatry’.

In this review I’ll start with the reference list as that is a good indication of what the authors are reading and see worthy of citing.


Here I look through all the references cited by this GIDS paper.

The Unacceptable Transphobic Worst

The reference list includes three separate citations of the same non-peer reviewed paid-to-publish book, H. Brunskell-Evans & M. Moore (Eds.), Transgender children and young people: Born in your own body’. The first of these, a chapter ‘The transgender experiment on children’ by Stephanie Davies-Arai, the “founder” of Transgender Trend. An anti trans lobby group formed by a Davies-Ara, a sculptor with no real life or clinical experience of transgender children has been extensively criticized for its lack of rigour and transphobic bias. As Rachel Pain revealed, “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”.

Marchiano, L. (2018), is another chapter from the same publication, ‘The language of the psyche: Symptoms as Symbols’. We may question why GIDS clinicians working for the evidence based NHS are referencing such overt propaganda. In combination with the positive review of this same by another GIDS clinician, Midgen (2018) this begins to look like a organised attempt  to provide a veneer of respectability to an un-evidenced anti-trans-children agenda. I wonder if this is the intention of the multiple inclusions, to legitimise the illegitimate.

The known to be flawed research cited without critique

Also cited is the ‘Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood’ an article we have previously reviewed in detail and exposed as flawed in both methodology and presentation of the evidence base on “desistance”. Desistance in itself is a problematic concept which refers to children who were gender non-conforming and who do not express a transgender identity in adolescence. This is not the first time GIDS clinicians have cited this article to shore up their desistance theories that are rejected by evidence-based professional elsewhere. The flaws in this specific paper are multiple as discussed in this blog two years ago.

In 2018, since writing the critique, three peer reviewed academic journal articles (by Elhrensaft, Pyne and Temple Newhook and others) have been published, analysing and exposing the failings in Steensma’s work on desistance. A response article by Steensma himself in 2018  outlined that he felt his own work had been misinterpreted and misapplied by others (“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”).

None of these 2018 articles criticizing the very foundations of the flawed prior research on desistance  are cited in this GIDS paper. This ignorance of the current literature is a common theme in GIDS publications (see Butler et a 2018, and our review of the Evidence section of GIDS website)

Another reference in the new GIDS paper is Giovanardi, G. (2017) a former GIDS clinican,’Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents’. This is another paper frequently cited by GIDS clinicians, and one of the few publications distributed to families, despite the multiple failings in this paper which we addressed at length in our 2017 blog.

As noted, this paper, published in a new, un-ranked journal that has since folded. The paper lacks academic rigour. Several of the references it cites are distorted including a critical paper by Simona Giordano, as she told us in interview:

“My work has been misrepresented”.

Another reference in the new GIDS paper is another extremely flawed article by Steensma, This claims kids attending gender clinics almost all end up cis and gay ‘Desisting and persisting… (2011)’. Again, we have highlighted the multiple flaws in this document previously in another 2017 blog.

GIDS relies on these same few flawed papers time and again, ignoring the criticism of these papers.

Steensma’s work is cited two more times, ‘Gender transitioning before puberty’ from 2011, and ‘more than two developmental pathways’ from 2015. Both of these publications suffer from the same flawed methodological approaches as the above.

One other reference, a 2011 Cohen Kettenis article on ‘Puberty suppression in gender identity disorder’ outlines the approach in place in the early 2000s in the Netherlands. In a field that has moved on significantly in the past decade, a paper outlining best practices ten years ago, is hardly salient.

The citation of GIDS colleagues

Three are papers from the former head of GIDS (Di Ceglie, D), articles published from 1998 to 2009 based on older data. This field has moved on a great deal in the past twenty years.

Two are articles by GIDS second in charge Wren, both focused on uncertainty.

One is by current head of GIDS Carmichael (on rise of referrals of kids assigned female at birth). One is a 2009 description of the GIDS service.


The citation of Zucker – disgraced former clinician who compares respecting a trans child to feeding a delusional child dog food.

Two are by Zucker, including the hyper offensive ‘psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism’.

Another is by Steensma, Blanchard and Zucker ‘Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria’. Blanchard, is a deeply divisive figure, with no clinical experience working with children or young people, with an attitude to trans people widely regarded as deeply offensive.

Why is a modern service continuing to cite material by offensive outdated former clinicians with deeply transphobic views? Why continue to centre the work of authors whose body of work is deeply problematic and pathologising.


The citation of other non-mainstream gender services that are systematically cisnormative and pathologising

One is a paper from the outdated service in Finland (Kaltiala-Heino et al 2015 ‘Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development’. It is deeply troubling that GIDS is benchmarking its approach to youth gender care with the state health service of Finland, a country which still requires sterilisation before recognising a change of legal gender.

The irrelevant:

Two references are on psychoanalysis. One is on psychotherapy. Five references are on family therapy.  Two are on speech communication or role playing. One is on attachment narratives in psychotherapeutic interventions. One is a psychoanalytical account of one family’s experience (Marcus et al 2015). One is a paper I’ve not yet read from Norway (Roen, 2015) – it has been cited three times before (apart from self-citation).

Several are older books with titles like ‘Mind-body problems in family therapy’ from 1990, ‘Identity: Youth and crisis’ from 1968, ‘Development and validation of ego-identity status; from 1966. One’s on ‘Masculinity as Homophobia’ from 2004. One is a 2009 article on ‘Internalized homophobia’. One is the 2004 book by Judith Butler ‘Undoing Gender’.

Six are on gender variance and autism (these are references may well be worth following up but are beyond the scope of this particular blog).

Gender affirmative body of literature

The body of literature from Gender Affirmative professionals and researchers across USA, Canada, Australia and elsewhere is a large and growing body of literature..

This GIDS article contains two references that include authors and experts who support a gender affirmative approach.

One is an article on research priorities (Olson-Kennedy, J., Cohen-Kettenis, P. T., Kreukels, B. P., Meyer-Bahlburg, H. F., Garofalo, R., Meyer, W., & Rosenthal, S. M. (2016). Research priorities for gender nonconforming/transgender youth). This is cited purely for the statement “Longitudinal data examining the impact of social transition are sparse”.

And one is an article by Leibowitz, S., & de Vries, A. L. (2016). ‘Gender dysphoria in adolescence’. This is a 2016 literature review of research conducted prior to 2016 (including stacks of older pathologising literature). When I looked closely at the statements in the GIDS paper for which this is the citation, I saw that the reference is referring to the part of Leibowitz’s literature review where they cite work by Zucker (again), as well as an extraordinarily pathologising 2010 literature review by Lawrence a proponent of Blanchard, and author of books including the 2013 “Men trapped in men’s bodies: narratives of autogynephillic transsexualism”.  This reference may at a glance appear to be from the more affirmative Leibowitz, but is in fact yet more references to old pathologising research. Yet more Zucker.

Neither of these in any way represent the evidence from the substantial body of evidence coming from professionals who support trans kids and trans positive researchers who work respectfully with trans children and adolescents, in USA, Canada, Australia. Why is none of this sizeable body of literature cited? Have GIDS still not read it or is this a deliberate choice to completely ignore the existence of literature from a gender affirmative or trans-positive body of work in favour of promoting obsolete and fringe theories, described as non-evidence based by WPATH, the world authority on transgender health.

Summary of references 

The literature selected for inclusion in the bibliography is extremely biased, ignoring all gender affirmative literature published since 2016. It is dated, citing a number of older, discredited works and ignores up to date research. This is completely unacceptable in a field where older research has extreme cisnormative biases and flaws. It tends towards a clique of pathologising researchers such as Zucker, Blanchard and Steensma, it quotes material from journals and books that are not peer reviewed, it quotes material that is known to be flawed without mentioning the peer reviewed critiques of such work. Of most concern is that it includes work that is extraordinarily transphobic, written by anti-trans-children activists with zero clinical or lived experience, outright propaganda that lacks any academic credibility. Even a cursory review of the material reveals its flaws and lack of scholarship. The decision to include this here, is deeply troubling, at best this demonstrates that the authors lack ability to discern good from bad, or far more frightening, evidence that the UK Gender Children’s Service is listening to, and providing credibility to, anti trans lobby groups.

The bibliography as a whole makes me despair. These people are either extraordinarily poor at keeping up to date with modern evidence and research, or are mired in bias and committed to defending their (institutionally transphobic) positions. Or, I fear, both. These are clinicians working in the monopoly service for children and families like mine. We have no alternative but to force our children spend their time with these people – people who hold damaging outdated views about our children, or we need to go outside of the NHS. Even before the age of puberty – when there is no requirement for medical interventions, there is pressure from schools, GPs, family members, social services, to reassure them that our children are registered in the NHS service. A service that causes harm.

The institutional transphobia in children gender identity services in England and Wales should be a national scandal. But due to wider transphobia, skepticism, ignorance and cisnormativity, no one gives a damn about the harm caused to our children.

That was just the bibliography. Now to the paper.

First sentence:

“Young people presenting to the United Kingdom’s Tavistock & Portman’s Gender Identity Development Service (GIDS) are a diverse group and present requesting help with distress experienced as arising from a felt incongruence between their gender identity and their biological sex”.

