The Moment I Knew My Child Was Trans

February 27, 2018 / growinguptransgender / Leave a comment

This post is featured in the Huffington Post

It’s 6am on a Saturday morning as I write this. I’ve been awake for hours, worried about the latest impact of a targeted campaign of hate directed at my child and those like her. Thinking about whether I can do anything to stem the tide.

I don’t have long.

Soon the kids will be tearing down the stairs, asking for TV, porridge, a game.

When the interruption comes, I’ll be glad of it.

I’ve been asked by Susie Green, CEO of Mermaids, to take a look at a document that has been put out by “Transgender Trend”, an organisation which claims to support parents who are questioning a ‘trend’ of children ‘identifying as transgender’.

This isn’t the first time I am left with my stomach in knots as I read lies and distortions about my child and our family. The idea that people spend so much time and energy making my daughter’s life harder, chipping away at the limited acceptance and support that she has, is frightening – I need to respond, I need to help her, she’s already faced so much.

The document, a Resource Pack for schools, is predictably awful in many ways. Outright lies, misinformation, fake news wrapped in a glossy veneer – the latest weapon of a long campaign aimed at making the lives of trans children impossible – painting them as mentally disturbed, as deluded, as a threat. It is so flawed it is hard to know where to begin. I’ve made a start, but having got to page five with pages of critique, the approach isn’t sustainable. Time is short.

How did I get here?

I’ve known Susie for years now. She was the volunteer who picked up the phone when I first contacted Mermaids looking for support.

I’d registered with Mermaids weeks before, and tried phoning several times, but, understaffed, and relying upon a small group of trained volunteers, the charity had taken a month to reach my application and phone to guide through their assurance process. Those weeks had been tough, my wife and I were at breaking point, worried, isolated, without support. The call from Susie was a life-line, reaching out through the dark. “Is now a good time, she asked?”.

It was evening, Susie had been working the late shift, and had pulled into a service station on her drive home to call. It wasn’t her usual time on the Mermaids rota, but after hearing several answer phone messages, and recognising a family in crisis, Susie had sacrificed her evening to come to our aid.

Over the next hour, glass of wine as crutch, my words rushed out. How our child, who we had presumed a boy, had been stating for years that they were a girl. How their happiness had disappeared, the joy gone from their eyes, how we had a deeply upset and depressed child who cried every night and was losing out on their carefree childhood. How we’d spoken to a psychologist, our GP, school staff – how we’d read every book and article we could find. We had found stories of other parents with children like ours, but had never spoken to anyone who understood what we were going through. We felt utterly alone. Searching online for support we’d come across medical definitions of gender dysphoria on the NHS website including links to Mermaids.

I told Susie how our child had been growing increasingly miserable in recent months and had told us that the one thing they wanted in the world was for us to call them a girl. How we had continued to reject her night after night, saying we loved her but we couldn’t take that step. Yet our child was fading before us. We had finally made the earth shattering decision (for us as parents) to say yes, we can call you girl.

The words fell over each other as I talked to Susie, trying to keep my voice steady whilst emotions churned inside. I spoke about how no one else understood what we were going through, how we faced judgement and disapproval, how we’d lost close friends who wouldn’t understand. Susie listened.

“It’s ok”, she said, as I struggled to maintain composure, the tears silently streaming down, “I know”.

Susie told me about her experience, and her child, Jackie, who she had thought was a boy but who fought the world to be seen as a girl. Jackie and Susie had conquered prejudice, bullies, violence and the ultra-conservative UK medical system. It had been tough, but Jackie had come through, stronger and confident in her identity as a young woman.

“How is your child now,” Susie asked?

I took a gulp of wine, before speaking again,

I told Susie how since we had accepted our child as a girl, since we had stopped our nightly cycle of rejection and denial, the joy had come back into her life. How she had started talking about books and toys and animals again. How she had started to laugh and smile. How she had grown in confidence. How the stress and weight of the world on her shoulders had lifted. How a simple shift in pronoun had transformed our sad depressed child into one with the happiness of a child who has finally been seen by their parents.

“That’s your answer,” said Susie. “You found out, just as I did, what the scientific consensus supports, whatever you do, as parents, you can’t make a child be a gender they’re not”.

Years have passed since that phone call.

We’ve had our share of challenges, all related to how the world treats children like my daughter. We’ve been on a huge learning curve, and our friends, family and school have learnt alongside us. Support at school was critical. Great leadership from the head teacher and a proactive zero tolerance approach to bullying, including misgendering, meant that the school adapted quickly, accepting our daughter completely. Our child is now loving school, learning, growing and enjoying spending time with her friends – who love and accept her as a girl, and as trans.

Our focus has shifted – trying to help build a society that is ready for our daughter. A world that will love and accept her as we do – a world where she doesn’t face prejudice, discrimination and hate. A world where she can read a newspaper without seeing trans people mocked, feared, treated as lesser.

My daughter is still my daughter. She is happy. Thriving. Her being transgender is the least interesting thing about her. She’s just a girl.

I’d like to say more but the children are awake, my time is up. I’ve been called to judge a Lego-making competition. The weekend awaits.

My wife and I blog here. You can also reach us on Twitter: @DadTrans & @FierceMum

Transgender trend ‘School resource pack’ – A teacher’s perspective

February 19, 2018February 19, 2018 / growinguptransgender / 4 Comments

Transgender trend ‘School resource pack’ – A teacher’s perspective –

The writer has more than 12 years experience in teaching, including head of year in secondary and within a SEND setting.

As a teacher my first question is who has written this?

Who are the authors?

Usually on resources you see a whole load of signatories, accreditation and endorsing organisations. Here there’s nothing.

How am I meant to use it?

It is not a resource pack (it contains no specific resources) and I can see no practical application for it.

Looking at the linked website, ‘about us section’, the organisation claims to be founded by a group of parents who have created a website and twitter account but have no other stated organisation purpose or role which gives them legitimacy.

The website ‘founder’s’ primary previous job experience is being an ‘accredited communication skills trainer’ (read bullshitter?).

She mentions she founded a school and worked in various roles in the classroom and playground. This implies she is unqualified (if she was a trained teacher or head, or worked as governor, she would surely have mentioned that).

Reading more of her blurb it quickly links to a website full of naff stock photos and seems to be motivated to sell a book, which seems to be self-published.

Doing a cursory nose around the website’s FAQ section, the first FAQ they have chosen to address is very telling:

Aren’t you just transphobic?
No, we believe that transgender people deserve the same civil and human rights as all of us and should not face discrimination. As the term ‘phobic’ literally means ‘irrational fear’ we want to make it very clear that we are not afraid of, or prejudiced against, transgender people in any way.

Given the amount of prejudice content they are pedalling this answer is an immediate red flag.

It’s a bit like a organisation’s website (which is full of material that advocates racism) including a headline FAQ of : “Aren’t you racist?” Happily responding with – ‘No I’m not racist because racism actually means this’.

On to the publication in question

Despite being formatted like an official guidance document, the prejudice and agenda which came through from a brief look of the website are easy to spot.

The document starts by stating that it was developed in partnership with teachers and child welfare staff, again this is tellingly unspecific.

In these days of academies and free schools employing staff without specialised training to teach, the term ‘teacher’ has lost some of its protected status, and anybody who works in a school during the day from cleaners to ICT technicians has to attend child protection training about prioritising welfare. So you can see how they might have stretched some meagre credentials. Critically, it doesn’t state ‘welfare professional’ or name any specific roles such as ‘Head of Year’ or ‘Safeguarding Lead’

The introduction sets out its goal to “Manage the (se) issues” of official transgender schools guidelines.

The following content on Page 5 titled “why is it needed” is clearly anti-transgender rights and is scaremongering.

It is full of sensationalist soundbites equating gender non-conformity with sexual orientation, highlighting increases in referrals to gender clinics, and even implying that the internet is not to be trusted as it causes something they name ‘rapid onset gender dysphoria’ (thank goodness for Net Neutrality eh).

I almost give up at this point, I am not going to be reading their list of fallacies or ‘case studies’.

Both the title and details of the section ‘Transgender, gay, lesbian, ASD or troubled teenager?’ is very offensive not least to children who have suffered abuse or who have ASD.

As schools we have been tasked by the DfE to promote fundamental British Values of:

The rule of law.
Individual liberty.
Mutual respect for and tolerance of those with different faiths and beliefs.

I don’t see how this document can fit within these modern values.

I see no way that schools would touch this publication with a barge-pole.

Schools are time and money poor, therefore no one will have the time to read it, or the money to print it.

The priority of school leaders is the safety of young people and ensuring that they make progress.

For teachers this means reporting concerns on to the correct person and spending hours preparing lessons, marking and reporting data.

This document includes bad, unsupported, advice coming from a website with a clear agenda of prejudice against the children it claims to support. Reading it is a waste of teacher’s time.

If you are interested on how the Transgendertrend document fits within a long history of anti LGBT hate campaigns you should check out this brilliant review on The Queerness By Teacher Annette Pryce and Psychotherapist Karen Pollock:

https://thequeerness.com/2018/02/18/transgender-trend-follow-in-the-footsteps-of-other-anti-lgbtq-organisations/

The Erasure of Trans Children

February 9, 2018February 10, 2018 / growinguptransgender / 2 Comments

The current Scottish trans Gender Recognition Act consultation refers to ‘evidence that socially transitioned 16 year olds’ exist – but fails to include any acknowledgement of the existence of trans children under 16.

This got me thinking of the erasure of trans children.

All too often trans children are completely erased from discussions.

Without visibility this most vulnerable group of children continue to have their basic rights denied. All too often, trans allies and advocates avoid any reference at all to trans children – it’s too political, too controversial, or too outside of their personal knowledge. Trans children can just wait until they are 18 for fair treatment right? Maybe we can wait until the following generation, after trans adults achieve equality, and then consider trans children. Maybe your trans great grandchildren will be treated well.

Whilst trans advocates and allies pretend trans children don’t exist, the people who are left talking incessantly about children are those opposed to trans equality. Transphobes and trans-antagonists, railing ‘just think of the (cisgender) children’, ‘save them from the trans menace’!

Aside from a couple of notable exceptions (including Paris Lees) who exactly is speaking up for my child? Who cares about trans children?

I decided to do a small piece of simple research into the visibility or erasure of transgender children. I looked at the 208 submissions to the 2015 Women’s and Equalities Committee’s Transgender Equality Inquiry.

For each submission I searched for the use of the term ‘child’ (a search which will also find any references to children, childhood etc).

My results were pretty interesting. More detail is at the bottom of the post, but I’ll summarise the key findings here:

Over half of the submissions (58%) gave zero references to children (trans or cis). This included the vast majority of submissions from transgender adults, the submissions from nearly all government departments, from MPs, from Police forces, from the Royal College of GPs, from Action for Trans Health, from the Albert Kennedy Trust.

A further 16% only used the term children in reference to the (presumed cis) children of trans adults, to intersex children, or in a phrase like ‘looked after children’. This included the British Association of Gender Identity Specialists and the General Medical Council.

Three quarters (74%) of submissions contained zero references to the existence of transgender children

15% had only one or two very brief references to transgender children, some of which avoid acknowledging the existence of trans children. Both NHS England and Stonewall only mention children in reference to the existence of a “Children’s Gender service“. The Equality and Human Rights Commission manages only two references to “gender variant children” or “children whose gender identity is less well-developed or understood than that of an adult”.

89% of submissions to the 2015 Women and Equalities Commissions Transgender Equality Inquiry either didn’t mention children at all, or barely mentioned them.

The remaining 11% of submissions is where I now turn my attention:

Submissions that referred to children more than twice:

Only 23 submissions (11%) referred to children more than twice.

These can be roughly divided into three categories:

a) 7 submissions (3%) were from anonymous parents of transgender children/transgender children – This included 6 parents of transgender children, and one trans young adult who had been treated in children’s services. These submissions contained credible and relevant real life information on transgender children (but there were only 7 submissions from the families affected). These submissions were all anonymous – a great indication of how voiceless these children are.

b) 7 submissions (3%) were from people or organisations whose submission is supportive or neutral towards trans people, these included:

FOCUS: The Identity Trust provides 3 references to transgender children and 2 to gender-variant children
GIRES provides 4 references to transgender children, but doesn’t use the term ‘transgender’, simply calling them children (though in the context the references are to trans or gender variant children)
Lancashire LGBT provides 16 references to trans children,
Mermaids provides 21 references to trans children, children referred to gender services or children with gender dysphoria
Peter Dunne provides 5 references to transgender children
Polly Carmichael from the Children’s Gender Identity Service provides 21 references to trans or gender variant children, yet fails to use the term transgender children even once, instead referring to a variety of terms including ‘children experiencing difficulties in their gender development’ ‘unconventional children’ ‘children with GID’ ‘Children with gender dysphoria’ ‘children with gender incongruence’
The British Psychological Society is rather a mixed bag with one reference to “rare cases it has been thought that the person is seeking better access to females and young children through presenting in an apparently female way”, with 1 reference to transgender children and 1 reference to children with gender dysphoria.

c) 9 submissions (4%) were from people or organisations whose submission is negative or antagonistic to trans people:

A specific person, SJ, refers to children in terms of the threat posed by adults “luring children into women’s toilets in order to assault them”
A specific person, AF, provides 16 references about protecting children from psychologically disturbed individuals and gender ideology
Evangelical Alliance provides 7 references to the need to protect children
Lesbian Rights Group provides 14 references to children including outlining the ‘pressures on young people and small children to transgender’ and highlighting the ‘transgendering of children – a matter of concern’.
A specific person, MY, includes 7 references to protecting children including ‘from possible parental or other abuse’ and recommends ‘treating the parents’.
The group ‘Parents Campaigning for Sex Equality for Children and Young People’ contains 65 references to children focusing predominantly on gender expression / toy stereotypes as well as on the need to protect against ‘transgendering children’
‘Scottish Women against Pornography’ has 17 references that confuse gender identity with gender stereotypes
A specific person, SDA, provides 11 references to children focusing on gender expression/toy stereotypes and arguing the need to stop the ‘powerful trans activist lobby from pathologising normal childhood’ and arguing against ‘trans theory’
‘Women and Girls Equality Network (WAGEN)’, by Dr Julia Long, contains 13 references to children focusing on stereotypical gender expression/roles and arguing against ‘transgendering of children’.