Straight away they are using outdated language. The 2018 Endocrine Society Guidelines (which later in the paper they claim GIDS works to) states that ‘the terms biological sex and biological male or female are imprecise and should be avoided’. This can only be read as a a direct challenge to the international guidelines from a pathologising UK children’s service.

Second sentence:

“many meet the criteria for gender dysphoria (GD). The extent to which this can be understood as a normal variation of gender expression, a social construct, or a ‘pathology’ is a matter of ongoing debate”

Last year the World Health Organisation formally recognised that being trans is not a mental illness, GIDS meanwhile think that there is still debate on whether it is a normal part of human diversity or a pathology. This view while outdated, is not surprising GIDS is founding in psychiatry rather than medicine.

“While broadly similar discussions could be had about the nature of any psychiatric diagnosis, the question about what is at stake – in the different ways we might describe or seek to make sense of this embodied distress – takes on a unique salience in a domain where young people, their families and clinicians, are facing complex decisions around possible medical interventions in physically healthy and developing bodies.

This is indistinguishable from the anti-trans rhetoric the paper later quotes. The  emphasis on psychiatric diagnosis is astonishing given the WHO removal of in-congruent gender identity from categorisation as a mental health condition.

“prospective follow-up studies have shown that childhood GD is strongly associated with a lesbian, gay or bisexual outcome in adulthood and while estimates vary, the majority of participants in these studies did not seek out medical interventions for GD; the assumption being that gender dysphoric feelings requiring medical intervention receded around or after puberty (Ristori & Steensma, 2016).”

This is a failed understanding of the evidence base which focused on children diagnosed with Gender Identity Disorder (which included gender non-conformity) not on children diagnosed with Gender Dysphoria. The categorically false claim that gender dysphoric kids are likely to end up ‘cis and gay’ is critiqued here and the work cited to evidence this claim is falsely applied (Ristori & Steensma, 2016) as argued in detail here

“Factors contributing to persistence and desistence of childhood GD are still largely unknown,; however, it seems that in some cases a period of questioning and exploring sexual identity may be the key (Steensma & Cohen-Kettenis, 2015)”

There is no acknowledgement that the concept of desistance is deeply offensive and pathologising. There is no mention of the approach elsewhere which prioritises ensuring a child’s well-being and self-worth in the present, without fixation on prediction of future identity. The claim here that exploring sexual identity is key to resolving gender identity is a conflation of gender identity and sexual orientation, based on the same methodologically flawed Steensma study debunked here.

“Adult studies indicate that later onset GD, as well as biological maleness and sexual attraction to individuals of a different gender from the adolescent’s biological sex, may predict a more challenging treatment course and outcome, and historically more late-presenting adolescents have been male (Leibowitz & de Vries, 2016).”

This misrepresents Leibowitz paper which is not evidence, but rather an overview of older literature.

The statement about the majority of late presenting adolescents being ‘male’ (assigned males), is instead a reference to a Zucker 2012 study. If GIDS are yet again citing Zucker they should state so rather than hiding it with a reference to the more progressive Leibowitz. Also in the Leibowitz paper the term ‘natal male’ is used which the GIDS clinicians have chosen to alter for ‘male’ (not to infer ‘natal male’ is good, but ‘male’ alone is worse). The context of the quote is vital, and here missed, in the very next sentence of the Leibowitz paper they state that other studies find more assigned females in adolesence, something the GIDS paper omits to mention.

The first part of the Leibowitz citation, appears in the original Leibowitz paper as:

The relevance of sex ratio, age of onset, and sexual orientation lies in the fact that adult studies have revealed that natal maleness, late onset GD, and a sexual attraction to individuals of a different gender from the adolescent’s natal sex may predict a more challenging treatment course and outcome (Lawrence, 2010; Smith et al., 2005a; Smith, van Goozen, Kuiper, & CohenKettenis, 2005b).

GIDS have made the decision to amend the language from Leibowitz’s ‘natal maleness’ to the deprecated ‘biological maleness’. Also note the references underpinning this claim are from older studies published in 2010, 2005 and 2005. Using a 2016 reference to cite findings published in 2005 is misleading – especially given how different to world was for trans youth healthcare 15 years ago.

Looking at the most recent of these studies – the 2010 Lawrence paper. It turns out this is itself a literature review of older work, an overview of studies from as far back as 1974. The paper itself is extraordinarily pathologising and dated. Is this the best we can expect from our NHS in 2019?

However, current referral patterns to child and adolescent gender identity clinics in the western world demonstrate a shift in the sex ratio, with many more female-bodied young people referred, especially in adolescence, in the context of an overall increase in the number, diversity and mental health complexity of referrals, including the observation that many young people seeking help from gender clinics are also neurodiverse and/or meet criteria for a diagnosis of an autism spectrum condition

Again, ‘female-bodied’. Clinicians in other countries successfully write about gender diverse children and adolescents without mis-gendering them. It is not hard to do. This is lazy, cisnormative and disrespectful.

“Tentative hypotheses which emphasise primarily biological, social or psychological processes have been proposed to make sense of why young people with ASC may be at higher risk of GD, although they have rarely been tested (see Van Der Miesen, Hurley, & De Vries, 2016)”

‘Higher risk of GD’. This use of “risk” pathologises trans identities and reinforces the false and harmful concept that  a child being trans is, in and of itself, a bad outcome.

In a retrospective chart review of referrals to Finnish clinic over a 2-year period (n=47), Kaltiala-Heino et al. (2015) found that 65% presented with adolescent onset GD, defined as age 12 and above, and most (n=41) were female-bodied. The authors identified five distinct groups; the largest group developed gender identity development difficulties in the context of confused identity more broadly, with histories of social exclusion and persistent bullying when younger. In adolescence, they presented with social anxiety and depression, most often with self-harm and suicidal ideation (if not attempts); were socially and/or academically marginalised and had very high expectations that medical interventions for GD would solve their difficulties. A comparable profile – of young people with adolescent onset GD, significant psychological difficulties (histories of trauma, psychosis, body dysmorphic disorder and severe depression) and expressions of certainty about medical interventions being the only solution – has been observed in the gender identity clinic at the Toronto Centre for Addiction and Mental Health (Zucker et al., 2012). A retrospective chart review of referrals to GIDS 2009–2016 (n=4148) showed that the vast majority of referrals were adolescents, with the sex ratio favouring female-bodied young people (1:2.1) in this age group (Carmichael, 2018). There was a sharp increase in referrals, with referrals for male-bodied adolescents increasing by 55% on average each year and for female-bodied adolescents by 105% over this 7-year period (Carmichael, 2018).

That the authors choose to cite studies from only the trans sterilising Finland, and from the utterly discredited Zucker reveals the inherent bias of the paper. There is no citation of the evidence base of the children who are thriving with a gender affirmative environment. No mention of the known link between minority stress / family rejection / transphobia and poor levels of well-being amongst trans youth. Again the language is outdated. It is interesting that a recent critique by the Guardian’s US staff rejected the the transphobia  of the UK head office, highlighted that the language of ‘female-bodied’ was unacceptable. Through the use of this language of stigma, the UK Children’s Gender Service is codifying and giving authority to systemic transphobia.

A significant proportion of young people in GIDS are also neurodiverse and may present with traits of ASC and/or a diagnosis. Between April 2011 and August 2018, 48% of children and young people who were seen in GIDS and whose parents completed the social responsiveness scale (SRS), a quantitative measure of autistic behaviours in children and young people, scored in the mild to severe range (n = 2073). Ten per cent of female-bodied young people scored in the severe range, as did 7% of male-bodied young people.

As GIDS service users we have grave concerns as to the validity of these findings. We have multiple first hand reports of GIDS forms being destroyed or never returned by parents and youth. One of the stated reasons for this is their deeply pathologising language. It would be useful to have data on completion rates before giving any credence to these figures.

“The dilemmas around how and when to respond to requests for medical intervention come alive in particular ways when working with these young people. These are inherently ethical questions, as well as medical and psychological ones and views are often polarised (Wren, in press). A number of concerned parent groups characterise the willingness to provide such intervention to young people as the medicalisation of psychological and social ills. In relation to female adolescents, this is constructed as simply confirming an identity conceptualised as often the only viable escape route from the oppressive gender and sex-role stereotypes society applies to girls and women (DaviesArai, 2018). A competing discourse, also represented by parent groups, promotes young people’s rights to medical treatment and can be characterised in terms of its emphasis on the ‘privileged access’ they have to their own bodily experience; this arising in part from the contexts of a health care system and broader sociocultural milieu in which trans people have historically been pathologised and dismissed (Wren, 2014). The GIDS clinician has to navigate through these competing forms of knowledge and justice claims, always ‘working at the edge’ of the boundary between 4 Clinical Child Psychology and Psychiatry 00(0) mind and body. In doing so, there is an attempt to preserve a space for thinking and to hold a balanced view, which attends to complexity (Di Ceglie, 2008, 2009)”

Here GIDS clinicians are stating that they are listening to and take note of the views of organisations like Transgender Trend, a group of anti-trans lobbyists who actively campaign against trans rights, especially trans children’s right. This “group” has only had two named members (the founder DaviesArai is cited above for a non-peer reviewed book chapter). Neither of the two named members of Transgender Trend are current GIDS service users or have ever had children within GIDS. This group share materials claiming that trans identities are deluded and should be treated with conversion therapy. There is no evidence they represent any significant numbers of parents of current GIDS service users. By referring to these anti trans lobbyists as ‘parent groups’, and by citing them in the bibliography – GIDS are engaged here (not for the first time) in legitimising one of the UKs most prominent anti trans campaign groups. This legitimacy is extremely harmful – the Transgender Trend resource pack for schools, if followed by a school, not only would break law as per the Equality Act, but would cause significant harm to LGBT pupils which may include GIDS service users. The group was forced to apologise and withdraw a sticker campaign which encouraged students to bully trans pupils. Yet here are GIDS clinicians giving legitimacy to this hate campaign.

In this paper, GIDS contrast the view of groups like Transgender Trend with the view of parents like myself, who want their child to have evidence based, modern, respectful, trans-positive healthcare.

They position GIDS and themselves as half-way between parents like myself and Transgender Trend. Halfway between accepting trans children as a part of natural diversity to be loved and supported, and denying the mere existence of trans children and considering such children deluded and psychologically ill. These two ‘positions’ are not equally valid. They are not equally supported by evidence or experience. Positioning GIDS as halfway between the two, considering either as equally valid, risks causing significant harm.

Educating parents

One important issue that is not mentioned in the paper, is the role of GIDS in educating parents. The vast majority of cis parents, raised in a cisnormative and transphobic UK, educated under section 28 (UK law forbidding school education about LGBT people), start out highly ignorant about trans children. In other countries’ children’s gender services, educating parents, and educating wider media, schools and society about gender diversity is a top priority for gender clinicians. In the UK GIDS does not perform this role (sometimes doing the exact opposite, and giving credence to un-evidenced groups like Transgender Trend, failing to publicly distance themselves from fringe theories around ‘social contagion’ and failing to even condemn anti-trans publications like the Transgender Trend resource pack for schools).

We know from speaking to senior GIDS staff, that the majority of kids arriving in their service as adolescents (ie the cohort in this new GIDS paper) are not supported by their parents. This topic is not mentioned in the paper. It is unclear whether any of the youth who have not yet been approved for medical intervention in this data set, are being held back by lack of parental approval.

There is zero acknowledgement in this paper of the critical role GIDS staff should be playing in educating parents and society on gender diversity. There is zero acknowledgement of the harm caused when parents fail to support their trans adolescent.

Back to the new GIDS paper

“Following psychosocial assessment and provided that a young person is in established puberty and can give informed consent, they may be referred to the paediatric endocrinology clinic to undergo a brief medical assessment with a view to commencing hormone blocking treatment.”

Puberty blockers are reversible. Some trans kids start puberty at age 8. Puberty blockers are regularly given to cis kids in precocious puberty at age 5 or 6. Informed consent from a child is not required for puberty blockers. Consent from a parent on behalf of a child is sufficient. I worry that they are moving towards claiming Gillick competency is needed before blockers, which will deny timely care to kids who start puberty early (which is likely to discriminate especially against kids who are not white who are more likely to start puberty at an earlier than average age), and kids who are considered less able to be Gillick competent at say age 11 or 12 (which I’m guessing is likely to discriminate against kids who are neurodiverse). Restriction on timely access to blockers are also likely to discriminate against trans masculine kids (who on average start puberty at an earlier age than trans feminine kids). This is not considered in the paper.

The Study Aim

“This study aimed to develop an initial understanding of those young people who presented to GIDS with GD emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or no longer felt that their gender identity was incongruent with their biological sex, through (1) an overview from the authors’ caseloads of their demographic and shared characteristics and (2) two more detailed case examples.”

The Sample

They started with a sample of 156 cases of adolescents age 12 and older at age of first assessment whose psycho-assessment phase ended with them categorised as ‘open case’ (47 ‘male-bodied young people’; 109 ‘female-bodied young people’). The paper does not define what ‘open case’ means, but I interpret it to mean cases where the adolescent has not been approved for referral on to endocrine services (=not been approved for blockers) at the end of the assessment phase.

Four (2.5% total) dropped out after one session (no mention on if they dropped out to go private) and no acknowledgement that GIDS often does not know when kids go private.

20 (13% total) female-bodied young people intended to pursue medical interventions in adult services. 4 (2.5% total ) gave practical reasons as to why they were not seeking medical interventions at that time (two males; two females). 12 (8%) cases met criteria for GD emerging in adolescence, were actively requesting medical interventions at outset of assessment and ceased wishing to pursue medical interventions and/or no longer felt that their gender identity was incongruent with their biological sex.

Interesting that they combine ‘ceased wishing to pursue medical interventions’ with ‘no longer felt their gender identity was incongruent with their sex’ – these are very different categories and makes no sense to lump them together.

116 (75%) were still wanting to pursue medical interventions in GIDS.

The latter figure is not stated specifically, and had to be calculated by deduction. This is a strange omission.

The figures as presented here show that 2.5% dropped out after one session (no discussion on if they went private or waited to get referred direct to adult services). 13% were forced to wait for treatment in adult services. 2.5% had practical reasons for not wanting to have medical interventions at this time. 75% were still wanting and waiting for medical interventions. And 8% either no longer felt the need for medical interventions (but still trans) or decided they were not trans.

Remember these are all percentages of the youth arriving at the service at age 12+ who have not been referred for blockers at the end of their (9 month) assessment.

The 8% who no longer wanted medical interventions is presented in the paper as 12% for no given reason (It appears they exclude the first three categories to get a lower denominator to give the impression of a larger number…). I find it poor practice to exclude categories from the sample size at the analysis stage, without clear justification – it biases the statistics.

The authors (in the next section, not in the main sample data section) break this 8% up into the two categories, stating that 7 (4% total) decided they were cisgender and 5 (3%) were trans but decided they didn’t need medical intervention.

Other facts

“The mean length of the psychosocial assessment was 9.6months (range=2–14 months). The mean number of assessment sessions was 6.6 (range=2–9 sessions). The mean number of individual appointments was 1.7 (range=0–4 sessions) and the mean number of family sessions was 5 (range=1–8 sessions)”

As GIDS service users the interesting, though unspoken finding from this sample is that of these ‘open cases’, 88% (75% + 13%) are still wanting to access medical treatment, but have found their pathway to medical intervention denied (or delayed) even at the end of a 9.6 month (average length) assessment. Note the NHS service specification gives an assessment period of 3-6 sessions over 6 months – yet this group have had an average 9.6 month assessment. There is no mention of the time period of this data set, nor of the average length of wait before first appointment. For the past 2 years waiting times have always been over 10 months, and in past years have risen to over 20 months – so the amount of time waiting before a 9 month assessment is relevant information.

With 88% of these adolescents still waiting and wanting medical intervention even after a 9 month assessment, this is a service operating under an extremely cautious model. Missing from this new GIDS paper is any reflection of potential harm caused through this prolonged assessment period. There is no acknowledgement of the harm of withholding fully reversible puberty blocking medication from extremely vulnerable trans kids. The evidence base (ignored by GIDS) states that withholding puberty blockers is not a neutral option and will cause harm (Giordano, 2014) Yet the England and Wales service continues to do this.

There is no reflection of the impact on vulnerable youth (88% of this sample) of:

  • waiting up to 20 months after they have finally worked up the courage to
    • a) tell their parents
    • b) persuade their parents to go to their GP
    • c) persuade their GP to give a referral to GIDS,
  • to then undergo a 9.6 month assessment
  • to at the end of this 9.6 month assessment still be denied any access to fully reversible medical interventions (hormone blockers).

There is no discussion of the powerlessness of being kept in a prolonged state of waiting, with no clear end in sight and no power to influence the monopoly power of GIDS gatekeepers (not to mention the kids with unsupportive parents and unsupportive GPs that can make the process longer still).

And we know that the adolescents most likely to be kept in this state of prolonged denial of timely interventions, are neurodiverse adolescents (and allistic adolescents without parental support).

It is interesting that only 4% of the ‘open cases’ (the cases of kids first seen at age 12 or older which were ‘open cases’ at the end of a 9.6 month (average) assessment) were kids who seemingly decided they were cisgender.

The paper focuses on this 4% (this is not 4% of all youth, just 4% of the youth denied access to blockers after the assessment phase). The paper provides no reflection of society or familial pressure to identify as cisgender and no reflection of the known experience of gender diverse people having a number of ‘unsuccessful’ transitions before returning to a transition later in life.

It is highly significant that it is the 4% minority of ‘open cases’ which  GIDS choose to focus their publications on.

Also we have no information provided here on statistics as to how many kids aged 12 and older at first assessment are cleared for medical intervention at the end of the assessment phase. So we have no idea what percentage these 7 individuals are out of the overall caseload of kids in the GIDS service. Although we know the percentage will certainly be less than 4% of all 12+ year olds. Omitting this data, and denying us sight of what percentage of all youth aged 12+ in the service are these 7 kids, seems like misleading manipulation of the statistics.

They also note here that “the majority of the 12 cases” who were not wanting medical intervention ‘had not received a formal diagnosis of gender dysphoria’ (again they have reverted to grouping together the 5 individuals who are trans but don’t need medical intervention and the 7 who are cisgender – for no clear reason). Again this is confusing at best – why are we talking about a sample who have not been diagnosed with gender dysphoria?

Case Vignettes

Out of their 7 individuals who have seemingly decided they are cisgender, the authors pick 2 to write up a case history. The 2 individuals picked are supposedly representative of the other 5.