These 9 trans-antagonistic submissions listed above contain 151 references to children. This is nearly more references to children than the other 199 submissions combined.

One qualification to the above research summary: I only searched for use of the word ‘child’ (or ‘children’). It is possible that some submissions focused on children without using the word children. Some submissions may, for example, have used the term transgender youth or adolescent – a more in depth analysis could consider more search terms – but arguably a decision to utilise the word ‘youth’ and avoid the word ‘child’ in a submission is itself a value judgement on the existence or not of trans children and is itself part of a culture of erasure of trans children.

Conclusion

Transgender children are almost completely invisible in society. Trans children need allies speaking up for them.

Yet over three quarters of submissions to the Women and Equalities Commission 2015 Transgender Equality Inquiry contained no acknowledgement of the existence of trans children.

The submissions with the most references to children (cis or trans) are those written by individuals and groups opposed to trans rights. Inputs on transgender children are overwhelmingly written by those ideologically opposed to supporting transgender people. Transphobic individuals and groups are being allowed to set the conversation on children, meaning the actual issues of enormous importance to trans children aren’t even on the agenda. The debate is instead being framed as between (trans-antagonistic or trans sceptical) people who care about protecting children versus trans adults. To re-frame this debate, we need trans advocates to talk about trans children.

Stop the erasure of trans children!

There were over 40 submissions from individual trans adults (or adults with a trans history/adults of trans experience). Almost none of these submissions from trans adults mentioned trans children. Parents of trans children are unable to speak openly (all submissions from parents were anonymous). Cisgender parents of trans children are also sometimes unsure about our credibility speaking out on trans issues. Trans children cannot speak for themselves. Someone needs to speak up.

Hardly any trans-supportive organisations mentioned trans children in their submissions. If your organisation only listens to the voices of trans adults, you are excluding the most vulnerable trans group. Organisations like Stonewall (whose 2015 submission ignored trans children) have a trans advisory panel consisting of only trans adults. Yet it is very clear from this review that transgender adults can’t be assumed to speak up for the needs of current transgender children.

Organisations aiming to support trans equality need to either work with parents of trans children (most of whom are cis, some of whom are trans), or, at the very least, make sure that at least one trans adult is designated to represent trans youth (reaching out to older trans adolescents directly) and we need at least one trans adult designated to represent trans children (reaching out to parents supporting trans children, as the stakeholders who best understand the very many challenges facing trans children).

Without proactive effort to engage with parents and families of trans children, trans children will remain voiceless.

The erasure of trans children in the 2015 submissions to the Trans Equality consultation is shocking.

We must do better for trans children.

Let’s start with the current Scottish GRA consultation (open to submissions from anywhere in the world – and we know those opposed to rights and respect for trans children are submitted from all over the world).

Please complete the short questionnaire on a reformed Scottish Gender Recognition Act. At a minimum please include in your submission acknowledgement of the existence of trans children. Better still, refer to the issues and challenges that affect trans children. If you don’t know any trans children – then get in touch with families of trans children, or organisations like Mermaids.

Trans children exist and they desperately need support.

Don’t leave them voiceless and invisible.

#SomeChildrenAreTrans #GetOverIt

Further info on the findings

Methodology

I looked at all 208 submissions to the Women’s and Equalities Committee’s Transgender Equality Inquiry.

For each submission I searched for the term ‘Child’ (a search which also found any reference to children, childhood etc).

Limitations of the research findings:

1) This research was carried out quickly to give an overview of the data. I looked at all 208 submissions, but quickly and without moderation of findings – some level of errors and oversights are likely.

2) The keyword used was ‘child’ (to include children). It is possible that some submissions focused on children without using the word children. Some may for example have used the term youth. Arguably the decision to utilise the word youth and not child is itself a value judgement on the existence or not of trans children and is part of a culture of erasure of trans children. The Gendered Intelligence submission uses the phrase ‘young trans people’ which refers to “people aged 25 and under”

Over half of the submissions (117 = 56%) gave zero references to children (trans or cis).

This included the vast majority of submissions from transgender adults, the submissions from nearly all government departments, from MPs, from Police forces, from the Royal College of GPs, from Action for Trans Health, from the Albert Kennedy Trust.

Another 16% (34), only used the word children when quoting the title of an NHS Department (eg Child and Adolescent Mental Health Services (CAHMS); in reference to the children of transgender adults, in a generic reference to childhood, in reference to intersex children, and in brief references to children in the phrase ‘looked after children’ or ‘children’s homes’. This group included the British Association of Gender Identity Specialists, the General Medical Council and Gendered Intelligence.

Organisations that refer once or twice to the existence of trans children

26 organisations (13%) had only one or two very brief references to transgender children, copied in table below:

Some of these avoided the term transgender children, only referring to ‘children in the gender service’ for example the single reference to trans children by Stonewall states “The Tavistock and Portman is the only specialist clinic, providing early intervention treatment for children and young people.” NHS England similarly only describes the ‘Children’s clinic’.

Table: Organisations that refer once or twice to transgender children

Organisation	Reference to transgender children
The Albert Kennedy Trust	“The right of the parent to support a child through their assignment is important.”
Genderagenda	“Typically, 1 child per class will come out to me and another will say I know someone trans/non-binary and ask for help supporting them.
The Government Equalities Office has one reference to trans children, quoting Ofsted	“Ofsted’s Common Inspection Framework, which takes effect in September 2015 and covers standard inspections of early years, schools and further education and skills providers, requires inspectors to pay particular attention to the outcomes of a number of specific groups, including transgender children and learners.”
A young trans adult makes one reference	“I feel that children are discovering what trans means through the internet rather than in a classroom environment, and I fear that as a result, either children would grow up with a slight bias, or children who are trans would not realise this until many years later, when it is more difficult to transition. “
LGBT consortium	“Medical interventions for children and adolescents have been inadequate and do not meet international best practice standards”
LGBT Youth Scotland	“Further, transgender young people are aware of their gender identity and begin living in their acquired gender far earlier than the age of 16. We recommend implementing provision which would enable parents and carers to give consent for a child or young person to receive a GRC under the age of 16”
National LGB&T Partnership	Medical interventions for children and adolescents have been inadequate and do not meet international best practice standards
Outreach Cumbria	‘Fourthly there is no local support for children and adolescents with gender identity difficulties with the nearest (and only) gender clinic being the Tavistock and Portman Clinic in London
A volunteer with the Albert Kennedy Trust	“Early access to transitioning and being accepted from a young age is vital to the emotional and mental well being of a trans person and therefore families, social services and the NHS should work with all trans children and trans youths to be able them to decide their future and how they wish to live.”
Support U	“Most of the above issues all apply to young trans people, although more education of peer groups of trans children would help”
Terry Reed	“Numbers presenting for treatment have grown at ~23% p.a. over the last couple of years. In the children and young people group, the growth is even faster. inclusion of transgender people: adults, adolescents and children, in sport.”
Trans Media Watch	“Louis Theroux’s recent documentary on trans children for the BBC also received much acclaim
UK Trans Info	Provide a method for children and teenagers who are below the usual age requirement to obtain gender recognition with the consent of their parents or guardians, or without their consent through the courts where it is in their best interests.
Anonymous	“Ensure that those working in proximity with minors are aware how potentially transgender children can and should be helped.
Equalities Officer, on behalf of UNISON Bournemouth Higher & Further Education Branch	Ensure the implementation of compulsory, trans-inclusive PHSE curriculum in order that children are made aware of the issues facing trans persons, help trans children access support, and tackle transphobic behaviour before it begins. Without access to educational information and resources on gender identity, trans children may be placed under undue stress, confusion, and harm. Through the provision of compulsory gender identity education within the PHSE curriculum, work can be done to make trans children aware that they’re not alone, that discriminatory behaviour they may face is not acceptable, and of the support available to them.
University of Leeds	Particularly vulnerable groups include intersex bodied people and trans children under 18
Scottish Transgender Alliance	With growing social acceptance, the annual number of children and adolescents coming out as transgender has increased five-fold over four years
Anon	There is a need for a more robust communication / awareness programme to help parents who believe their children may be gender dysphoric , and how they can help and cope
Anon	A close family friend has a trans child who, age 8, told his teachers that he wanted to be a boy and have ‘boy parts’. The school reported his parents to the social services, assuming that the child had been abused, based on no other evidence
Individual	Studies indicate that the majority of trans people know they are trans by the age of 7, and many experience distress throughout their childhood. A growing number of children are transitioning, and the lack of any legal recognition until a child is 18 is starting to cause problems, for example with names in school systems and examination certificates.
Individual	Inclusion of trans history as a compulsory element of the UK schools national curriculum, linking it to organisational support for trans children, adolescents, their families, and their friends
Individual	We need to be intervening sooner, so that trans-children grow up with a chance of fitting in to society and being truly inclusive, and non-trans children will grow up with understanding and tolerance, rather than behaving in a segregatory manner and ostracising trans-people

On Gender Stereotypes

February 6, 2018April 12, 2018 / growinguptransgender / 5 Comments

Someone recently wrote in to this blog, saying, in essence, that they ‘would like to support trans children’s rights, but can’t get over a nagging fear that children who are simply non-conforming are being pushed into identifying as trans’. The writer remembers being a ‘tomboy’ who hated dresses, and fears that such traits in today’s society would lead to her ‘being pushed into being a trans boy’. She asks whether a ‘butch woman who identifies as a woman can still be a woman’.

This is the way that very many people who are ‘on the fence’ about supporting trans rights feel. It is not dissimilar to the way I myself once thought about trans people, back when I had never knowingly met a trans person, back before I knew my daughter, back when a lifetime of ignorant media portrayals had depicted trans people, almost always trans women, as clichés of femininity.

Anyone who finds themselves thinking this way, please take a minute to consider a few things.

First consider where are you getting your information from? Have you met trans people who you consider to be making their lives harder and facing enormous discrimination simply from ignorance that girls can climb trees and boys can like dolls? Or do you perhaps know very few or zero actual trans people, and you are basing your judgement on media portrayals? If the latter, consider whether such media tropes are written by, directed by and feature trans people, or whether they simply project non trans (cis) people’s interpretation.

Second, can you really scrutinise the first statement – that you would like to support a marginalised group’s rights, but only once you have been persuaded by them that they deserve your support. Only once you have been persuaded that they are not naively/stupidly enthralled to stereotypes.

Can you not hear how that sounds?

It is not dissimilar to someone saying ‘yes I’ll support Muslim rights, as soon as they persuade me they’re not all terrorists’, or ‘yes I’ll support the rights of people on benefits, as soon as they persuade me they’re not lazy’ or ‘yes I’ll support asylum seekers rights, as soon as they persuade me they’re not criminals’.

I’m all too aware that certain people on the far right in our society hold all of these prejudiced views.

There is a mainstream portion of our society who would never dream of stating or even thinking those statements. Who understand that these sentiments and generalisations are grounded in media misrepresentation, ignorance and hate. Who would not buy into media vitriol about other minorities, yet fall into the trap of believing that trans rights, and trans children’s rights, need to be earned, can be withheld, are in some way conditional upon those children (and their parents) proving that their specific trans child is not a stereotype, and is not in fact a non-conforming child ‘forced into a trans identity’.

The insinuation that trans children are just non-conforming children being led astray is pervasive, a scare story proactively spread by those who want to marginalise trans people.

This accusation is thrown at parents like myself daily:

Why couldn’t you just let your boy play with dolls? (…she doesn’t like dolls)

Why couldn’t you just let him do ballet and wear a princess dress (…she likes football and prefers witches)

Those accusing us of stereotypes are the ones seemingly obsessed with outdated notions of gender specific toys and interests.

They worry that parental narrow mindedness or ignorance leads us to presume a ‘tom boy’ must be a trans boy, that a feminine boy must be a trans girl.

Because of course us blinkered parents of trans kids are tied to stereotypes and couldn’t love a non-conforming child.

Because of course, in their mind, all trans girls love pink and dolls and sparkly tiaras, and all trans boys must be ‘tom girls’ who hate dolls and dresses.

Having met many score of trans children, this couldn’t be farther from the truth. Trans children, and trans people in general are those who are tearing down the gender boundaries.

Of course we told my daughter that she could be whatever type of boy she wanted to be. This was totally misunderstanding the point and made our child deeply sad.

It is true that media depictions of trans children often focus on gender stereotypes, with pink = girl.

Every time I see any depiction of trans kids on TV I count the seconds until the trans girl pulls out a doll or the trans boy kicks a football. But guess what. I know scores of trans girls who had zero interest in dolls or dresses. I know trans boys who collect dolls.

Trans children are no more stereotypical than any other children.

The same for trans adults of course. Some trans women are extremely glamorous and feminine (just like I know some cis women who are always in dresses and makeup). Some trans women wear jeans and t-shirts and rarely if ever use makeup – just like me and tons of cis women. Gender expression is not the same as gender identity.

If you are ‘on the fence’ about whether to stand up for trans children, please question where you are getting your assumptions about transgender children from. If it is coming from a transphobic and ignorant media, or if it is coming from anti-trans children political groups, consider if the information you receive is biased, loaded or spun. Would you accept rhetoric about Muslims from Britain First?