They had “a diagnosis of an ASC and significant risk including suicidal ideation and self-harm. In both cases, the referral was presented in such a way as to assume that medical transition would be the primary intervention required to alleviate gender-based distress; however, they had not received a formal diagnosis of GD”

Here the authors present a table of the characteristics of the 12. Again grouping the 7 who are cisgender and the 5 who are trans but decide they don’t need medical intervention. It is problematic and unhelpful to combine these two categories together and smacks of deliberate manipulation. This criticism would be avoided in part if  table (ref) was split up into the two different groups allowing comparison.

The two case histories presented are presented without acknowledgement of author weighting, or bias, and extrapolated to represent and support a narrative.

Case history one had not socially transitioned nor expressed a wish to socially transition, and chose to drop out of the service before his 8th appointment. He had one follow up appointment at which point “he spoke openly about continuing to feel confused about his identity and was still struggling with low mood”. He had no medical intervention through GIDS, not even blockers.

Case history two was a 14 year old adolescent assigned female at birth, who had socially transitioned to male 18 months before their first appointment. At some point over the 13 month assessment she was prescribing the contraceptive pill to stop periods. At a later point she confirmed she no longer wanted to pursue any medical intervention through GIDS (ie did not want hormone blockers – though for an assigned female who is already needing to bind and has already started their period, hormone blockers are of limited usefulness anyway – this is not discussed in the article). At a later point, at age 16 (again, without having accessed any GIDS specific medical interventions) the individual moved back to female pronouns.


“The case review yielded cases of young people who were predominantly female-bodied with high levels of social communication difficulties, suicidality and self-harm. While a sex ratio favouring female-bodied young people, higher levels of mental health complexity and neurodiversity have been observed more broadly in referral patterns in GIDS and elsewhere (Aitken et al., 2015; Carmichael, (2018); Kaltiala-Heino et al., 2015; Van Der Miesen et al., 2016), the presence of these features was particularly pronounced here.”

This may be true, but let’s check the  sparse facts as presented. 7 individuals out of 156 (4%) of the ‘open cases’ (cases aged 12+ at referral who were not referred for medical intervention after a 9 month assessment) decided they were cisgender (most of whom were never formally diagnosed with gender dysphoria). We don’t know clearly the assigned gender of these 7. We know that the 12 (including the 5 who were trans but decided they didn’t need medical intervention) included 9 assigned female at birth and 3 assigned male at birth.


Here’s a thought – there is no voice of any child or adolescent in this paper. It is meant to be a portrait of two case studies, but where is the adolescent’s own words? The focus is primarily on the clinician’s view. Secondary is the parent’s view. Absent is the adolescent’s view in their own words.

Back to the paper

“It was striking that a clear majority of the young people had either an existing diagnosis of ASC or would be likely to obtain one; a higher number than would be anticipated in the context of the already observed elevated levels of ASC in GIDS cases.”   

From the 12 (again, no information on the pertinent 7), we know that 7 had a diagnosis of an ASC prior to first appointment and 5 did not. 4 out of the 5 without a formal ASC diagnosis completed a ‘Social Responsiveness Questionnaire’ and 1 was rated a normal range and 3 severe. Discussing the meaningfulness of this questionnaire and issues around ASC is beyond the scope of this blog.

“Assessment consisted of at least six sessions in most cases – at the upper end or beyond what the existing GIDS protocol suggests – although notably there was also considerable variation in assessment length. This may be illustrative of neurodiverse children needing more clinician-facing time to convey their experience due to their progressing through gender identity development along differing timelines or frameworks than neurotypical peers (Van Schalkwyk, Klingensmith, & Volkmar, 2015). This is in line with initial clinical consensus guidelines for this population, which recommend an extended diagnostic period and the need for clinical decisions to proceed more slowly due to the myriad ‘social, adaptive, self-awareness, communication and executive function complexities’ of this population (Strang et al., 2018, p. 107). The findings suggest further research and service development is needed on this theme, including greater collaboration across services to share learning and explore whether such young people may require different or adjusted assessment protocols. Interestingly, the majority of the young people had not received a formal diagnosis of GD prior to coming to GIDS, and it may be that this contributed to their capacity to engage with an extended and exploratory assessment process through which an individualised formulation could be co-created. Furthermore, discussions between comparable gender identity services internationally could help to shed light on the function and timing of providing a diagnosis of GD”

Here the authors are arguing that extended assessment could be beneficial for youth with ASC (Autism Spectrum Conditions?). Let’s not forget, they are arguing that it is beneficial to extend the time for which neurodiverse youth are denied access to fully reversible puberty blockers. They are focusing on 7 individuals who ended up identifying as cisgender, and presuming this path needs to be applied to all neurodiverse youth. Let’s not forget, they are not considering in this study any negative impacts on the 88% of youth in this sample who have continued to be denied puberty blockers, youth who are still wanting and waiting for medical intervention even after a 9 month assessment phase. The GIDS authors also make here a rather bizarre suggestion that the lack of a formal diagnosis of Gender Dysphoria was perhaps in some way related to these 7 individuals ending up identifying as cisgender. They suggest there is a benefit in delaying or denying diagnosis for youth who are eligible for such a diagnosis. This is a spectacularly un-evidenced jump. And worrying in its implications. It is reckless to make such a jump.

“It was also the case that the majority of young people had not made a social transition. Longitudinal data examining the impact of social transition are sparse (Olson-Kennedy et al., 2016); existing studies have focused on those with childhood onset GD and drawing on limited case data, suggest that the process of re-identifying with one’s original gender role can potentially be stressful in terms of fear of teasing and feelings of shame around being ‘wrong’ (Steensma & Cohen-Kettenis, 2011).

It is unethical to state this. The Steensma 2011 study took a sample size of 2 individuals, an neither of these individuals had socially transitioned. We review this in a 2017 blog in detail (see second half of this blog). This cannot be used as evidence of the harm of social transition as is clearly inferred here

It is possible that for some of the cases identified in the case review, living in the gender role congruent with their biological sex was one factor, which facilitated the opportunity for meaningful exploration in the assessment phase as opposed to premature ‘foreclosure’ of identity (Marcia, 1966), although it was also the case that some young people who had already socially transitioned did feel able to live once again in the gender role congruent with their biological sex. For some young people (such as Louise, described above), social transition may be felt to be precisely the platform through which a meaningful exploration of different adult roles can occur and/or may in the longer-term turn out to be a necessary and sufficient means through which to live life well as a gendered person.

The GIDS clinicians recognise the potential benefits of social transition for case study number two, who had socially transitioned, and then makes a second social transition. But they also conclude that for case study one, not having socially transitioned may have been part of his becoming comfortable with a cis male identity. There is no acknowledgement of choice and autonomy here. Case study number one never wanted to socially transition. So he cannot be used as an example of the potential benefits of not supporting a social transition. A child who never wanted to socially transition, cannot be used to argue for denying the social transition of a child who desperately wants to do. It is a marked failing of this paper that GIDS do not acknowledge this distinction.

“In both the cases described here, a number of common themes can be noted, including experiences of teasing/bullying (including of a homophobic nature) prior to the onset of GD, a sense of exclusion and isolation, difficulties in social communication and engaging with peers, distress in relation to awareness of a developing sexed body and difficulties separating from parents. In retrospect, these young people’s initial determination to medically transition and the subsequent shift in this sense might be better understood in the context of a broader identity confusion (Kaltiala-Heino et al., 2015). Of course, there are multiple factors influencing outcome. However, it possible that in different ways for these two young people, the GIDS assessment provided a platform through which issues of homophobia and internalised shame, familial narratives and relational ruptures, and beliefs and fantasies associated with mid-adolescence (Dallos & Vetere, 2009; Newcomb & Mustanski, 2010; Waddell, 1998) could be meaningfully thought about and integrated into a story of who one is becoming.”

I feel this is the role that GIDS clinicians want to have. They want to focus on parental attachment, identity confusion, internalised shame etc. And perhaps there is a role for this with some children and adolescents. But they seem to look for these issues with every child. They cannot seem to conceive of what role they should be playing in caring for kids who just are trans. Kids who do not benefit from extended psychoanalytical evaluation and enforced ‘exploration’ of self. This tension in the service is not acknowledged at all.

Conclusion as per the authors

“The study highlights the need for the psychosocial assessment to nurture a space in between the internal and external worlds of these young people (Marchiano, 2018). Such an assessment would need to be properly located in a developmental framework which takes seriously the inescapable in between-ness of adolescence and joins with young people and their families to broaden the narratives available to them, to make sense of gender-based distress.”

Conclusion as per the evidence in the paper

The conclusion I would write based on the data in this paper:

Out of a sample of 156 youth, aged 12+ at referral, who had not been approved for medical intervention after a 9.6 month assessment period, 88% are still waiting and wanting medical intervention. The impact on the wellbeing of these 136 adolescents of denial of timely, safe, reversible medical intervention is not considered a research priority by this team. 7 youth (4%) out of this sample (of those adolescents not approved for medical intervention after a 9.6 month assessment) decided they identified as cisgender. These 7 had not had any GIDs specific medical interventions.

End: This is another deeply flawed and potentially harmful publication from GIDS. My concern is that given their monopoly provision and total power, no-one in the UK NHS establishment will notice, yet alone care.

First Day – Trans children on TV


Australian TV (ABC) has now released for global download the children’s TV programme “First Day”.

“First Day (2017) follows main character Hannah as she finishes primary school and begins her secondary schooling. Hannah experiences all the excitement and fear associated with this transition, but her first day of high school is even more significant: it’s the first day she will wear a girl’s uniform to school and go by her chosen name, rather than the boy’s name she was given at birth”.

The download costs £6  ($11 AUS) and is a 17 minute programme.

It is a children’s show, perhaps aimed at ages 6 – 13.

It is the first children’s tv show I’ve seen with a trans girl played by a trans girl.

This authenticity shines through the show, with a beautiful, moving, authentic performance from the fantastic Evie MacDonald. She was 12 years old at the time of filming.

It starts with the main character Hannah, on her last day at her junior school, where she is still being called a boy and wearing boy’s uniform. She meets with the head of a new secondary school (there’s a discussion over bathroom use with the head initially requiring her to use the sick bay bathroom).

It shows her being bullied by a group of mean girls at her junior school.

It shows her having fun over the summer with her brother, enjoying playing football in her back garden, enjoying the bike she gets for Christmas, and shopping for her new girls school uniform. It shows her worries as the new girl, starting a new school where she doesn’t know anyone.

She starts her new school with her girl’s name and uniform, and meets a new group of friends who welcome her in with kindness.

Then her bully from junior school transfers to the school. Calls her by her old name.

It shows her worry and fear, wondering what will happen next.

It shows her finding the courage to stick up for herself, and to offer kindness and friendship to her old bully, who is herself having some problems.

It is a gentle, kind, positive and child friendly programme that any child could watch and enjoy.

First Day (2017) is one of four films in the ‘International Day of the Girl Collection’ – a compilation of short films that explore pivotal and challenging moments in the lives of 12-year old girls.

ABC has also produced a school’s pack to accompany the First Day show, with specific teaching resources aimed at year 6 and 7 (aimed at last year of primary and first year of secondary – ages 10 and 11).

This wonderful teaching toolkit explores the themes of transition, identity, values, friendship, diversity, resilience and inclusivity

“The ACTF has developed the First Day Teaching Toolkit to support Year 6 and 7 teachers and students who are using this important film in the classroom. The resource explores key themes from First Day, and helps students to prepare for, process, and reflect on their own transitions to secondary school. The learning tasks encourage inclusive behaviours in the classroom, and reminds students that we are all more alike than we are different.”

The short (21 pages) and beautifully produced toolkit shows how (in some ways) Australia is leaps and bounds ahead of the UK in the way we support and care for trans kids in our media, in our schools, in our society.

Butterfly was the first UK tv drama about a trans kid, and has taken us here in the UK some important steps forward in considering trans children in our families and in our world. But, Butterfly showed the trans kid as the problem, it showed how hard it is for cis people to love and support a trans kid, it showed a parent’s perspective. We did not get to understand or really empathise with the trans child, and although the young cis boy in the main role made a great attempt, it did not bring an authentic portrayal of a trans girl.

First Days gets a lot right. It shows the experience from the perspective of the trans girl. She is not shown as a problem, as a difficulty. Instead we join the ride with her, empathising with her as we walk in her shoes, in challenges we have all faced, bringing in universal themes of how it feels to be different, how it feels to be the new kid, how it feels to worry about how you will be perceived, how you will be treated. Wondering where you fit in and whether you will find friends.

It reminds me of the authenticity of the trans girl in the award winning US short film “The Real Thing“. Another amazing young actress to watch out for : Sophie Giannamore

Having a trans girl in the main role means that the whole show is seeped in the authenticity that you just do not see when cis kids are cast to play trans kids. Maybe this would change if you have cis kids who know and are friends with trans kids – but at the moment the cis portrayals come across as (inaccurate) guess work.

Also a shout out to the wonderful Aussie mum of a trans kid Jo Hirst for her support to the show (see here for our review of her brilliant children’s book).

UK schools and educators would be well placed to bring this resource and this moving, gentle and authentic programme about a trans child starting senior school, into their teaching.

And UK (or any) media considering programmes featuring trans kids need to involve trans kids, parents of trans kids, trans writers, directors, producers in their shows. Far too much content does not accurately represent trans lives – There are tons of interesting, nuanced, moving stories to be told – stories that are more authentic are more believable, more moving – are better!

So buy First Day! Let’s have more of this please ABC! & Let’s have it shown on BBC

Support young trans acting talent like Evie MacDonald – I can’t wait to see she does next!


Review: A House For Everyone, interview with author, Jo Hirst

There are too few books which speak with authenticity about the experience of transgender or gender diverse children.

The majority of books about gender diverse children (10,000 dresses, My Princess Boy, The Boy in The Dress) focus on gender expression. These stories should be commended for celebrating children who break free of strict gender boundaries, but their message, that some boys, some potentially trans kids, can wear ‘girls clothes’ – always dresses, can be seen as subtly reinforcing the very stereotypes they aim to break – clothes after all, do not have a gender. These books rarely focus on gender identity, ie. who that child is, instead focusing on what they wear, or their play and friendship preferences.

Many of these stories follow a well worn trope of a child who is initially picked on for being different, is upset by this, and then following an event or intervention, is accepted by others. This simple message of celebrating difference might be helpful for children not experiencing these issues to understand the experience of those who are, but has the potential to cause shame and upset in those children who are already experiencing stigma due to their gender non conformity.

While there have been a handful of attempts to tackle gender identity in children in an accessible way, these frequently rely upon the same gender stereotypes of the gender expression books above. It is difficult, even for adults to get to grips with gender identity, how then can this be successfully handled for a child while avoiding pitfalls of stereotyping toy choices or the pink = girl, blue = boy gender binary.

Jo Hirst’s book, A House for Everyone, is a revelation. The picture book tells the story of a group of friends who are gender diverse. Together, they build a tree house and each child is introduced to the reader in turn. It is a simple and short book with delightful art. There is a strong and fast girl who has short hair and never wears dresses, a trans boy, a non binary child, a boy who loves dresses, and a boy with long hair who likes art, flowers and sport.


Jo, is both a parent of a transgender child, and a feminist critical of gender stereotypes. She is one of the voices leading the call for school uniform reform in Australia, and has spoken out about gender stereotypes.

I spoke to Jo about her book and what her hopes are for trans children:

@DadTrans: Your story includes both a trans boy and a non binary child, what motivated you to include these characters?

Jo:  I wanted a story that would include transgender children and children who’s gender expression might differ from the social ‘norm’. It was important to me to show a clear difference between gender identity and gender expression. And at the same time let all children know that wherever you fit on the gender spectrum, no one is tied down to any stereotypes. Toys, clothes haircuts- these things don’t have a gender, it’s about what makes you feel comfortable.  I chose a trans boy because of my son but also because they are underrepresented in children’s literature and in the media space in general.(Compared to trans girls) I’m not sure why that is as they are certainly out there in large numbers.

It was also very important to include a non binary child. While we are starting to see more young adult books with non binary characters, there are almost no books for young children, apart from “Are you a Boy or a Girl” [By Fox and Owl]. When the Trans Pathways research was done in Australia last year, 46.8% of the young people surveyed identified as non binary. I meet a lot of young non binary people here in Australia. If your child has not met a trans or non binary person yet, it won’t be long! It’s a good idea to get the conversation started

@DadTrans: We’ve found a lack of books which both cater to trans & gender diverse children and also don’t fall back on gender stereotypes. How did you address this issue in A House for Everyone?

Jo: I was very aware of not only not wanting to fall back on gender stereotypes but also to make the story a very positive one. The plan was to just have the story without any explanation of Gender initially. But after testing the first version on groups of parents and teachers, I found that the pronouns alone were not enough to explain who the children were, and what their gender identity was. I added some ‘notes for grown ups’ including terms, as well as a lesson plan, links to resources and further reading.

@DadTrans: A House for Everyone is your second book focusing on gender identity in children. How does your first book, The Gender Fairy, differ? What lessons did you learn along the way?

Jo: The Gender Fairy was about two binary transgender children making a social transition. The main purpose of that book was to let transgender children know they are normal and they are not alone, that there are other children like them. While The Gender Fairy doesn’t have the same focus on gender stereotyping, there is an opportunity to talk about how society stereotypes boys and girls especially at the beginning of the book. At the same time, many young transgender children do gravitate towards stereotypical boy and girl toys and clothes, just the same way cisgender children do. I do love that the gender fairy themselves are non-binary, and my favourite line is the last one when the children ask the fairy whether they are a girl or a boy, and the fairy answers “does it matter?”

@DadTrans: What other books would you recommend for trans or gender diverse children and their parents?

Jo: The Rainbow Owl website has a fantastic list of books and resources which they keep up to date with latest releases. (That’s recommended for parents by the Australian Psychological Society and reviews books for all ages from all over the world)

@DadTrans: What do you see as the biggest challenges facing transgender children and young people?

Jo: I would quote the trans Pathways research which found without family, school and community support 48% of trans youth had attempted suicide. It’s an uphill battle to get support in the face of backlash from transphobic conservatives and media. At a time when (in Australia at least) our doctors and psychologists are telling us to support our kids they are making it really hard. The hardest part is when kids are weaponised is political debates.