On Media Tropes of trans children

I’ve identified three key factors why the vast majority of media does not present a true picture of trans children:

Media stereotyping
Societal expectations
Personal narratives (of children and families)

1. Gender stereotypes are pervasive in media coverage of trans children. There are many reasons for this:

Media stereotyping: TV shows regularly confuse gender identity with behaviour, toys or interests. Some media pieces seem to do this maliciously, to undermine the validity of trans children, to suggest to unaware viewers that non-conforming children are being made trans. In other media pieces the stereotyping may be unconscious. This is particularly the case when transgender people (directors, producers, narrators) are not involved. Many (but not all) trans adults and parents of trans children are acutely aware of the distinction between trans and gender non-conforming – and of the difference between gender expression and gender identity

Simple soundbites: Documentary producers often seek to tell a simple story, and select and edit soundbites to fit their narrative. This usually reinforces a ‘traditional’ and expected depiction wherein gender expression (eg clothing) and toy preferences (boys = trucks, girls = dolls) are highlighted as synonymous with gender identity. The public as a whole is still poorly informed – many people don’t know what the term gender identity means, many have never heard the term cisgender, or assigned gender, and some are unsure whether a trans girl is someone who was assigned male or female at birth. Documentaries need to ‘hold the hands’ of an ill-informed general public, taking small bite size steps into the world of gender identity. In this context, it is hard for a brief media piece to quickly convey complex and nuanced information on identity. It is much easier to revert to old clichés to help tell the story, looking for soundbites like ‘I adored dolls when I was little’ or ‘I was born in the wrong body’. I’m not denying that some trans people do say these things, and for some trans people this is their truth. But this is not the heart of the story for very many trans people, yet these same clichéd and simplified stories are the ones we see in the media time and again. Reporting on adult trans people seems to be moving towards more complex and nuanced stories about identity – not yet so for trans kids.

Simplified Visuals: Documentary makers like to use imagery to tell their story. A gender identity is not something that can be photographed or visually depicted. Trans kids, like all kids, will have items of clothing of a variety of colours. But it is the photo of a trans girl wearing pink that will make the documentary, that will be selected for the front cover. Trans girls, like most cis girls, will sometimes wear pink. Indeed it is hard to avoid pink in the girls section of most stores. Media images of trans girls almost always show them in pink – this does not mean trans girls wear pink any more often than cis girls. My trans daughter actively dislikes pink.

Participant selection: Some trans girls like football and trousers and climbing trees. Some trans girls like dolls and princesses and pink. Documentaries will give greater emphasis to the latter over the former (I hardly ever see the former shown, despite knowing plenty of trans girls who would rather climb a tree or play a computer game than dress as a princess). Many trans girls will like a wide range of toys, both dolls and cars and will gladly play with both. Which footage will make it into the documentary though? Of course, it will be the clichéd footage of the trans girl with the doll. This is very similar to the clichéd media portrayal of trans women always being introduced showing them putting on make-up. This is part of the truth for some people, but it is manipulative – emphasising stereotypical and clichéd aspects of lives that are rich, nuanced and complex.

2. Gender stereotyped expression may also be more prevalent in trans children, at some stages of their life due to external pressures

Medical gatekeeping: Adult gender identity services, for a very long time, insisted that trans women adhere to restrictive (and often outdated) gender stereotypes as a condition of acceptance for treatment. Trans women who might out of preference dress in a less stereotypically feminine manner were forced to conform to outdated stereotypes in terms of dress and hair style, or be denied support. This type of regressive gatekeeping is still experienced in children’s services, with reports of trans teenagers being told they need to ‘dress in a more stereotypically feminine manner’ or ‘need to sit in a more masculine posture’, or wear certain clothes, or style their hair in certain ways.

Securing support from other children: Trans kids want to gain the support of their peers. Adhering to a very stereotypical gender presentation is a way of signalling their gender identity to other children. When my child was trying to persuade her peers to address her as a girl she took to wearing sparkly hair clips as a visual queue of her identity. One day in the car en route to a party she lost her hair clips. She descended into uncontrollable sobs. When questioned she explained:

‘If I don’t have hair clips in, they will call me a boy’.

Since being accepted as a girl by all her peers, she soon stopped wearing hair clips. It was never about the hair-clip – it was about wanting to be seen by others and respected as a girl.

Asserting identity to parents: Trans kids desperately want to show their parents their identity. Clothing is an obvious route to asserting identity. When we were calling her a boy, my child refused to wear trousers (from a very young age). A very rigid and strident insistence on wearing dresses is for many trans girls a way to communicate their identity to their parents. Gender non-conforming boys like to wear dresses because they like the dress, maybe it sparkles, maybe it has a fun pony on it, maybe it is brighter than the dull colours in the boys section. But for transgender children, clothing is a means to an end, a useful way of trying to communicate and assert their identity. How do you know if it is a gender non-conforming boy or a trans girl? Listen to what the child is saying. Are they focused on liking dresses? Gender non-conforming child. Are they consistently, persistently and insistently saying ‘I am a girl’ and getting deeply upset and depressed when called a boy? That was our daughter. Once our daughter was accepted by us as a girl, her clothing choices gradually shifted to what is now a fairly neutral presentation for a girl – sometimes wearing dresses but most of the time preferring leggings or jeans.

3. Narratives of the child and their parents

Some parents of trans children like stereotypes and some parents like simple narratives that help explain their situation to a sceptical world: Parents of trans kids come from all walks of life. This is not an ideology that only parents with a certain world view sign up to. Trans kids appear in all kinds of families. These families are as varied as wider society, and the families of trans kids will mirror the views and prejudices of wider society.

Some parents of trans kids have very stereotyped and gendered expectations for their children. These parents, when recalling the childhoods of their transgender children, will remember and highlight examples of non-gender conforming behaviour. Such families may well say ‘It made sense that she was a trans girl, as she always liked dolls’. This does not mean that playing with dolls made the parent conclude their child was transgender, rather it meant that once she accepted her child as a girl, she recalled and emphasised examples of non-conforming behaviour that help her understand and accept her child.

Other parents do not have gendered or stereotyped views of children. These parents do not see any clear and simple correlation or causation between the clothes or toys that our children preferred, and their gender identity. Such parents present a more complex and less ‘packageable’ narrative. Such parents do not produce the short media friendly soundbites that documentaries rely on. This more complex parental narrative almost never appears in media depictions of trans children – instead media prefers the parents who say “my child loved dolls so I knew she was a girl”.

Some children need a simple answer: Our daughter has always known she is a girl. Like many children asked to explain her gender identity she cannot do so easily and simply. She quickly got tired of being asked “but why do you think you are a girl?” Gender identity is hard to explain, and adults would struggle to find an answer beyond ‘I just do’. When children assert an identity different to what was expected there is undoubtedly societal pressure to justify how they feel in some way. It would not be surprising to me for children to gravitate to emphasising examples of their own non-conforming behaviour or interests as extra justification for who they are. Especially when this is the depiction of trans children they see in the media. Especially when even the diagnostic criteria used by children’s gender identity services (in the UK and elsewhere) requires stereotypical ‘cross gender interests, behaviour, play preferences’ as credentials for being considered transgender (Gender Identity alone is not sufficient, children are expected to conform to stereotypes of behaviour, clothing or play preferences in order to be deemed gender dysphoric).

There is a popular children’s book written by a transgender girl called “I am Jazz” that seems to equate her liking ‘girls activities’ with being a trans girl. When I first read it with my trans daughter she noticed this and said “that’s silly, of course boys or girls can both like dancing/pink/ballet”. My trans daughter has a more nuanced understanding of the difference between identity and interests. And she shares my dislike of gender stereotyping.

It is possible to criticise some books and programmes about trans children as reinforcing stereotypes without jumping to a rejection of transgender children.

It is possible to dislike gender stereotypes and still want trans children to have happy and safe lives.

It is possible to want the best for gender non-conforming children and still want trans children to be treated with respect, dignity and acceptance.

Those of you on the fence about trans rights can carry on weighing up whether my daughter has proved her ‘not a stereotype’ credentials enough to be shown kindness, respect and acceptance.

I meanwhile will carry on raising a kind, confident, happy child.

I will carry on helping all my children to see beyond the stereotypes, limitations and restrictions society places on girls and boys (and non-binary people).

And I will teach them the importance of tolerance, kindness, and respect, especially for those who we don’t understand, especially for those who are different.

Research update: 12/04/2018

Research evidence is emerging which appears to confirm our experience of parenting a socially transitioned child:

Olson & Enright (2017) in the first ever study of socially transitioned children and stereotyping found that “transgender children and the siblings of transgender children endorse gender stereotypes less than the control group. Further, transgender children see violations of gender stereotypes as more acceptable, and they are more willing to indicate a desire to befriend and attend school with someone who violates gender stereotypes than the control participants. These results held after statistically controlling for demographic differences between families with and without transgender children.”

Trans power

January 27, 2018January 27, 2018 / growinguptransgender / Leave a comment

We were pleased to be recognised on Metro’s trans power list (@DadTrans)

Trans Power List: Top Activists and Influencers

But with the greatest love and respect to all the wonderful advocates on that list (and to the far greater number of amazing advocates who were not on that list) that has got to be the Worst Power list ever!

Where are the trans MPs?

Where are the trans judges?

Trans newspaper editors?

Trans media barons?

Trans billionaires?

The fact that a UK trans power list includes cis parents who blog and tweet anonymously is a great indication of where the power currently lies.

Unless we just haven’t yet been initiated into the ‘all powerful trans lobby’……

(hint hint can we join the secret lobby already?)

Happiness can wait

January 22, 2018January 22, 2018 / growinguptransgender / 1 Comment

Since 6-year-old Jazz Jennings appeared in a 2007 US documentary, the social transition of young transgender children has rarely been out of the media. With increasing awareness accompanied by increasing evidence of the mental health benefits of acceptance and affirmation, more parents across the world are supporting their transgender child to socially transition.

A social transition is defined by the American Academy of Pediatrics thus:

“COMMON STEPS IN SOCIAL TRANSITION

For children of any age, gender transition means allowing the child to choose how they express their gender. Children may:

Wear clothing that affirms their gender, such as skirts for transgender girls

Adopt a hairstyle that affirms their gender, such as a short haircut for transgender boys

Choose a name that affirms their gender

Ask others to call them by pronouns (such as “he” or “she” or “they”) that affirm their gender

Use bathrooms and other facilities that match their gender identity”

Social transition is completely reversible if the child determines it’s not right for them.”

Some ‘experts’ in Europe, in opposition to experts in North America and Australia, caution against social transition. A example of a European ‘expert’ cautioning against social transition is a 2017 Swedish publication on transgender children by Louise Frisen et al:

The Frisen article has some positive sections, but it does also include some outdated statements that I am weary of reading in journal articles:

“Follow-up studies show that no more than about 20 percent of pre-puberty children who meet diagnosis criteria for sex dysphoria will have a residual desire for gender confirmation [6-8].”

And I was shocked to see this recommendation:

“Restraint for the younger with early social transition

Since no more than about 20 percent of prepubertal children who meet gender diagnosis criteria will have a residual desire for gender confirmation [6-8], the recommendation for the younger children is restraint regarding early social transition (living as the perceived gender). It is important to discuss the social consequences and to be aware that the majority of the younger children will not have a remaining desire for gender confirmation.”

The recommendation against social transition, and the two statements quoted above rely on just three sources:

Drummond KD, Bradley SJ, Peterson-Badali M, et al. A follow-up study of girls with gender identity disorder.Dev Psychol. 2008: 44 (1): 34-45

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

Wallien MSC, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008: 47 (12): 1413-23.

The above reference 6 (Drummond) and reference 8 (Wallien) are two discredited studies on desistance that have been widely criticised see here

Reference 7 (Steensma) is a study with totally unreliable conclusions, as discussed here:

The Swedish paper contains no acknowledgement that the data it quotes on the number of transgender children continuing to be transgender as adults are highly contested and could be completely wrong as discussed here

I am so tired of seeing these same unreliable (unscientific, unethical, unsound, shambolic) studies trotted out time and again in journal articles.

Parents of transgender children do not normally have the time, the access to the referenced literature (in inaccessible / expensive academic journals) or the capacity to fact check the advice they are given. And they should not have to. This is literally the job of the supposed experts writing papers like this latest Swedish one. The reliance on discredited studies and conclusions is deeply worrying.

And the advice against social transition can cause serious harm.

he Swedish study advising against social transition is worrying, not only due to the inclusion of unreliable/discredited research in their paper as discussed above, but also due to the exclusion of critical information that Swedish parents (and those caring for Swedish transgender children) have a right to know such as research demonstrating the benefits of social transition, and the positions of world leading experts from the American Academy of Pediatrics and ANZPATH, both of whom endorse social transition.

The Swedish paper does not mention the latest research study from Olson in the United States showing that socially transitioned and supported children have higher levels of mental well being than children who are living as their natal sex:

“Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.”

The Swedish paper fails to mention the guidance from the American Academy of Pediatrics that social transition is positive:

“In many cases, the remedy for dysphoria is gender transition: taking steps to affirm the gender that feels comfortable and authentic to the child. It is important to understand that, for children who have not reached puberty, gender transition involves no medical interventions at all: it consists of social changes like name, pronoun and gender expression.

While acceptance and affirmation at home can help a great deal, children do not grow up in a vacuum, so even children with supportive families may experience dysphoria. Nonetheless, families and doctors of transgender children often report that the gender transition process is transformative — even life-saving. Often, parents and clinicians describe remarkable improvements in the child’s psychological well-being.

The American Academy of Pediatrics describes social transition as “transformative – even life saving”. They continue:

A child’s gender transition is almost always a positive event. Often, the child’s debilitating gender dysphoria symptoms lift, diminishing difficult behavior that came with them. Dr. Ehrensaft calls this the ex post facto (“after the fact”) test: a dramatic reduction in stress, and blossoming happiness for the child and family, indicate that social transition has been the right choice. Along with joy at this renewed well-being, families are often thrilled to find that gender transition removes the emphasis on gender in a child’s life. With their gender identity no longer in conflict, the child can focus on the important work of learning and growing alongside their peers. Many children feel relief, even euphoria, that the adults in their life have listened and understood them.

This describes exactly our experience. Over night our daughter went from incredibly sad and distressed to a happy, carefree child. She went from wanting to talk about gender every single night to completely losing interest in the topic once the world was set to rights as we had accepted her as a girl.

The American Academy of Pediatrics are also very clear why those who, like the Swedish experts, advocate for delayed transition for all children, are wrong:

Delayed Transition: Prolonging Dysphoria

“delayed transition prohibits gender transition until a child reaches adolescence or even older, regardless of their gender dysphoria symptoms.