@DadTrans: You have spoken before about the lack of gender stereotyping in your own childhood. How much do you think that has influenced your books?

Jo: Parental roles, clothing and toys were not overly gendered in my own early childhood. My mother was a builder when I was growing up in the 1970’s with her own “Handywoman Service” and my dad was an English and History teacher who was an equal hands on parent which was unusual for that generation. My mother has what some people would describe as a masculine gender expression and has always identified as cisgender. I have always been able to see the distinction between gender identity and gender expression. The character ‘Ivy’ in A House for Everyone is very like my mum. She likes to have her hair cut very short, never wears dresses, was the fastest runner at school and was always the leader.

@DadTrans: As the mother of a trans child, what are your hopes for your child and the current generation of trans & gender diverse children?

Jo: I’ll be really happy when one day we don’t need books like this because everyone understands gender diversity.

I would like a world for my child and all children where being trans or gender diverse does not put you in danger. Where being trans and gender diverse does not mean you have less human rights than your cisgender siblings. Where all children have equal access to safe schooling, healthcare and supportive families and good friends. Pretty much what every parent wants for their child.


Final thoughts:

Review from @Fiercemum: A House for Everyone is exactly the book I’d been looking for, a book that includes and recognises and has space for, children who are transgender as well as those who are gender non-conforming. I’ve read it with a wide variety of children – and I see how much representation of diversity matters.

The book includes a trans boy and a non-binary child, two categories that are under-represented in books aimed at primary school age. One of the biggest responses I’ve had whilst reading the book, was from a gender non-conforming 5 year old cis boy, who was incredibly moved and validated by the book’s depiction and acceptance of gender non-conforming boys, boys with long hair, or who like sparkly dresses. The strong and fast girl Ivy, the group’s leader, is a character who would have spoken to me as a child, as a dress-hating cis ‘tom boy’, and is a character who resonates strongly with my trans daughter, who similarly loves climbing trees and having adventures.

In a world where many books about trans girls depict ultra femininity, in a world where many books about trans kids conflate and blur the differences between trans identity and gender non-conformity, A House for Everyone is a welcome breath of fresh air.

I recommend it for parents and schools to read with trans kids, for gender non-conforming kids, for kids who are diverse or different to their peers, for kids who love adventure, for kids who need to know that this world is diverse, that being different is ok, that there really is a space for everyone.


Other children’s books on gender we’ve enjoyed:

You may also want to check out the following books we’ve liked (in a rough order of reading age):

Red, A Crayon Story

‘Pink is a Girl Color’ and other silly things people say

Are you a boy or a girl?

Vincent the Vixen


Lily and Dunkin


Biological Sex is a social construct


I recently tweeted, as an aside, that biological sex is a social construct, and the backlash and attacks were swift, incredulous and heavily reliant upon very basic biology.

There is a common perception amongst those who have given it little thought, that gender is a social construct, whilst biological sex is solid and rigid and fixed and binary and scientific. Those who wish to attack and marginalise trans girls like my daughter, like to argue that her biological sex is male, as though that is a scientific fact.

They are wrong.

To unpick this we need to tackle several different issues.

Biological Sex

Biological sex is a term used to refer to a person’s sexually differentiated biology. It encompasses a range of sexually differentiated traits and processes including:

  • Sex determining genes (e.g. the SRY gene on a Y chromosome often promotes testosterone driven development, the presence of the WNT4 gene can promote ovarian development, the DMRT1 gene suppresses an oestrogen driven path)
  • Enhancers outside of genes (in junk DNA) that regulate the SOX9 gene
  • Sex chromosomes (e.g. XX or XY)
  • Sex hormones in a fetus in the first phase of fetal development (high oestrogen or high testosterone)
  • Sex hormones in a fetus in the second phase of fetal development (high oestrogen or high testosterone)
  • H-Y antigen
  • Functioning of sex hormone receptors (hormones can be present but not processed)
  • External primary sex characteristics (penis or vagina)
  • Gonads (ovaries or testes)
  • Type of gamete (egg or semen)
  • BSTc (sexually differentiated brain region)
  • Sex hormones at puberty (high oestrogen/progesterone or high testosterone)
  • Secondary sexual characteristics (oestrogen driven puberty or testosterone driven puberty)
  • Post puberty levels of sex hormones

The term biological sex often presumes that there are two biologically discrete types of people:

Type one is XX in every cell of their body, has raised levels of oestrogen as a tiny foetus, causing the development of ovaries and eggs, and the development of a uterus and vagina, has a second surge of oestrogen as a foetus (potentially contributing to development of a female gender identity), has ovaries that release a surge of oestrogen at puberty, causing oestrogen driven secondary sexual characteristics including periods, breast development, maturation of eggs and the ability to become pregnant and carry a foetus.

Type two is XY in every cell of their body, has raised levels of testosterone as a tiny foetus, causing the development of testes and semen, and the development of a penis, has a second surge of testosterone as a foetus (potentially contributing to development of a male gender identity), has testes that release a surge of testosterone at puberty, causing testosterone driven secondary sexual characteristics including Adam’s apple, hair growth, raised height and maturation of semen capable of fertilising an egg.

Social construct

A social construct is when we put artificial boundaries around groupings that are really more complex and messy. Biological sex is certainly a social construct.

In order to prove biological sex is a social construct we only need to find one example of a person who does not fit into the two neat biological boxes outlined above.

We know that up to 1.7% of people are born intersex/born with diverse sex traits.

These ‘exceptions’ exist because the idea of two binary biological sexes is just that – an idea – something we humans have come up with to explain and simplify our world – a social construct.

Biology is complex

There are many examples where individual biology lies outside of two clear cut binaries of sex differentiation.

Sex chromosomes come in more options than two. Although most people have XX or XY sex chromosomes, a small portion of the population have sex chromosomes outside of these two options. There are people whose sex chromosomes are XXY or XXYYY for example.

Sex chromosomes do not always align with other sexually differentiated biological features. For example:

A woman who for all purposes appeared as a typical cisgender woman, including typical internal and external genitalia, oestrogen driven primary and secondary sexual characteristics, getting pregnant and giving birth to a healthy baby, who upon testing in late adulthood, was shown to have XY sex chromosomes.

Individuals can even have different sex chromosomes in different parts of their body – For example a woman who has some cells with XX sex chromosomes and some cells with XY chromosomes

“new technologies in DNA sequencing and cell biology are revealing that almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body.”

Some babies are born with genitalia that does not fit a simplistic binary. These babies were, and in many place still are, operated on, having their bodies surgically altered without consent, by a world that couldn’t bear to acknowledge that sex has never been a simple binary.

Even gonads do not fit a simple binary – there are XX people with an ovotestis—a gonad with areas of both ovarian and testicular development.

A 70-year-old cisgender man, a father of four, was found during surgery to have a womb.

Genes are more influential in sex differentiation than perhaps we imagine – researchers found that activating a gene in mice changed gonads from egg producing to sperm producing post-natally (in grown mice). Inactivating a different gene turned adult testicular cells into adult ovarian ones.

Hormones are hugely influential on sex differentiation, and hormone levels fluctuate – and are not binary. Cisgender women usually have both testosterone and oestrogen in their bodies. Cisgender men usually have both testosterone and oestrogen in their bodies. Hormone ratios and levels fluctuate from individual to individual (and from day to day and month to month and year to year).

Complete androgen insensitivity syndrome (CAIS) occurs when a person’s cells are unresponsive to testosterone, usually because hormone receptors are not working. People with CAIS have Y chromosomes and internal testes, with external genitalia developing along an oestrogen driven path, and secondary sexual characteristics at puberty also developing on an oestrogen driven path (breast development, wider hips etc).

There are people whose testosterone was suppressed as a fetus, who develop oestrogen driven primary sex characteristics (characteristics typically associated with cisgender women), and who have a surge in testosterone at puberty, developing testosterone driven secondary sexual characteristics (secondary sexual characteristics typical of a cisgender male eg low voice and adam’s apple).

Biology is complex and there are multiple intersex variations outside of a sex binary.

There is a biological underpinning to gender identity

The Endocrine Society has concluded there is a durable biological underpinning to gender identity. See here and here

“Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity”

There is likely a role of genetics and genes. There is likely a role of hormone levels whilst in the womb. Hormones and genes are both biological processes. Complex non-binary biological processes.

Given the biological underpinning to gender identity, it is bad science to separate out gender identity from being part of biological sex.

Endocrine Society

A simplistic binary model of biological sex always has been a social construct, glossing over the complexity and messiness of natural human diversity. The Endocrine society (2017), well versed on the complexity of the human endocrine system, is very clear:

“Biological sex, biological male or female: These terms refer to physical aspects of maleness and femaleness. As these may not be in line with each other (e.g., a person with XY chromosomes may have female-appearing genitalia), the terms biological sex and biological male or female are imprecise and should be avoided.”

The term biological sex is imprecise and should be avoided. In place of the term biological sex we can use the term ‘sex traits’, acknowledging that sex traits are not binary, acknowledging that complex variations in sex traits are part of natural human diversity.

Trumpian Approach to Science, Trumpian Approach to Minorities

Sex traits are extremely complex. Not binary.

I’ve read some articles recently that argue as follows. They state that the majority of people do neatly fit into a sex binary. They point out that people who do not fit into a neat sex binary are a minority. They argue that we should not care about minorities. They really do betray their Trumpian urges.