There is evidence that both reparative therapy and delayed transition can have serious negative consequences for children”

Many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition.”

Delayed-transition advocates treat unnecessary or mistaken gender transition as the worst-case scenario, rather than balancing this risk with the consequences of the delay.

Untreated gender dysphoria can drive depression, anxiety, social problems, school failure, self-harm and even suicide.

There is no evidence that another transition later on, either back to the original gender or to another gender altogether, would be harmful for a socially transitioned child — especially if the child had support in continuing to explore their gender identity.

While delaying a child’s gender exploration can cause serious harm, a deliberate approach is wise. Some children need more time to figure out their gender identity, and some do best by trying out changes more slowly. For these children, rushing into transition could be as harmful as putting it off. The problem with “delayed transition” is that it limits transition based on a child’s age rather than considering important signs of readiness, particularly the child’s wishes and experiences. A gender-affirmative approach uses this broader range of factors, with particular attention to avoiding stigma and shame.”

For children with mild gender dysphoria, the family and therapist’s affirmation of their gender expansive traits often relieves their distress. For this group, it appears that gender dysphoria — and even a moderate desire to change gender — can result from trouble reconciling their masculinity or femininity with being a girl or boy. Adolescents affirmed in their gender-expansive traits are happier and healthier, whether or not they grow up to identify as transgender.

Other children have an insistent, consistent and persistent transgender identity; they thrive only when living fully in a different gender than the one matching the sex assigned at birth. In differentiating these children from the gender-expansive children described above, clinicians use two general rules: They focus on a child’s statements about their sex and gender identity, not their gender expression (masculinity or femininity), and they look for “insistent, consistent and persistent” assertions about that identity. Clinicians help these children and their families socially affirm the child’s gender identity.

The latest ANZPATH (Australian Professional Association for Transgender Health) provides similar clear, evidence based guidance for those supporting transgender children:

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

Social transition should be led by the child and does not have to take an all or nothing approach.

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

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

Acceptance = love. Rejection = shame

Remember, social transition is a fully reversible change involving a change of pronoun, perhaps accompanied by a change of hair style, clothing, name. Nothing medical at all.

At its heart, a social transition is a clear message to a child that they are OK, that they are accepted, that they are not wrong or broken, that they are loved.

The Swedish study takes the view that there is a paucity of evidence, therefore children should not be supported to socially transition.

I agree that there is a paucity of rigorous long-term scientific studies on the outcomes for children who from an early age are supported and accepted.

What does exist is a whole heap of anecdotal evidence of the huge benefit of social transition. I personally know of over a hundred families for whom social transition has been transformational for their child’s happiness. Experts in Australia and America have found the same.

I have met scores of families whose only regret is that they did not embrace and support their child earlier. This includes our child. She was miserable every day – in acute distress. Since social transition she is one of the happiest children you can find. Loving school. Loving her friends. Having a wonderful childhood. Time and again from parents all over the world I hear the exact same story. A story that I hadn’t even heard before I lived it with my child.

From these very many happy socially transitioned children, I know of 2 cases where after a few years of social transition, the child has said to their parent, I want to try living as my assigned gender. In these small number of cases, a second social transition occurred that was no more difficult than the first social transition. At all stages a child needs to feel loved and accepted, that their family are listening to and respecting them. I know of a few more children who have grown into embracing a more nuanced or complex non-binary identity as they have got older (perhaps as they grow more aware of the existence of space between two binaries). Again – no known harm to those children whose understanding of their identity expands over time – as long as they are loved, cared for and accepted.

What is very well evidenced is the great harm that is caused when children are rejected, forced to live a lie, told that who they are is wrong or disturbed or shameful or unacceptable. The message trans girls learn quickly when their parents refuse to call them a girl.

Parents of transgender children know all too well that there is not enough useful research out there. We know that we have been deeply let down by past decades of research on transgender children that is not useful. Let down through the transphobia, homophobia, cis-het-normativity and or sheer incompetence of past researchers who failed to distinguish between trans and gender non-conforming children, and failed to explore which options would lead to the best outcomes for transgender children – including of course the option to affirm, love and accept them.

Much transphobic research continues in this vein. A few researchers, like Kristina Olson from the Trans Youth Project at the University of Washington, are now tracking the outcomes of socially transitioned, affirmed, supported children.

The initial results are very promising, with a number of recent research studies documenting evidence that trans children do know who they are, even young children, and that the outcomes for trans children who are loved and accepted as their identified gender are positive.

But proper science takes time.

These longitudinal studies will be of enormous help to the next generation of transgender children – those children who are not yet born. But my child cannot wait.

In the meantime, loving parents of transgender children have to make the best possible decisions based on the limited evidence that we have now.

As stated in the American Academy of Pediatrics Guide: Supporting Transgender Children (that I recommend reading in full):

“Not treating people is not a neutral act. It will do harm”

And in the guidance from ANZPATH Treatment Guidelines for Trans and Gender Diverse Children (summarised here):

“withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal”

The suggestion that ‘do nothing’ is even an option for parents of insistent, consistent, persistent transgender children is a mis-characterisation of life with a distressed child. As I describe in an earlier blog post

People say: “The best course of action would be for parents not to make any decisions at all”

This shows little understanding of what it is like to parent a transgender child.

Life is full of decisions.

Before making the extremely difficult and heart-breaking decision to support my child, for months I made the decision to say ‘I love you, but no, you are not a girl you are a boy’ and watched their sad face.

For months later, when they said ‘I am a girl’ I decided to change the subject or look away.

For months further I avoided directly calling them a boy but decided to sit in silence as others called them a boy and I watched their shoulders hunch in and the sad look of rejection on their face.

For months further I sat with them at bedtime as they cried and listened to them say ‘but I am a girl’ and I decided not to say ‘that is OK, we love you whatever’.

Life with a very insistent transgender child is full of difficult and painful and troubling decisions for a parent who cares deeply for their child.

Making a decision finally to say ‘that’s OK, we love you whatever’ was the latest in a very long line of decisions.

Which eventually moved on to ‘OK, we’ll call you a girl’, and ‘OK, we’ll help others to call you a girl’ and ‘OK, we’ll help others to understand you are a girl’.

We do not wake up one morning and think, wouldn’t it be fun to choose this incredibly hard and traumatic path for our children.

The above are my words from a couple of years ago. My perspective and understanding has shifted a great deal over the past few years and I no longer see being transgender as a negative or scary thing (though I dearly wish my child would not have to face a transphobic world or deal with prejudice and hate). But at the time I was ignorant and very afraid.

Parents do not consider supporting their child to socially transition on a whim. Take a look at the first 5 mins of this video in this link and see the experience of one American family.

Parents working up the courage to support their transgender child already have to overcome their own transphobia and ignorance (the vast majority of the cis parents I know knew nothing at all about trans children before our own child).

Parents working up the courage to support their transgender child already face extreme hostility from wider society. We already face social isolation and losing friends and family. It is not easy, even when a parent knows in their heart it is what their child needs.

Parents in this situation need ‘experts’ who understand what is at stake, who present all the facts and all recent research including the evidence in favour of social transition. We need experts who are willing to offer support and guidance to families and children for whom extended delay, extended rejection, extended denial of identity is cruelty to our transgender child.

To force children to live as their assigned gender, when doing so is causing them deep distress; to tell them to ‘wait until we have long term data’, when we know anecdotally how many children benefit from social transition, when we know zero evidence of harm, is gross negligence.

The ‘experts’ telling families to ‘wait until we have long term data on the outcomes for those socially transitioned children who we know are currently happy and thriving’ are telling parents to keep their child in a state of deep distress for no good reason. These ‘experts’ like this Swedish author have presumably not spent night after night holding a deeply distressed miserable child. They presumably have not watched their child shrink and lose all enjoyment of life. They also can’t have spent much time around children like mine who absolutely shine with happiness now that they have socially transitioned.

On one level, supporting a child to socially transition seems like the biggest, scariest, most inconceivable step in the world. And, at the time, for a family surrounded by a sceptical and transphobic community, it is.

But, on another level, it is just a change of pronoun. It is the smallest change in the world, and the biggest bargain out there. For this small change I got my happy child back. For this small change my child found love and acceptance instead of rejection and shame. For this small change my child got a carefree childhood full of games and play and friends and fun.

Yet “Just wait” they say.

Reminds me of this tweet from @charllandsberg:

It also brings to mind this quote from the inspirational Sarah McBride:

“When we ask people to wait patiently for their rights, we ask them watch their one life pass by without the dignity they deserve”

These children, children like my daughter, only get one childhood.

They can spend it happy, supported, loved and accepted –

or miserable, rejected, shamed.

We need to stop letting transgender children down.

Childhood is now.

Happiness cannot wait

Puberty Blockers (GnRHa)

November 27, 2017January 19, 2018 / growinguptransgender / 4 Comments

Safe and reversible

Puberty Blockers are recognised by credible experts around the world as a safe and reversible intervention that delays puberty for transgender or gender questioning adolescents.

According to the 2017 Endocrine Society Guidelines (Hebree et al, 2017):

“We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development

These recommendations place a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm from early pubertal suppression.”

“We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists.”

Adolescents are eligible for GnRH agonist treatment if:

1. A qualified MHP has confirmed that:

the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),

gender dysphoria worsened with the onset of puberty,

any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,

the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,

2. And the adolescent:

has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,

has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,

3. And a pediatric endocrinologist or other clinician experienced in pubertal assessment

agrees with the indication for GnRH agonist treatment,

has confirmed that puberty has started in the adolescent (Tanner stage $G2/B2),

has confirmed that there are no medical contraindications to GnRH agonist treatment.

The latest clinical guidelines for treating transgender children are the Australian Guidelines (Telfer et al, 2017). They say the following about puberty blockers:

“Referral of a Child with gender dysphoria to a paediatrician or paediatric endocrinologist experienced in the care of trans and gender diverse adolescents for medical treatment, ideally prior to the onset of puberty”

“puberty suppression typically relives distress for trans adolescents by halting progression of physical changes such as breast growth in trans males and voice deepening in trans females and is reversible in its effects”

“The adolescent is given time to develop emotionally and cognitively prior to making decisions on gender affirming hormone use which may have some irreversible effects”

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

“puberty suppression medication is reversible”

“The main concern with use of puberty suppression from early puberty is the impact it has on bone mineral density”. Reduction in the duration of use of puberty suppression by earlier commencement of stage 2 treatment must be considered in adolescents with reduced bone density to minimise negative effects.”

Criteria for adolescents to commence puberty blockers

1. A diagnosis of gender dysphoria in adolescence

2. Medical assessment including fertility counselling

3. Tanner stage 2 pubertal status has been achieved. This can be confirmed via clinical examination with presence of breast buds or increased testicular volume and elevation of luteinising hormone

4. The treating team should agree that commencement of puberty suppression is in the best interest of the adolescent and assent from the adolescent and informed consent from their legal guardians has been obtained

Australian References:

The Australian evidence base regarding puberty blockers focuses on three main sources:

Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study, de Vries et al (2011)

AIM: To compare psychological functioning and gender dysphoria before and after puberty suppression in gender dysphoric adolescents.

METHOD: Of the first 70 eligible candidates who received puberty suppression between 2000 and 2008, psychological functioning and gender dysphoria were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment.

MAIN OUTCOME MEASURES: Behavioral and emotional problems (Child Behavior Checklist and the Youth-Self Report), depressive symptoms (Beck Depression Inventory), anxiety and anger (the Spielberger Trait Anxiety and Anger Scales), general functioning (the clinician’s rated Children’s Global Assessment Scale), gender dysphoria (the Utrecht Gender Dysphoria Scale), and body satisfaction (the Body Image Scale) were assessed.

RESULTS: Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both sexes, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1. Gender dysphoria and body satisfaction did not change between T0 and T1. No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment.

CONCLUSION: Puberty suppression may be considered a valuable contribution in the clinical management of gender dysphoria in adolescents.

Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment, de Vries et al, (2014)

BACKGROUND: In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.

METHOD: A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.

RESULTS: After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.

Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria, Costa et al, 2015:

AIM: This study aimed to assess GD adolescents’ global functioning after psychological support and puberty suppression.

METHOD: Two hundred one GD adolescents were included in this study. In a longitudinal design we evaluated adolescents’ global functioning every 6 months from the first visit.

RESULTS: At baseline, GD adolescents showed poor functioning with a CGAS mean score of 57.7 ± 12.3. GD adolescents’ global functioning improved significantly after 6 months of psychological support (CGAS mean score: 60.7 ± 12.5; P < 0.001). Moreover, GD adolescents receiving also puberty suppression had significantly better psychosocial functioning after 12 months of GnRHa (67.4 ± 13.9) compared with when they had received only psychological support (60.9 ± 12.2, P = 0.001).

CONCLUSION: Psychological support and puberty suppression were both associated with an improved global psychosocial functioning in GD adolescents. Both these interventions may be considered effective in the clinical management of psychosocial functioning difficulties in GD adolescents.

101 adolescents were deemed ‘immediately available’ to receive blockers. This group was assessed at baseline, after 6 months of just therapy, after 12 months including 6 months blockers, and after 18 months including 12 months blockers. “The immediately eligible group, who at baseline had a higher, but not significantly different psychosocial functioning than the delayed eligible group, did not show any significant improvement after 6 months of psychological support. However, immediately eligible adolescents had a significantly higher psychosocial functioning after 12 months of puberty suppression compared with when they had received only psychological support. Also, their CGAS scores after 12 months of puberty suppression (Time 3) coincided almost perfectly with those found in a sample of children/adolescents without observed psychological/psychiatric symptoms.”

“In conclusion, this study confirms the effectiveness of puberty suppression for GD adolescents. Recently, a long-term follow-up evaluation of puberty suppression among GD adolescents after CSHT and GRS has demonstrated that GD adolescents
are able to maintain a good functioning into their adult years [De Vries 2014 see above]. The present study, together with this previous research [De Vries 2014], indicate
that both psychological support and puberty suppression enable young GD individuals to reach a psychosocial functioning comparable with peers.”