They argue that because intersex or transgender people do not fit within a socially constructed sex binary, we should ignore (or erase) their existence.

That is not how science works.

You can make a political decision to ignore and disenfranchise and abuse minorities like intersex or transgender people. But you do not get to claim that your political decision is underpinned by science.

One article focused on a specific variation and claimed it was irrelevant as it only affects 0.1% of people. In the world that would make for the whole population of Switzerland!

Population estimates of intersex people are 1.7 %. Recent population estimates of trans people range from 0.5 to 6%. Combined (though of course there are people who are intersex and trans) that’s up to approximately 52 million people – equivalent to the population of South Korea!

A world that ignores and marginalises and disenfranchises people just because they are different, just because they are a minority, is an unjust world.

The idea of a rigid sex binary (biological sex) is flawed science. It is wrong. It is a simplification.

Are we saying that biology doesn’t matter?

No! Biology of course matters. No one is denying that there are important biological differences between humans that impact on our lives and on how society treats us.

People with a uterus can face real biological risks and opportunities (e.g. pregnancy and child birth) that people without a uterus do not face (this includes some trans masculine people as well as many but not all cis women). Let’s build a world that is fairer to all people with a uterus.

People presumed to have a uterus face social and cultural discrimination including in employment, (and this discrimination impacts on trans girls as well as cis girls).

Biology does matter. Cis people’s biology matters. And trans people’s biology matters too.

Trans people are as biologically real, biologically valid, as cis people. Just there are fewer trans people, and most of our science and laws and assumptions are written about cisgender people.

Outdated basic biology is not an acceptable basis upon which to inflict harm on my trans daughter. We need to develop a more sophisticated understanding of biology.

We need to understand that much of our conversations around biology are cisnormative, assuming everyone is cisgender. We can widen our horizons and make space for conversations about trans people within our understanding of human biology.

The starting point for this is an acknowledgement that our traditional ideas of binary biological sex is a social construct that works and can even be helpful (in simplifying a complex world) most of the time – but that it specifically does not work, and causes harm, when applied to transgender and intersex people.

In the latter part of last century, in some places, we reached a point where the social construct of rigid gender roles, gender norms and gender stereotypes were found to be unhelpful (and harmful) to enough people to be challenged and discarded.

This century we have reached a point where the social construct of rigid binary biological sex is unhelpful (and harmful) enough to be challenged and discarded.

Bigotry not biology

Given that there is a biological underpinning to gender identity, my daughter’s gender identity is part of her biology.

Saying a trans girl is biologically male is not science. It is bigotry. It is simplifying complex reality to fit an anti-trans agenda. To other and marginalise and stigmatise trans girls.

My daughter is a girl. Her gender identity is female. Her biology is the same as many other trans girls.

Her biological existence as a transgender person is as valid as the biological existence of any cisgender person.

Her GP registration says female. Her passport says female. Her birth certificate may currently say male (due to an inadequate legal system in the UK), but will at some point in the future be corrected to say female.

There are those who purposefully call my daughter a boy and a male. They deny the lived reality of trans people, and deny decades of scientific literature on trans identities. They don’t care a jot for my daughter’s wellbeing.

There are those who call my daughter a girl, but at the same time say she is a ‘biological male’. This makes no sense whatsoever. Calling my daughter ‘biologically male’ is just as rude as calling her a boy. It is also biologically incorrect, ignoring the biological underpinning of gender identity and the current and future biological differences between a trans girl and a cis boy.

Biological terminology shifts and evolves along with our understanding of the world. There is no situation in which it is acceptable, or scientifically correct, to call my daughter biologically male. It is akin to calling her a cisgender boy or a cisgender male.

Of course my daughter has some biological differences to the average cisgender girl. Trans girls are in some ways biologically different to cis girls. No one is denying that or would ever want to deny that.

If you want to talk about sexually differentiated organs, of course most trans girls have a penis and do not have a uterus (but don’t spend your time thinking about my child’s genitals, it is seriously weird and inappropriate).

The term ‘biological male’ denies the known biological underpinnings of gender identity.

It denies the physiological differences between trans people and cis people, with likely influence of genes and pre-natal hormones, including impacts on brain development.

It denies the reality that trans girls like my daughter will likely never go through a testosterone driven puberty but instead an oestrogen driven puberty, meaning they will never develop secondary sexual characteristics like an adam’s apple or facial hair, instead developing breasts and wider hips.

It denies the biological reality that very many trans women have less testosterone in their bodies than cisgender women.

It denies the biological reality that many trans women have more oestrogen in their bodies than cisgender women.

It denies biological complexity just so that you can impose the word ‘male’ on my daughter to control her, to other her, to misgender her and to cause her harm.

It is an imposition of cisgender power onto the bodies of trans people. It is not good enough.

The people clinging to ‘biological sex’ have the understanding of and respect for science of President Trump. They have similar levels of respect for minorities.

Zinnia Jones has written:

“calling trans women “male” is often an intentional choice meant to promote public fear and advance discriminatory laws”.

“Many people don’t like it when trans women call ourselves female because it undermines the forms of transphobia that rely on thinking of us as men”.

Science calls bullshit on your outdated bigotry.

Biological sex is complex, messy, overlapping. There is a ton of evidence of this, and only someone with Trumpian levels of ignorance can attempt to deny this.

The term ‘biological sex’ is outdated and needs to be thrown out, along with other outdated concepts that we as a society have ditched. There have been numerous historical parallels, where other areas of complex variation were overly simplified and fixed, usually to enable those with more power to use rigid categories as a way of policing and controlling those with less power (rigid class and race categorisations spring to mind).

A binary understanding of biological sex is a simplification that causes harm to those for whom the multiple components and processes contributing to sex differentiation do not all neatly align. This includes people who are intersex and trans people.

Being trans is not a choice, there is a biological underpinning of being transgender.

We can find a way to live within a complex messy world of biological diversity whilst providing dignity and respect to those who are in a minority.

Specialists agree

Dr Joshua Safer, Endocrinologist and President of US Professional Association for Transgender Health has recently stated:

“The idea that a person’s sex is determined by their anatomy at birth is not true, and we’ve known that it’s not true for decades,” said Dr. Joshua D. Safer, an endocrinologist and executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System in New York. He is also president of the United States Professional Association of Transgender Health.

“We know that there is a significant, durable biological underpinning to gender identity,” Dr. Safer said. “What we don’t know are all of the biological factors at play that explain gender identity. As far as we in the mainstream biological-medical community understand it in 2018, it is hard-wired, it is biological, it is not entirely hormonal, and we do not have identified genes, so we cannot specifically say it is genetic.”

Genetics does play a role, though. In studies of twins, if one is transgender, the other is far more likely to also be transgender if they are identical, rather than fraternal twins. Identical twins are near matches, genetically; fraternal ones are not. The findings are similar for twins who have Type 1 diabetes, which is known to have a strong genetic component.


The World Professional Association for Transgender Health (WPATH) board recently released a statement in response to Trump’s plans to enforce a narrow binary of biological sex upon transgender and intersex Americans (abridged below):

The WPATH Board of Directors expresses its strongest disagreement with the intention of the Trump administration to define human gender as the sex recorded at birth based on visible genital formation and to restrict changes, all via regulation. It has been known for decades that sex and gender cannot be determined solely by birth anatomy or chromosomes. More recently, the durable biological underpinnings for gender identity have become better understood within the mainstream medical and scientific communities.

The Trump administration’s past efforts to erase transgender people from American society indicate that its officials believe that XX or XY chromosomal testing to be definitive and definitional. However, this testing is insufficient to measure the known factors that affect the actual sex or gender of a sentient human being.

To acknowledge the diversity of sex and/or gender present in all human beings gives life and potential to those millions of people whose characteristics are not simply defined by sex chromosomes.

WPATH member physicians and researchers stand ready to testify before Congress to protect and defend the health and well-being of all transgender and gender-nonconforming people.

Here’s Dr Vilain, director of the Center for Gender-Based Biology at the University of California

“So if the law requires that a person is male or female, should that sex be assigned by anatomy, hormones, cells or chromosomes, and what should be done if they clash? “My feeling is that since there is not one biological parameter that takes over every other parameter, at the end of the day, gender identity seems to be the most reasonable parameter,” says Vilain. In other words, if you want to know whether someone is male or female, it may be best just to ask.”

#ProtectTransKids #ScienceIsComplex #BiologicalSexIsNotBinary

#TransgenderPeopleAreBiologicalToo #BiologicalNotMythological #MinorityRights

For support on Intersex issues in the UK please contact IntersexUK:

Email- | Twitter-  | Facebook- IntersexUK

Scottish Children’s and Young Person’s Commissioner supports trans children


The Scottish Children’s and Young Person’s Commissioner submitted to the recent Scottish consultation on Gender Recognition outlining the clear legal reasons why transgender children cannot be omitted from a route to Gender Recognition.

The Commissioner’s role is “to protect and safeguard the human rights of children and young people in Scotland, with particular reference to the United Nations Convention on the Rights of the Child (UNCRC)”

The Commissioner provided important context to the consultation

Background of this proposal: It is important to understand what is being proposed by this legislation. This does not impact upon children and young people’s right to affirm their gender identity in day to day life, including in schools. These rights are already enshrined in law via the Equality Act 2010 and many young people in Scotland have transitioned already. Likewise, these proposals do not impact on children’s right to access and consent to medical treatment, which was enshrined in Scots law by the Age of Legal Capacity (Scotland) Act 1991.