The American guidelines similarly describe blockers as “fully reversible” saying:

To prevent the consequences of going through a puberty that doesn’t match a transgender child’s identity, healthcare providers may use fully reversible medications that put puberty on hold. These medications, known medically as GnRH inhibitors but commonly called “puberty blockers” or simply “blockers,” are used when gender dysphoria increases with the onset of puberty, when a child is still questioning their gender, or when a child who has socially transitioned needs to avoid unwanted pubertal changes.

By delaying puberty, the child and family gain time — typically several years — to explore gender-related feelings and options. During this time, the child can choose to stop taking the puberty-suppressing medication. However, most children who experience significant gender dysphoria in early adolescence (or who have undergone an early social transition) will continue to have a transgender identity throughout life. Puberty-suppressing medication can drastically improve these children’s lives. They can continue with puberty suppression until they are old enough to decide on next steps, which may include hormone therapy to induce puberty consistent with their gender identity.

The UK service specification (citing Costa et al, 2015) agrees:

“In adolescents with GD, psychological support and puberty suppression have both been shown to be associated with an improved global psychosocial functioning. Both interventions may be considered effective in the clinical care of psychosocial functioning difficulties in adolescents with GD”.

As demonstrated by the above, there is a clear consensus amongst gender specialists worldwide that puberty blockers are fully reversible and this is supported by the peer reviewed academic literature.

Recent claims from the UK Gender Identity Service

In spite of the consensus and evidence in support of puberty blockers as safe and reversible, there have been recent reports from families with children in the UK Gender Identity Service that clinicians have advised against them. One clinician is reported as saying “puberty blockers may not be as reversible as we thought” and there have been reported attempts to dissuade dysphoric pubertal youth from puberty blockers. More worryingly there are also reports from parents that on occasion clinicians have stated that they will not permit referral to the Endocrinology service (for reversible puberty blockers) “until we are completely sure of things”.

If some clinicians are working in this way, this appears to be both outside of the UK Protocols and not in alignment to the accepted international good practice. While it is as yet unclear how widespread this reluctance to prescribe puberty blockers is, the crux seems to centre on a ‘feeling’ by some in the UK children’s gender service that puberty blockers ‘might change outcomes’, making children ‘continue as trans’ who may otherwise have ‘shifted to a cisgender identity’.

This unsubstantiated criticism of hormone blockers has recently started to filter into mainstream media, for example, in this magazine article which raises concern about the reversibility of blockers:

“Blockers are often described as “fully reversible”, and it is true that if you stop taking them puberty will eventually resume. But it is not known whether they alter the course of adolescent brain development”

The above critique of blocker reversibility isn’t attributed in the article, but the main criticism of the gender affirmative approach in the article is Bernadette Wren, the Head of Psychology at the UK Children’s Gender Service who is described in the article as “nervous” of an approach where “children who begin taking blockers early on in puberty, followed immediately by cross-sex hormones, will never produce mature eggs or sperm of their own”. Wren continues, “Can a 12-, 13-, 14-year-old imagine how they might feel as a 35-year-old adult, that they have agreed to a treatment that compromises their fertility or is likely to compromise their fertility?”.

It is puzzling that the UK service are dissuading use of blockers for dysphoric transgender adolescents, particularly given the clear consensus amongst respected centres of expertise globally. Perhaps there are further clues from a speech given at WPATH 2016 (the international forum for transgender health) by Polly Carmichael, the Head of the UK children’s service:

Here’s is a lengthy extract from the last quarter of Polly Carmichael’s speech to WPATH in 2016 including the text from slides:

Slide text:

“Rationale for the blocker: Are all aspects reversible?

The blocker as a diagnostic aid

The blocker as time to explore, understand, consolidate

The blocker as reversible treatment

Experience some puberty? Tanner stage 2

Stage of puberty not age

Transcription of audio for this slide:

“So to end I want to raise some points for us to think about

Rationale of the blocker. Are all aspects of the blocker fully reversible? Is anything really fully reversible? If you don’t do something it has an effect. If you do something it has an effect

And also we are working within a developmental trajectory so things are changing all the time

However, I think we had the view of the blocker as a diagnostic aid. It was also a time to try and alleviate stress, unless I’ve got this completely wrong, to explore and understand more and consolidate, support young people to be thinking about their next step. It is a reversible step in terms of if you stop it then your pre-programmed milieu resumes, but I would question whether it is a completely reversible treatment, we also have the idea of young people should experience some puberty, to tanner stage 2. I think that was around the idea the majority of people presenting to services pre puberty not necessarily going forward post puberty and wanting physical interventions and so maybe within that there was some thought that puberty perhaps had a role to play in terms of young people’s development in terms of their sense of their gender identity”

Next slide text:

Balancing evidence and Practice

Behavioural and emotional problems, largely attributed secondary to gender dysphoria, are expected to be relieved by supressing puberty, whilst general functioning has shown to improve after a staged programme starting by blocking puberty De Vries et al 2010, 2014

Dutch team have published longer term data – but little prospective data available – wide age range

No consensus yet between professionals in the field regarding the use of puberty suppression. Doubts related to lack of psychological and long term physical outcomes such as bone health and cardiovascular risks. Nevertheless, several teams are exploring the possibility of lowering the current age limits for early medical treatment although they acknowledge the lack of long term data Vrouenraets et al 2015 Cohen Kettenis and klinck 2015

Transcription of audio for this slide:

“I think we all, you know, feel the blocker and physical treatments are crucial and vital and have been the biggest step forward for young people. And certainly their use that was pioneered in Holland has been incredibly successful, but actually the Dutch are the only team really who have published long term prospective studies about this, so there is very little data available and also the data we have is on very wide age ranges. And I guess I was surprised to see but it makes sense that very recently in 2015 an excellent paper giving young people a voice a qualitative study looking at the views of young people, 13 young people between the age of 13 and 18 and really was concluding that there is no consensus so I think around the world we are practicing very differently”

Next slide text:

Number Mean Age Age Range

Mean age young people at EI clinic 162 12.82 8.99-15.1

Natal Males 70 12.89

Natal Females 92 12.97

Mean age at started blockers 119 13.59 10.5-15.5

Natal Males 54 13.64

Natal Females 65 13.54

Mean age at start CSH 25 16.18 16-16.5

Natal Males 10 16.21

Natal Female 15 16.17

2 stopped treatment

Transcription of audio for this slide:

“In terms of our service we have had 44 young people in our early intervention project, who were part of a research project but we have now had 162 young people go forward for early hypothermic blockers and the age range reflects the fact it is by stage not by their age, but 2, only 2 have stopped treatment. And in both of those cases they have stopped treatment because they are wanting to explore a different gender identity. One is in a very supportive environment and wishes to try living in a different role without treatment for a while.

So I guess there is a question about why, Why none, why none stop if they’ve started on the blocker more or less, so I guess that begs the question that either we are not putting forward enough, that there are some people who would benefit from this who are missing out on this treatment. Or that in some way this treatment in and of itself may have an impact and may put people on a path. I totally support this treatment but I think it is about how we conceptualise it, the framework within which it is offered”

Next slide text:

Summary

T1 Outcomes show

Overall no change in psychological functioning (YSR and CBL)

Natal girls showed an increase in internalising problems from To to T1 as reported by their parents

No change in self-harming thoughts or behaviours

No change in Gender Identity or Gender Dysphoric feelings

No change in perception on primary or secondary bodily characteristics

However a change over time in neutral sex characteristics (feet, face, nose, height, eyebrows, hands, chin, shoulders, calves, adam’s apple).

Transcription of audio for this slide:

“So in terms of our early intervention I guess the other thing is that our results have been different to the Dutch we are about to publish these and we haven’t seen any change in terms of psychological wellbeing and so on. There was a change over time in neutral sex characteristics, but interestingly this was a change, there was a study done through our service looking at the general population in terms of this where also there was an increase in dissatisfaction and so it seems to reflect that rather than something specific to this group. I think this is to do with the timing at which we took our measures but what is more important in terms of the qualitative data all of the young people have been resoundingly thrilled to be on the blocker and not wanting to stop and found it to be an incredibly positive experience.”

This presentation was in March 2016 but the expected paper on the outcomes for the 162 adolescents on blockers has not (as far as we’re aware) yet come out. It does have some fascinating results mentioned – out of 162 people only 2 did not continue with treatment after blockers. Polly Carmichael considers this a troublingly high rate of continuation, and proposes two theories: either not enough people are getting an opportunity to use blockers, or blockers are changing the outcomes. The tone of the presentation and repeated use of the question ‘is anything reversible?’ gives a clear indication of which way she is inclined.

This is very much the territory of the ‘hunch’. A specialist seeing a certain trend and making a guess, or hypothesis, about causation. The step between hunch and proven theory is having some evidence and data to back this up.

There are several alternative explanations for the low drop out rate after using blockers:

One, Carmichael is mistaken in her starting assuming that a large number of adolescents normally desist from a transgender identity at puberty – after all, this assumption is based on desistance statistics that are very widely discredited. See here and here

Two, Carmichael is overlooking the extreme difficulties for a child to gain access to the service pre-puberty and the extreme delays and gate-keeping once in the service before any approval is given for blockers. These delays and barriers in the UK system mean that only the most clear, insistent and consistent children reach the point of early provision of blockers. Children who are in any way less certain (ironically, the youth who perhaps would most benefit from thinking time), are very much less likely to get listened to by their parents, referred by their GP, accepted by the service, and approved for blockers. If only the children who have a long track record of insistent and clear identities are prescribed blockers, then it is not at all surprising that those are the children who continue to be insistent and clear once ‘on’ blockers.

Importantly, despite having developed a ‘hunch’ about hormone blockers changing the outcomes (making children persist as trans who would otherwise be cis or making children who had expressed a desire for physical intervention continue to have this desire for physical intervention), the UK service is yet to provide any peer reviewed publication (nor any open access to service data), in support of this claim.

Anecdotes and hunches that seem to fit with a perceived data pattern are not evidence. Competent evidence based science needs to be based on data and research shared with the world in peer reviewed research journals. If the UK really has any evidence that blockers are not reversible (beyond the above speculation), they need to present it to the world through peer reviewed publication.

How are GIDS backing up their hunch?

UK families have asked UK GIDS for evidence of this ‘hunch’ of blockers not being reversible. In spite of having a dedicated research centre, the Tavistock GIDS rarely share research literature with families (and the research section of their website is woefully out of date). However clinicians at Tavistock GIDS have recently been circulating a paper by a former member of staff called Giovanardi. This paper reportedly been distributed both following requests for information on blockers from parents, and also as part of their blocker information sessions:

“Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents – Guido Giovanardi – Porto Biomedical Journal Volume 2, Issue 5, September–October 2017, Pages 153-156

Now at first glance it might seem curious to choose a paper published in a new and not yet ranked journal – anyone with a knowledge of academic journals will be aware that quality and peer review standards vary widely between journals, which is why journal accreditation and ranking is so important, to separate the quality journals from those that will publish flawed or inaccurate material.

This paper provides very little in the way of positive evidence about the effectiveness of blockers. It states that “many professionals remain critical about the puberty-blocking treatment”, ignoring the substantial bodies from Endocrine Society, to American Academy of Pediatrics, the American College of Osteopathic Pediatricians and the Executive of the Australian and New Zealand Association of Transgender Health, not to forget the original pioneers from the Netherlands who endorse puberty blockers.

The three sources for the claim that many professionals are critical of blockers include:

i) Cohen‐Kettenis et al (2008)

ii) A fringe view point (in a letter) from a group from Berlin who believe people can’t be considered trans until after “psychosexual development has been completed” and

iii) Stein (2012) which contrasts the expert opinion and clinical evidence in favour of puberty blockers of experts from US and Netherlands, against the author’s personal un-evidenced concerns.

These sources provide little by way of evidence that respected professionals in 2017 are critical of blockers as Giovanardi suggests.

Giovanardi focuses their paper heavily on potential negatives of blockers, listing nine reasons against blockers:

1. At Tanner stage 2 or 3, the individual is not sufficiently mature or authentically free to take such a decision.

2. It is not possible to make a certain diagnosis of GD in adolescence, because in this phase, gender identity is still fluctuating.

3. Moreover, puberty suppression may inhibit a ‘spontaneous formation of a consistent gender identity, which sometimes develops through the “crisis of gender”’.

4. Considering the high percentage of desisters, early somatic treatment may be premature and inappropriate.

5. Research about the effects of early interventions on the development of bone mass and growth – typical events of hormonal puberty – and on brain development is still limited, so we cannot know the long-term effects on a large number of cases.

6. Although current research suggests that there are no effects on social, emotional and school functioning, ‘potential effects may be too subtle to observe during the follow-up sessions by clinical assessment alone’ (p. 1895).

7. The impact on sexuality has not yet been studied, but the restriction of sexual appetite brought about by blockers may prevent the adolescent from having age-appropriate socio-sexual experiences.

8. In light of this fact, early interventions may interfere with the patient’s development of a free sexuality and may limit her or his exploration of sexual orientation.

9. Finally, for trans girls (natal boys with a female gender identification), the blockage of phallic growth may result in less genital tissue available for an optimal vaginoplasty.

Out of the 9 listed criticisms, 8 have no relevance to the reversibility of blockers.

Point one and two are saying adolescents are too young to decide about blockers or too young to be diagnosed as transgender. These are both disputed, neither point is a reason to go through the wrong puberty, especially assuming blockers are reversible (Giordano, 2008; 2010).

Point 4 and 6 refer to Steensma et al (2008) with point 4 discussing the problematic work on desistance. Point 6 is actually positive, in favour of hormone blocking treatment, albeit with some unsubstantiated ‘are there things we don’t know?’ tacked on, without clear rationale.

Point 5 merely mentions there is a lack of rigorous evidence. We know this. This is not however, a reason to do nothing as doing nothing is ‘not a neutral decision’ (Simona, 2008). It is not logical to say do nothing until we have excellent evidence, The Australian guidelines (Telfer et al, 2017) is neatly succinct:

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

Giovanardi’s Point 7 and 8 suggest that blockers have some important impact on sexuality. The only reference for point 7 and one of two references for point 8 is an article by a fringe group from Berlin (Korte et al, 2008). They maintain that adolescents should complete all pyscho sexual development before any intervention at all, and wrote a letter arguing against the view of the Endocrine Society (2009 clinical practice guidance) on a variety of areas, including disagreement that there is any biological cause for gender identity. The global Endocrine Society (2017) has recently concluded there is significant and conclusive evidence for a biological underpinning.

Korte et al (2008), crucially does not contain any new research or data, it instead reviews other people’s data meaning it is not a quality source for a new conclusion. This Berlin group are also firmly in the, now discredited, “blame the mother” camp, see for example, this delightful section in their paper:

“A profound disturbance of the mother-child relationship can often be empirically demonstrated and is postulated to be a causative factor”. ” The desire to belong to the opposite sex is held to be a compensatory pattern of response to trauma. In boys, it is said to represent an attempt to repair the defective relationship with the physically or emotionally absent primary attachment figure through fantasy; the boy tries to imitate his missing mother as the result of confusion between the two concepts of having a mother and being one (e15). In girls, the postulated motivation for gender (role) switching is the child’s need to protect herself and her mother and from violent father by acquiring masculine strength for herself”.

“This explanatory approach ascribes primary importance to a desire on the parent’s part for the child to be of the opposite sex. A high rate of psychological abnormalities in the parents of children with GID has been reported in more than one study. It is essential, therefore, to explore thoroughly the psychopathology of the child’s attachment figures and their “sexual world view,” including any sexually traumatizing experiences they may have undergone, in order to discover any potential “transsexualogenic influences”.

This old fashioned ‘blame the mother’ approach to transgender children has been discredited, see this from Winter et al (2016), in the Lancet:

“to date, research has established no clear correlations between parenting and gender incongruence”

The Berlin group go on to talk about autogynophelia and fetishistic transvestism. This is outdated, utterly discredited, and damaging nonsense. Are the Tavistock GIDS seriously endorsing and suggesting parents read such hurtful, uncredible, and transphobic material?

Point 9 mentions lack of penile tissue for later surgery. This has historically been a concern as a limiting factor on certain surgical techniques for trans women, however, surgeons have now developed, and are continuing to develop alternative techniques, noting that the desire for surgery is far from universal. Giovanardi’s argument here against puberty blockers for trans girls age 12 based on potential impact on surgery prospects as an adult, is deeply perplexing. It would perhaps be worth noting in a discussion of potential surgical interventions, but hardly a reason to not offer hormone blockers.

In summary, not one of the 8 reasons discussed above are related to the question of whether blockers are reversible.

Point 3 alone in Giovanardi’s paper is the critical one for this discussion. It is the only supposed ‘evidence’ presented for the irreversibility of blockers:

“3. Moreover, puberty suppression may inhibit a ‘spontaneous formation of a consistent gender identity, which sometimes develops through the “crisis of gender”’

Giovanardi’s paper provides one single reference for this claim; Simona Giordano (2007).

Giordano is a respected researcher in the field of medical ethics, who has written extensively on the importance of treatment of gender dysphoria. This reference, citing a proposal for new guidelines for treatment of gender dysphoric children and adolescents, seemed so unlikely I immediately re-read her paper to locate the section being referred to by Giovanardi. Here is a more lengthy quotation:

Clinical Benefits and Risks of treatments for AGIO

Puberty delaying hormones. These have the following benefits:

a. The main benefit of early physical treatment is arrest of pubertal development, and, consequently, arrest of the suffering of the patient (CohenKettenis et al., 2003, p. 171).
b. Arresting the progress of puberty gives adolescents more time in which to achieve greater certainty about their innate gender identity.
c. The administration of blockers will prevent the development of secondary sexual characteristics of the undesired sex. In turn, future treatment would be less invasive and painful (for example, breast removal in female-to-male patients and painful and expensive treatment for facial hair in male-to female patients will be prevented; the voice will not deepen, and nose jaw and crico-cartilage (Adam’s apple) will be less developed)) (Cohen-Kettenis et al., 2003, p. 171).
d. Successful adaptation is associated with early start of physical treatment (Cohen-Kettenis et al., 2003, p. 171).

The risks are currently under scrutiny. The British Society of Paediatric Endocrinology and Diabetes, composed by the UK team involved in the treatment of gender dysphoric young people, believes that interrupting the development of secondary sexual characteristics may disrupt the fluidity that characterises puberty, and arrest the natural changes that may occur in this period (BSPED). In other words, in theory, blockers may inhibit the spontaneous formation of a consistent gender identity, which sometimes develops through the ‘crisis of gender’.

Although the concern is serious and should always be taken into consideration when administering therapy in early puberty, it is also known, as stated above, that the vast majority of AGIO adolescents (unlike pre-pubertal children) almost invariably become AGIO adults (Cohen-Kettenis et al., 2003, p.172), even where hormone-blockers
have not been administered. This means that there is a clear expected benefit in the vast majority of cases of adolescents requiring treatment

Giordano’s paper outlines several evidence based reasons in favour of puberty blockers. She includes in one lone paragraph a note that some UK specialists involved in the treatment of children ‘believe’, (have a hunch), that puberty blockers could make people continue as trans who could otherwise be ‘saved’ and made ‘cisgender’ (I paraphrase…). This is presented as opinion with no evidence. Giordano clearly concludes the paper arguing in favour of hormone blockers “there is a clear expected benefit in the vast majority of cases of adolescents requiring treatment”.

The only ‘evidence’ of blockers not being reversible in Giordano’s paper is this description of UK specialists having a hunch about potential impact.

“My work has been misrepresented”

I wrote to Dr. Simona Giordano to ask if their work has been misrepresented. Here, with permission, is their reply in full:

“You are right. My work has been misrepresented, because I was only citing one possible concern, to say that this concern is misplaced. As many others.

Likewise other research is misrepresented. Sex typing, for example is usually completed at the age of 6 or 7 and it is not true that during adolescence gender identity fluctuates. It may and it may not.

The BSPED guidelines I referred to in my article at the time were withdrawn very soon after. My paper and all my work is very clear on my stance. Since my first 2007 article I have been consistently analysing the ethical and clinical arguments 1. Against provision of GnRHa to adolescents with GD and 2. For age-based provision, and I have been arguing for over 10 years now that I could not find one individual ethical or clinical argument that could justify a policy of non-intervention.

I have been arguing since then that “waiting” is not necessarily a “precautionary” approach; omission of treatment can have severe psychological, social and physical hideous consequences. Omissions in this area can be much more risky than action. Harm reduction is a legitimate goal of medical care. Moreover, importantly, blockers, in the very literature cited by Giovanardi, are regarded and presented as a diagnostic tool as well as a therapeutic tool. So it is incorrect, in my opinion, to talk about GnRHa just as a medical treatment; it is part of the diagnosis.

Of course, each individual adolescent deserves to receive a treatment plan adapted to his or her individual needs; professionals must retain discretion as to what they believe to be in the best interests of the child. A policy, or clinical guidance, that across the board sets an age, or suggests waiting till Tanner Stage 4 or until advanced phases of pubertal development is extremely risky, and may prevent professionals from making this type of judgement based on individual needs.

We shared our analysis with Dr Giordano and she was kind enough to read and make the following observations,

“There is a passage in your blog:

“Wren continues, “Can a 12-, 13-, 14-year-old imagine how they might feel as a 35-year-old adult, that they have agreed to a treatment that compromises their fertility or is likely to compromise their fertility?”.”

From this point of view, an adolescent should be refused cancer treatment, because unable to imagine how she or he will feel at the age of 35 having agreed to a treatment that compromises fertility, and therefore be left to die with cancer. No valid response would be that ‘cancer is lethal and gender dysphoria isn’t’ because it is well known that gender dysphoria can be lethal and is often lethal if untreated. The oncologist would say: “She may lament being infertile when she’s 35 but at least she’ll be around to complain!”; the transgender adolescent may say the same: “Even if in the future I will suffer because of my infertility, at least I will be around to suffer!”.

Reversibility. The issue of ‘are blockers reversible?’ is misguided. It would be more precise to say that once the treatment is interrupted, spontaneous development re-occurs with no irreversible changes having taken effect, rather than ‘blockers are reversible’, or ‘treatment is reversible’.

The issue of bone mineral density is not an issue of ‘reversibiity’ but rather an issue of the side effects of the medications. These medications may have this side effect (potentially). There are no firm data as yet, but this has been a concern for a long time. It has not been possible to gather precise data, because peak bone mass is accrued around the age of 26-27, and the population of patients treated with GnRHa is still too young to have a solid evidence base. But even assuming that one day we have the data, and these data show that patients who have been treated with GnRHa are more likely to develop bone mineral density issues than untreated patients, this potential side effect is to be balanced with 1. The benefits and 2. The likelihood of harm and suffering associated with withholding treatment. There may be clinical arguments too to be evaluated (ie what can be done clinically to reduce the risks that may be associated with the medication).

I believe it is misguided to debate about reversibility, because of course nothing is ‘reversible’ in the sense that once we have done something, we can’t reverse (I wrote this in response to Russel Viner in 2008). Here what matters is the side effects, the benefits v harms. So when we discuss whether something is reversible or not we risk losing sight of the relevant issue, which, it seems to me, is rather whether the treatment is overall beneficial, considering the likely benefits and the potential risks.”

The UK service therefore distributed to parents a journal article as ‘evidence’ to back up their belief that blockers are not reversible. The sole evidence within this paper written by a former member of the UK GIDS staff (Giovanardi, 2017) is a reference to another paper (by Giordano, 2007), which was, in turn, quoting the UK service’s un-evidenced belief. An unpublished hunch evidenced by a paper that references another paper that refers to that same hunch. We have found ourselves lost in parody. Simply put, this is not good enough!

In summary

The journal article (Giovanardi, 2017) given out to parents of service users by the Tavistock GIDS misrepresents evidence on the question of reversibility of blockers. It quotes research that is far from mainstream (outdated, pathologising and transphobic).

In a paper that claims to be a summary of evidence, it omits major (positive) studies and, in the discussion on the risks of being on blockers for too long, omits entirely any discussion of the recommendations endorsed by gender affirmative specialists to proceed to cross sex hormones earlier in case impacts on bone mass (Hembree et al. 2017). A quote from Rosenthal, a leading US endocrinologists (and one of the authors of the global Endocrine Society Guidelines) is included in a recent magazine article:

“Rosenthal worries about the few British children who, having begun puberty at age nine, will have to take the blocker for seven years until they have reached the age of consent. “That can be very risky to their bone health and perhaps even for their emotional health, to be so far out of sync with their peers in terms of pubertal development,” he says. At his clinic, he has administered cross-sex hormones to patients aged 14, and sometimes younger.”

(Note, though we twice take expert quotes from a recent magazine article, this article is itself deeply flawed – see Marlo Mack’s compelling essay for further discussion).

It is extremely concerning that some clinicians in the Tavistock GIDS are handing out to parents such a poor article as this Giovanardi paper. We see three options. Either:

1 They believe in the type of positions outlined in the articles referenced in the Giovanardi paper (which means they are potentially deeply transphobic and hold discredited and out-dated views on transgender people). Or;
2 They don’t look at the quality of the research they are reading and take the conclusions as robust evidence without checking the actual evidence base (which would make them incompetent). Or;
3 They have a ‘hunch’ that blockers are bad and are actively looking for any research that confirms their feeling (from which we would assume they were unethical and biased).

There is significant evidence on the benefits of hormone blockers to trans youth. The UK withholding or delaying blockers is extremely damaging. The UK needs to put up peer reviewed data to substantiate any ‘hunch’ they may have, or desist from spreading unsubstantiated rumours. Advice to parents needs to accurately portray current evidence – to do otherwise is both unethical and risks harm.

So what have Tavistock GIDS published on puberty blockers?

It is equally curious that the Tavi are handing out the Giovanardi paper from a new journal, and not referring parents to their own paper on puberty blockers, from the respected Nature, (Costa et al, 2016).

Here are key quotes from this 2016 paper, written by two specialists at the Tavistock GIDS, indicating both the evidence for the timely use of hormone blockers and, in agreement with the wider research consensus, that they are clearly reversible:

“Puberty suppression using gonadotropin-releasing-hormone analogues (GnRHa) has become increasingly accepted as an intervention during the early stages of puberty (Tanner stage 2–3) in individuals with clear signs of childhood-onset gender dysphoria”

“The existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence”

“To date, only one long-term follow-up study has indicated that a treatment protocol including puberty suppression leads to a psychosocial functioning in late adolescence that is comparable to non-gender-dysphoric peers”

“To date, only one study has assessed the effect of GnRHa on cognition in gender dysphoria, reporting no evidence for a deleterious effect of puberty suppression on brain activity and related executive functioning”

“Research has begun to focus on the effects of puberty suppression on quality of life in prepubertal and adolescent individuals with gender dysphoria, indicating that this early intervention could improve their psychosocial functioning and wellbeing”

“A team from the Netherlands has been an influential leader in promoting a protocol — the so-called Dutch protocol — which recommends treatment of minors with gender dysphoria after an extensive psychological and psychiatric evaluation, with puberty suppression at the age of 12 years and after the first stages of puberty (Tanner stage 2–3) have been reached. This team have also provided evidence that no young individual eligible for GnRHa has dropped out of treatment or shown regret during puberty suppression. The cornerstone of this approach is the evidence that, although puberty suppression seems to reduce the gender-dysphoria-related distressand seems to be a relatively safe and reversible procedure, not treating gender dysphoria in childhood cannot be considered a neutral option, as delaying treatment until late adolescence or adulthood might lead to the development of psychiatric concerns, social isolation, and impaired functioning.”

“Our opinion is that the enlightened decision would be to allow puberty suppression when the adverse outcomes of a lack of or delayed intervention outweigh the adverse outcomes of early intervention in terms of long-term risks for the child. In other words, if allowing puberty to progress seems likely to harm the child in terms of psychosocial and mental wellbeing, puberty should be suspended.”