The current consultation focuses solely on the legal process through which that transition is formally recognised by the state and it is vitally important to young people who are transgender, non-binary and intersex because of the rights and protections that formal recognition of gender identity affords.

The Commissioner then outlined relevant international legislation:

The UNCRC and gender recognition: The UNCRC does not directly address the issue of legal recognition of gender identity. A number of articles are nonetheless relevant to this consultation. In particular:

  • Article 3: This requires that in all matters concerning a child, their best interests shall be a primary consideration.
  • Article 6: States parties are obliged to ensure to the maximum extent possible the survival and development of the child.
  • Article 8: Outlines children’s right to preserve their identity.
  • Article 12: Requires States to provide all children who are capable of forming their own views with the right to express them and for due weight to be given to their views in accordance with their age and maturity.
  • Article 16: Provides children with a right to privacy.
  • General Comments 12 (on the right of the child to be heard) and 20 (on the Rights of the Child in adolescence) and the concept of developing capacities through which children exercise their rights. Both General Comments elaborate on the concept of the evolving capacities of the children, a concept which is explored in full in the UNICEF Innocenti/Save the Children publication The Evolving Capacities of the Child by Gerritt Landsdown .

Other Human Rights Instruments: The International Covenant on Civil and Political Rights (ICCPR) and the European Convention on Human Rights (ECHR) are also relevant to this consultation. Both contain articles providing rights to privacy that are extremely close to those contained within Article 16 of the UNCRC. Article 8 of the ECHR has been successfully used to establish a right to legal recognition of gender through the European Court of Human Rights. As all other human rights instruments apply equally to children and adults, this can be interpreted as providing children of all ages with an equal right to recognition.

The Yogyakarta Principles: Although the Yogyakarta Principles do not have the same status as international law as human rights treaties, they affirm existing human rights in the context of sexual orientation and gender identity. They are an important means through which existing treaties can be interpreting and set an international standard of good practice with regards to LGBT rights. They were agreed by a panel of experts, in 2006. In 2017, 8 Additional Principles were added to the original 29. Of these, Principle 31 is relevant to this consultation. It states: Everyone has the right to legal recognition without reference to, or requiring assignment or disclosure of, sex, gender, sexual orientation, gender identity, gender expression or sex characteristics. Everyone has the right to obtain identity documents, including birth certificates, regardless of sexual orientation, gender identity, gender expression or sex characteristics. Everyone has the right to change gendered information in such documents while gendered information is included in them.

While sex or gender continues to be registered: iii. Ensure that no eligibility criteria, such as medical or psychological interventions, a psycho-medical diagnosis, minimum or maximum age, economic status, health, marital or parental status, or any other third party opinion, shall be a prerequisite to change one’s name, legal sex or gender;

The Scottish Consultation

The Scottish Consultation asked two specific questions on under 18s:

Question 5 The Scottish Government proposes that people aged 16 and 17 should be able to apply and obtain legal recognition of their acquired gender. Do you agree or disagree?

The Commissioner’s answer was:


In 2016, the UN Committee of the Rights of the Child issued General Comment 20 on the implementation of the rights of the child during adolescent. General Comment 20 outlines the way in which adolescents use “increasing levels of agency to take responsibility for their rights” in line with their evolving capacities as outlines in Article 5 of the UNCRC. Whilst this proposal increases the opportunity for transgender children to realise their rights, it is out of step with existing Scots law with regard to the recognition of capacity in children and young people, which more commonly presumes capacity from the age of 12 and provides children below that age the ability to exercise rights where they have capacity. This is discussed further in our answer to question 6. Notwithstanding that, the extension of these rights is particularly important for this group who are at a stage of life when they are transitioning from school to college, work or university; from childhood into adult life. It allows them to make these transitions with the protections that legal recognition of their identity provides them and reduces the potential for accidental outing, for having to explain their transition and from the additional administrative burden that accompanies changing multiple administrative records.

Question 6 (This question asked “Which of the identified options for children under 16 do you most favour? Please select only one answer.

  • option 1 – nothing for those under 16
  • option 2 – court process
  • option 3 – parental application
  • option 4 – minimum age of 12
  • option 5 – application by capable child

The Commissioner’s answer:

We support Option 5 (application by capable child). This option is most in line with the Age of Legal Capacity (Scotland) Act 1991 and the Yogyakarta Principles and Article 12 of the UNCRC, as interpreting via General Comments 12 and 20 of the UN Committee on the Rights of the Child. Scots law, in the Age of Legal Capacity (Scotland) Act 1991, has a longstanding presumption that children have the capacity to instruct a solicitor and consent to medical treatment from the age of 12. It is possible for a child under this age to exercise these rights if they have the capacity to understand what is involved in that decision. Young people seeking legal recognition of their gender identity may already have exercised these rights, in other aspects of their transition including change of name and consenting to medical treatment relating to their transition. It would be illogical for parental consent to then be required for legal recognition of a transition the young person has been able to effect without it. Article 2 of the UNCRC states: States Parties shall respect and ensure the rights set forth in the present Convention to each child within their jurisdiction without discrimination of any kind…” Denying transgender, non-binary and intersex children the ability to exercise their right to legal recognition, or making it contingent on parental consent, may constitute a breach of article 2. Likewise, Yogyakarta Principle 31 (C iii) requires that States: Ensure that no eligibity criteria, such as … minimum or maximum age, economic status, health, marital or parental status, or any other third party opinion, shall be a barrier to change one’s name, legal sex or gender. Save for capacity, children and young people should not be subject to different or additional tests than adults. The process must still be self-declaratory. We are aware that Ireland has introduced a process for under 18s that differs significantly from that for people 18 and over. We would be very concerned if this was the approach taken in Scotland. Any test of capacity should be consistent with those in section 2(A) and 2(4A) of the Age of Legal Capacity (Scotland) Act 1991. We have consistently expressed out concern with the test of capacity associated with the extension of right contained within the Education (Scotland) Act 201612. Implementing addition tests for children with additional support needs is a breach of article 2 of the UNCRC and we believe potentially indirect discrimination under the Equality Act 2010. The same would be true were any addition test of capacity be used in relation to transgender, non-binary and intersex children through the proposed legislation. Were application for a gender recognition for 12-15 year olds to be subject to parental consent, it is essential that provision be made to enable children with capacity to exercise their rights in cases where: • a young person’s views differ from those of their parents, • where parents are in disagreement with each other; • where the young person is looked after • where there is no one with parental rights and responsibilities. The operation of such a process must be subject to additional consultation, including work with transgender, non-binary and intersex young people. The process should be grounded in children’s rights. We believe that courts are not the appropriate place to decide these matters and children report very mixed experiences of courts listening to their views in other matters.

Other relevant questions:

Question 10 Are any changes to section 22 (prohibition on disclosure of information)?

This is one protection which young people would gain access to with legal recognition of their transition and supports their right to privacy under Article 8 of the ECHR and Article 16 of the UNCRC. It is particularly important at points where information is being transferred from one service provider to another. Education records are covered by section 22 so this would increase the protections to young people’s rights to privacy as they move from school to further education, work or higher education.

Question 12 Should Scotland take action to recognise non-binary people?

YES We support the recognition of non-binary gender identities. Non-binary has become an accepted part of young people’s understanding of gender identities. An increasing number of young people identify as non-binary and should be entitled to the same legal recognition of their transgender peers. Yogyakarta Principle 31 (C ii) requires states to make available “a multiplicity of gender marker options”. This proposal also supports non-binary children’s right to an identity (article 8 of the UNCRC). This proposal also provides the opportunity to ensure that the births of intersex children can be registered promptly without them being assigned as male or female. Article 7 of the UNCRC states that “the child shall be registered immediately after birth”. Together with the extension of legal recognition to children with capacity, this would enable intersex children to assert their identity as they wish, using a social rather than medical model of gender.

International and national law is clearly on the side of the right of trans children to their identity.

This accords with the World Professional Association for Transgender Health’s 2017 Identity Recognition Statement:

The World Professional Association for Transgender Health (WPATH) further recognizes the right of all people to identity documents consistent with their gender identity, including those documents which confer legal gender status. Such documents are essential to the ability of all people to enjoy rights and opportunities equal to those available to others; to access accommodation, education, employment, and health care; to travel; to navigate everyday transactions; and to enjoy safety. Transgender people, regardless of how they identify or appear, should enjoy the gender recognition all persons expect and deserve.

Medical and other barriers to gender recognition for transgender individuals may harm physical and mental health. WPATH opposes all medical requirements that act as barriers to those wishing to change legal sex or gender markers on documents. These include requirements for diagnosis, counseling or therapy, puberty blockers, hormones, any form of surgery (including that which involves sterilization), or any other requirements for any form of clinical treatment or letters from doctors. Further, court and judicial hearings can produce psychological, as well as financial and logistical barriers to legal gender change, and may also violate personal privacy rights or needs.

WPATH advocates that appropriate gender recognition should be available to transgender youth, including those who are under the age of majority.

FYI We reviewed the Scottish consultation and the case for rights for transgender children to gender recognition here