“Since (the 1990s), puberty suppression has become increasingly accepted as an early intervention in young individuals with clear signs of gender dysphoria.”

“Puberty suppression is considered a fully reversible procedure and has been proven to be sufficiently safe. Suppression of puberty in children with gender dysphoria has the fundamental benefit for children of giving them time to reflect on their gender identity, obtain real-life experience living as the non-natal gender in dress and behaviour, and determine whether or not they desire the full transition. In our opinion, as the development of a body contrary to the experienced gender has been associated with several psychosocial distress parameters, puberty suppression can be considered a preventive treatment. The procedure has consistently been linked to an improved transition into the desired gender role, including in terms of physical appearance, and a more satisfactory outcome, even in the long term.”

“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.”

This 2016 Tavistock GIDS paper merits further discussion and we will be looking in more detail in our next research evidence review.

References:

Carmichael, P., Presentation at WPATH 2016; February 2016

Cohen‐Kettenis, P. T., Delemarre‐van de Waal, H. A., & Gooren, L. J. (2008). The treatment of adolescent transsexuals: changing insights. The journal of sexual medicine, 5(8), 1892-1897.

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The journal of sexual medicine, 12(11), 2206-2214.

Costa, R., Carmichael, P., & Colizzi, M. (2016). To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nature Reviews Urology, 13(8), 456-462.

De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.

De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.

Giordano, Simona. “Gender Aytpical Organisation in Children and Adolescents: Ethico-Legal Issues and a Proposal for New Guidelines.” Int’l J. Child. Rts. 15 (2007): 365

Giovanardi, G. (2017). Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents. Porto Biomedical Journal, 2(5), 153-156.

Growing up Transgender, A plea for better transgender research on the perpetual myth of ‘desistance’ and the ‘harm’ of social transitioning; 2017. https://growinguptransgender.wordpress.com/2017/03/04/a-plea-for-better-transgender-research-on-the-perpetual-myth-of-desistance-and-the-harm-of-social-transitioning/

Growing up Transgender, Diagnostic importance of starting puberty; 2017. https://growinguptransgender.wordpress.com/2017/11/25/diagnostic-importance-of-starting-puberty/

Growing up Transgender, GIDS.NHS.UK All the support a parent needs….; 2016. https://growinguptransgender.wordpress.com/2016/11/11/gids-nhs-uk-all-the-support-a-parent-needs/

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., … & T’Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903. https://doi.org/10.1210/jc.2017-01658

Korte, A., Goecker, D., Krude, H., Lehmkuhl, U., Grüters-Kieslich, A., & Beier, K. M. (2008). Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies. Deutsches Ärzteblatt International, 105(48), 834.

Mac, Marlo, Hit by trans friendly fire, 2017. https://gendermom.wordpress.com/2017/11/21/hit-by-trans-friendly-fire/

McCann, C. (2017). When girls won’t be girls. 1843. [online] Available at: https://www.1843magazine.com/features/when-girls-wont-be-girls [Accessed 27 Nov. 2017].

Murchison, G. (2016). Supporting and Caring for Transgender Children. Human Rights Campaign, 11.

Stein, E. (2012). Commentary on the treatment of gender variant and gender dysphoric children and adolescents: Common themes and ethical reflections. Journal of Homosexuality, 59(3), 480-500.

Telfer, M.M., Tollit, M.A., Pace, C.C., & Pang, K.C. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. Melbourne: the Royal Children’s Hospital; 2017 https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/Australian%20Standards%20of%20Care%20and%20Treatment%20Guidelines%20for%20Trans%20and%20Gender%20Diverse%20Children%20and%20Adolescents.pdf

Winter, S., Diamond, M., Green, J., Karasic, D., Reed, T., Whittle, S., & Wylie, K. (2016). Transgender people: health at the margins of society. The Lancet, 388(10042), 390-400.

Diagnostic importance of starting puberty?

November 25, 2017January 19, 2018 / growinguptransgender / 3 Comments

Several documents, including the Endocrine Society Guidelines, refer to the diagnostic importance of adolescents starting puberty. There is a belief that some youth cease to be transgender/dysphoric during the early stages of puberty and that ‘persistence’ can only be assessed after youth have experienced that first stage of natal puberty.

Here’s the Endocrine Guidelines 2017

“At the present time, clinical experience suggests that persistence of GD/gender incongruence can only be reliably assessed after the first signs of puberty.”

“Adolescents with GD/gender incongruence should experience the first changes of their endogenous spontaneous puberty, because their emotional reaction to these first physical changes has diagnostic value in establishing the persistence of GD/gender incongruence.”

The belief in the diagnostic importance of the early stages of puberty, leads in turn to the requirement that adolescents go through the first stage of a natal puberty, and the clinicians only prescribe blockers once they have noted increased distress at those early pubertal changes. The Endocrine Society’s criteria for prescription of blockers includes the requirements:

“gender dysphoria worsened with the onset of puberty”.

As mentioned in our earlier blog, the Endocrine Guidelines do not include any reference in support of this recommendation.

However, this quote does appear to correspond to a journal article by Steensma et. al., 2011.

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

We will therefore look at this in detail.

The abstract for this paper makes a wide number of claims:

“Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification.”

It offers as a conclusion:

Based on the significance most adolescents attribute to the period between the ages of 10 and 13, we suggest that clinicians should concentrate clearly on what happens in this phase of development. It is recommended to specifically address the adolescents’ feelings regarding the factors that repeatedly came up as relevant in our interviews (i.e. the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice), before any medical steps are taken (e.g., to suppress further pubertal development).

Steensma et al.’s above conclusion makes some very specific recommendations that have influenced clinical practice in settings, including the UK Gender Identity Service for Children.

Here is the ‘Evidence‘ section of the UK NHS Children’s Gender Identity Service website:

“Young people indicated that the period from 10 and 13 years to be most crucial in their feelings related to gender dysphoria. For both, the young people who continued having these feelings and for those where the feelings of gender dysphoria became less prominent, three main factors seem to have had an impact on their gender identity development. Firstly, the changes in social environment (gender roles and expectations become more distinct during this period of their life); secondly, the effects of a changing body through puberty; and thirdly the experience of romantic feelings and falling in love (Steensma et al, 2011).”

Other papers by Steensma have been criticised for poor and inaccurate research analysis, for drawing conclusions that are not based on the findings, and for overstating conclusions beyond what the data can support.

Key claims to consider as we look into the actual data in the Steensma paper are:

Is there robust evidence that “emotional reaction to these first physical changes has diagnostic value in establishing the persistence of GD/gender incongruence”.
Is there robust evidence that “the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice create changes in gender identity at this point in time”
Is there robust evidence that “”tanner stage 2 is a diagnostically important period for gender identity?” (Steensma’s conclusion does not mention tanner stage, instead mentioning age 10-13, but clinical guidelines now focus on tanner stage rather than age)
Is there evidence that “a significant number of trans children, previously undistinguishable pre –puberty, desist in the first stage of puberty” (between tanner 1 and 2)?

To the data! (Steensma et. al. 2011)

The study selected a sample of 25 adolescents aged 14-18, all of whom had been registered with the Dutch Gender clinic in childhood, but only 14 of whom had been still registered with the service at age 12-14. The 14 who had been with the service at age 12-14 (and were still with the service) were considered the ‘persisters’ (7 ‘male’ 7 ‘female’ – amab/afab?). The 11 who had left the service some time before the age of 12-14 were considered the ‘desisters’ (6 ‘male’ 5 ‘female’ – amab/afab?). The persisters had applied for puberty blockers. The desisters had not applied for puberty blockers.

The Steensma study interviews this sample at ages 14-18 and asks a wide range of qualitative questions, asking them to reflect upon their earlier views and experiences.

All 25 children had been diagnosed during childhood with Gender Identity Disorder (DSM 4). The diagnosis of Gender Identity Disorder is no longer used, and has been heavily criticised for not distinguishing between children who are transgender and those who are simply non-conforming, with no wish to change their gender and no need for medical interventions. The now discredited statistics on desistance, also published by Steensma amongst others, are known to be flawed as they relied upon the DSM 4 diagnosis, counting non-conforming children alongside transgender children.

With a DSM4 diagnosis, we cannot know how many of the original sample of 25 were just gender non-conforming. The possibility that a large number of children in this sample of 25 were non-conforming rather than transgender is given credence by the fact that the paper refers throughout to issues that are not centred on identity – the paper focuses predominantly on descriptions of gendered interests, play preferences and gender expression (as opposed to on identity).

It is also interesting to note that none of the 25 children in this sample had socially transitioned before the age of 12.

The paper makes the claim that ‘Adolescents with GD/gender incongruence should experience the first changes of their endogenous spontaneous puberty, because their emotional reaction to these first physical changes has diagnostic value in establishing the persistence of GD/gender incongruence’.

As we will demonstrate, this recommendation is built upon woefully shaky foundations:

Steensma et al (2011) claim to have identified three diagnostic areas:

social divisions
pubertal physical changes and
sexual orientation

all of which they claim are diagnostically critical in distinguishing between ‘persisters’ and ‘desisters’ between the ages of 10-13 years old.

The paper outlines the different ways that ‘persisters’ (those who were in the system at age 12-14 and applied for puberty blockers) and ‘desisters’ (those who had left the system before age 12 and never applied for puberty blockers) remember feeling ‘at around age 10-13’

1. Social Divisions

The ‘persisters’ recall social divisions between boys and girls increasing ‘at around age 10’. As the divisions between boys and girls increased, so did their wish to be grouped with the ‘other’ gender (with the gender matching their identity?) and they increased in their wish to socially transition. The ‘desisters’ did not respond in the same way. At this period of increased social divisions between boys and girls, the ‘desisters’ were not troubled to be grouped with their natal gender, and did not wish to socially transition.

Steensma et al interpret the above as evidence that the period of increased social division at around age 10 is diagnostically important. That we need to wait until social divisions between boys and girls increase at around age 10, and see whether children wish to be grouped with their natal gender without wish for social transition (=desisters) or whether they wish to be grouped with children of the opposite gender to their assumed gender and wish to socially transition (=persisters).

An alternative possibility (which cannot be determined from this data) is that the desisters were always gender non-conforming children, and the persisters were always transgender children. An alternative interpretation of the same research data is that when social divisions increase, the transgender children wish to be grouped with their identified gender, whereas the non-conforming children are untroubled with being grouped with their natal (=identified) gender. With this interpretation, the age of 10 and the responses to increased social division at this age, is not in fact diagnostically important. Instead, to distinguish transgender children from non-conforming children we need to ask them about their identity. Something, from the data presented, this study does not do.

This ‘finding’ focuses on an age, in this case the age of 10 (a time where according to Steensma et al, gender divisions increase in the Netherlands). This ‘finding’ is not linked to any stage of pubertal development or to any tanner stage.

2. View of puberty

The second distinction proposed between the ‘persisters’ and ‘desisters’ relates to their reported ‘view of puberty’. When interviewed several years later (at age 14-18) the ‘persisters’ recall having been very distressed by puberty:

“When I was 13, I started to menstruate and my breasts started to grow. I hated it! If we would have had a train station in our town I would definitely have jumped in front of a train. I didn’t go to school anymore, lost my friends and became totally withdrawn”.

The desisters, being interviewed at ages 14-18, do not recall being distressed about the physical changes of puberty. The desisters were almost by definition not distressed by puberty as they are the group who had left the service before age 12 and had not applied for puberty blockers. As throughout this paper, tanner stage of puberty is not discussed.

Steensma et al interpret this as evidence that experiencing “the first changes of their endogenous spontaneous puberty” was a critical diagnostic stage.

An alternative interpretation of this same research is that children who are distressed about puberty, who are still in the gender service at age 12, and who apply for hormone blockers, can be considered as ‘persisters’ (transgender). Children who are not distressed about puberty, are no longer in the service at age 12, and do not apply for hormone blockers, are ‘desisters’ (not transgender).

There is no evidence in this study that the desisters were distressed about the idea of puberty beforehand and desisted at age 11 (remember they had all left the gender service before age 12). There is no reference to tanner stage 2 in this study, and no evidence at all that desisters were distressed at tanner 1 but un-distressed at tanner stage 2.

The study even makes it explicitly clear that the desisters were not even distressed at the idea of puberty:

“For the desisters the anticipated feminization or masculinization of their bodies was not explicitly reported as particularly distressful”.

The desisters were not even distressed about anticipated puberty.

The most logical interpretation of this data that we can make is that we should not give puberty blockers to youth who have not applied for puberty blockers. And we should not give puberty blockers to youth who have left the gender service before age 12. It is our conclusion from the presented data that assuming the children left the service of their own accord, rather than leaving for other reasons, such as denial or delay in treatment, it seems most likely that children who have left the service before age 12 and have not asked for puberty blockers are probably not in need of puberty blockers.

Significantly, and at odds with the paper’s abstract, recommendations and conclusions, this study provides no evidence that children who are distressed about anticipated puberty desist after undergoing the first stages of puberty. It also fails to make a single reference to tanner stages.

Yet this is considered evidence that “Adolescents with GD/gender incongruence should experience the first changes of their endogenous spontaneous puberty”. The study provides no evidence to back up that conclusion.

3. Sexual attraction

The third section which Steensma et al. find to have diagnostic importance is that of developing sexual attraction. In the study (interviewing 14-18 year olds), all 14 ‘persisters’ described themselves as attracted to their natal sex, and saw themselves as heterosexual (transgender and heterosexual).

Steensma et al. extrapolate from this a conclusion that the development of sexual orientation is, in and of itself, diagnostic – that youths who are attracted to their natal gender but consider themselves heterosexual are therefore transgender.

This finding is problematic on multiple levels.

Firstly, and inexplicably, Steensma et al. consider it a noteworthy research finding that a transgender person attracted to their natal gender considers themselves heterosexual.

Secondly the sexual orientation of a sample of 14 transgender individuals (all describing themselves as heterosexual) cannot be considered diagnostic as even from a cursory review of the literature it is clear that transgender people can have a range of sexual orientations.

Thirdly, whether all 14 are heterosexual cannot itself be relied on – remember these are interviews with 14 – 18 year olds, adolescents at ages where many cisgender youth may not be open about their sexuality, why then should transgender youth be any different. Moreover these are transgender youths who are reliant upon a service for medical interventions and it can be speculated are attempting to provide the ‘desired answers’ to navigate their way through in a Gender Identity Service ruled by hetero/cis-normative gate keepers.

Also many of the ‘persisters’ seem to emphasise ambivalence or reluctance to start dating “I just don’t want to date now”.

There is a clear hetero cis normative bias, particularly for assigned females. The Steensma et al (2011) analysis notes that the desisting girls were all cisgender heterosexual and suggests that this is also diagnostic (implicit assumption that cisgender lesbians do not exist). The desisting boys it notes expressed a variety of sexual orientations.

Even within this data set it is unclear how Steensma et al consider sexuality diagnostic. Note again, there is nothing here about tanner stage, nor about at which stage of puberty sexual orientation became clear.

As an aside that I won’t go into here, the study is also methodologically flawed (it describes itself as applying grounded theory, but omits to include key parameters that are critical for a grounded theory approach).

Summary

What the Steensma et al. 2011 study claims to prove:

“Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification.”

What the Steensma et al. 2011 study actually proves:

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

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

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

What policy recommendations this study makes:

Based on the significance most adolescents attribute to the period between the ages of 10 and 13, we suggest that clinicians should concentrate clearly on what happens in this phase of development. It is recommended to specifically address the adolescents’ feelings regarding the factors that repeatedly came up as relevant in our interviews (i.e. the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice), before any medical steps are taken (e.g., to suppress further pubertal development).

What policy recommendations this study can justifiably make:

We should not give puberty blockers to youth who have left the service before the start of puberty, who are not distressed at the idea of puberty and who have not applied for puberty blockers. We should only give puberty blockers to youth who are still in the service, who are distressed at the idea of puberty and who apply for puberty blockers.

Tanner 2?

It is noteworthy that the Steensma study make no reference to tanner stage 2, instead focusing on the age of around 10-13 and the stage of emerging romantic/sexual feelings. Current practice in many countries has moved on from designating a minimum age for puberty blockers (age 12) to a stage based approach (tanner stage 2).

In other countries the approach is reportedly one where a transgender child’s identity is believed in childhood, where children approaching puberty are reassured that puberty blockers will be available at tanner stage 2 if required, where clinicians proactively monitor tanner stage, and where, at tanner stage 2, if a child is distressed at the idea of pubertal changes, puberty blockers are prescribed in a timely fashion.

In the UK flawed evidence like this Steensma study provides the foundation of an approach which is harmful to transgender children and adolescents. The UK approach uses flawed desistance statistics and studies like this one on the diagnostic importance of puberty to argue that transgender children cannot know their identity until puberty. The UK uses this (plus other flawed research again by Steensma) to argue against early social transition even for insistent, persistent, consistent and deeply distressed transgender children. The UK belief that previously trans children will desist at puberty means that pre-pubertal children are given no reassurance at all that puberty blockers will be available, leading to increased stress as puberty approaches. Parents report that the UK service does not seem to see any urgency in prescribing promptly at tanner 2, with parents feeling the need to fight for the service to monitor developing tanner stage and to prescribe in a timely fashion at tanner 2. Parents are confused about what possible reason clinicians could have for delaying prescription of hormone blockers to distressed children at tanner 2. They don’t understand why there is no sense of urgency or timeliness from the UK Children’s Gender Identity Service.

My guess is that this Steensma et al. 2011 study is part of the reason UK Children’s Gender Identity Service clinicians seem so reluctant to prescribe puberty blockers promptly at tanner stage 2. If they accept Steensma et al.’s conclusions and policy recommendations at face value (which they seem to), then they are led to believe that there is an unknown point in natal puberty where previously insistent trans children will suddenly ‘desist’. That there is no way of knowing beforehand which kids will desist. That the longer they can delay blockers the more likely adolescents are going to experience the elusive (and unknown) point in puberty when something as unpredicatable as falling in love could cause them to ‘desist’. Another child will be saved from transdom! And one child saved from transdom is worth inflicting major emotional harm on those who remain trans.

Summary:

This piece of research over states its conclusions and draws policy recommendations that are not in any way supporting by the data. This publication is cited twice in the new Endocrine guidelines. It is included in the references for WPATH Standards of Care 7. It is cited in numerous articles. It is quoted at length on the website of the UK Children’s Gender Identity Service. The claims made in this study are not robust and must be discarded.

The Reality behind the Myths about Trans Children: An Interview with us, Growinguptransgender

November 22, 2017January 19, 2018 / growinguptransgender / Leave a comment

Trans Children Myth Busting

Following recent negative news coverage, we thought it would be good to return to this interview with the LGBT children’s story publisher, Truth and Tails, in which we share our experience of raising a child who happens to be trans. We address many of the myths about Trans children, including advice for other parents, and the reasons for starting this blog.

For the first time we’ve published it here:

Background

We were interviewed by the lovely Truth & Tails, in March 2017, after they had read our blog and sent us a copy of their book ‘Vincent the Vixen’ which explores trans issues from the perspective of a gender questioning fox.

You can read the original interview in full here: Truth & Tails Interview

Interview Th

Truth & Tails: We first discovered the Growing Up Transgender blog back in October, when we read their post 10 reasons why the #dontjudgegender verdict makes families of transgender children concerned in response to a high court judge ruling on gender identity, which resulted in a seven-year-old being removed from their mother. The blog is written anonymously, to protect the family’s identity, by parents of a young transgender child living in the UK.

We spoke to the authors, about their reasons for starting the blog, what support is out there for parents of transgender children, and what the most common misconceptions are that they face day-to-day.

Tell us about the catalyst for starting the ‘Growing Up Transgender’ blog.

A few different things prompted us to start a blog. Firstly, we remembered how alone and confused we felt when we first realised our daughter might be transgender. We appreciated so much the few parents (mostly in America) who had shared their experiences online.

Secondly, we were frustrated by the huge amount of misinformation and distorted claims that are presented as fact on the internet. It took us a long time to be able to distinguish fact from fiction, and to distinguish helpful evidence based information from transphobic bigotry. Having thoroughly researched and understood the different issues, we wanted to share our understanding with others.

And thirdly, we noted a dramatic upsurge in anti-transgender children hysteria in the UK media. Fear-mongering media rhetoric has a direct impact on how adults, and in turn, their children treat our child. We felt compelled to speak out, yet also wanted to maintain our child’s privacy. A blog seemed like the best way to ensure our voices, and our experience of a wonderful trans daughter, could be shared. We hope our blog will in some way help other families dealing with this issue.

When did you realise your daughter was transgender, and how did you know? Is there a specific conversation that you remember?

Our daughter said she was a girl from a very young age. Daily. There was no one specific conversation that opened our eyes, it was more a very persistent stream of assertion over a long period of time. At first we didn’t take it seriously. We tried to dissuade. We tried to tell her she could be whatever type of boy she wanted to be. This was totally missing the point, and made her even sadder. Eventually it got to a point where we realised that we had a very depressed child, who felt rejected by her parents. We realised that we were letting her down.

What would you say to a parent who is beginning to have these sorts of conversations with their child?

Some parents worry about their boy playing with dolls, or preferring being friends with girls, or their girl rejecting dresses and wanting short hair. These behaviours that are related to how a child plays or dresses or expresses themselves are not focused on identity and there is no reason to think such children are likely to be transgender. My view would be not to narrow your child’s horizons, to allow toys to be toys and children to play however they like.

A much smaller number of parents will have the experience we have had, and other parents describe extremely similar experiences. A child who insists that they are a different gender to what you are expecting. A child who doesn’t perhaps care what toys or clothes they have as long as they are acknowledged as the gender they identify with. A child who repeats their identity consistently, persistently, insistently and gets increasingly sad and withdrawn, perhaps accompanied with concern about their body. For parents of those children, I would advise the following:

First, consider how scary and isolating it must be for a child to be repeatedly told that something they feel so deeply is unacceptable to those who love them mostly dearly. Listen to your child. Let them know that you love and accept them whatever. Let them know that you stand by them. Let them know that there are other children in the world who feel the way that they do. Let them know that some children feel like this when young, then grow up and don’t feel like this so strongly. Let them know that other children feel like this when young, then grow up and continue to feel like this and live like the gender they identify with. Let them know that both groups can grow up to have happy and well-adjusted lives. Let them know that either is ok with you. Let them know that they are not alone.

Secondly, find out more about the subject. Read as much as you can. But bear in mind that there is a vast quantity of material on the internet that is immensely transphobic; that is misleading, and even outright lies, and that may make you feel desperately scared for the future. I’d suggest reading some blogs by parents who are supporting their child in their gender identity, to understand that the worst-case scenario that you are fearing for your child really isn’t as bleak as you may be fearing. Our child has gone from a deeply sad to one of the happiest children you could meet since we told her we accepted her as a girl.

Thirdly, get some support for yourself as a parent.

What support is out there in the UK for parents of transgender children, and where have you personally found most support?

For us, the best source of support by a mile is other parents of transgender children. Find a way to reach out to other parents, for us it was through the charity Mermaids. Channels such as Mermaids provide a secure forum for parents to speak directly to each other, to provide a non-judgemental ear, to share experience, to be a shoulder to cry on. Many parents describe coming to terms with a child being transgender as a form of grief. Parents are often completely ignorant of the issue, and often have bleak views on the prospects for their child having a positive future.

In time, in person or virtually, parents come across remarkable trans young people and adults, and learn that with acceptance and support the outcome for trans children today is bright and hopeful. But that doesn’t immediately negate the very strong emotions that parents go through, particularly when they are doubting how to proceed, and particularly when they are facing judgement, criticism and hate from a wider society – including their own friends and family – who may not be willing to understand. Finding a support network, particularly if your own friends and family are not supporting you, is extremely important.

For transgender children approaching puberty, being registered in the UK Gender Identity Service for children at the Tavistock can be critical in case medical intervention (hormone blockers) is required. Waiting lists are extremely long: nine months from GP referral to first appointment and procedures once in the system are prolonged. Don’t wait until things are at a point of desperation to get a referral into the medical system. Better to get a referral a couple of years before puberty and pull out if you don’t later need it than delay referral and enter the waiting list at puberty when a two-year wait might become a major problem. Some GPs are supportive, many GPs are ignorant and unhelpful. Request a referral to Tavistock if you feel your child is transgender, and don’t let an ignorant GP tell you no.

What is the most common misconception about transgender children that you encounter, and what is your response?

There are so many misconceptions about transgender children that we wrote a whole blog on this topic! You can read it here.

The most common ones are:

Myth: Transgender children do not exist.
Reality: Yes, they do.

Myth: This is a modern, Western fad.
Reality: Transgender people have existed in societies throughout the centuries across the world, and there are millions of transgender people across Asia.

Myth: Parents are choosing this for their children to be trendy.
Reality: As a parent who has cried and cried buckets coming to terms with having a transgender child, I can assure you I would never have chosen this – although now I’m finally less ignorant I don’t in any way see it as the terrible path I once feared.

Myth: Kids who are just non-conforming (e.g. a boy who like dolls) are being pushed into being transgender
Reality: My child didn’t care what toys she played with as long as she was acknowledged as a girl. No one is pushing our children. This is just who they are.

Myth: Children are too young to make a life changing decision.
Reality: My child has not made a decision. They have not decided to change gender. They have always known they were a girl, it just took the rest of us a long time to catch up.

Myth: Transgender children can be turned into non-transgender children if you do X, Y, Z
Reality: There is no evidence for that, and a great deal of evidence that reparative therapy causes a great deal of damage.

Myth: Transgender children are likely to grow out of it.
Reality: Perhaps, but there is no clear evidence for this, and statistics quoted on this subject are extremely dodgy – read with care.

Myth: Transgender children/people will have sad and suicidal lives.
Reality: Emotional challenges experienced by transgender people are due to the hate and prejudice they face, not an inherent part of being transgender. Transgender children who are supported and accepted by their families are shown to have the same levels of mental health and well-being as other children.

What advice would you give to parents – not just parents with transgender children, but parents everywhere – around educating their children about gender and acceptance?

The world is a complex and diverse place. The more parents that share this diversity with their children, the more that let children know that it is ok to be different, the better for us all. Teaching love and acceptance will directly benefit your child too – at some point in everyone’s life they feel that they are different or an outsider – and having taught your child that difference is ok will stand your child in good stead whenever they find themselves on the outside.

Which children’s’ books about gender would recommend?

There is definitely a lack of books for younger children about gender. We’ve found many more interesting reads that have the central message that diversity is not only ok, but should be celebrated. We’re still finding our way a bit on books specifically about transgender children and haven’t found many our child identifies with, at least not in their entirety – however well-intentioned, books about boys who like dresses can sometimes perpetuate stereotypes of gender divide.

For young children, we like:
Red, A Crayon’s Story – Michael Hall
Red Rockets and Rainbow Jelly – Nick Sharratt
Vincent the Vixen – Truth and Tails (our daughter has loved this book)

For older children:
Lily and Dunkin – Donna Gephart

is blog has been verified by Rise: R4c1d40dc407da1a0ac3a1e615a7f7e16

About Truth & Tails:

Truth & Tails are a publisher who aim to write stories for young children in a straightforward, sensitive, and easy way. They seek to explain difficult concepts like feminism, racism, gender, and sexuality to children, and believe in the strength of stories to help children grow up with a sense of understanding, empathy, and acceptance of those who are different to them.

Endocrine Society consensus on a ‘durable biological underpinning to gender identity’

November 18, 2017November 18, 2017 / growinguptransgender / 6 Comments

A response to Endocrine Society Clinical Practice Guideline for transgender health

In September 2017 the Endocrine Society published a new clinical practice guide titled: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” Journal of Clinical Endocrinology & Metabolism (JCEM), Nov 2011.

Accompanying the guideline is a position statement: https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

This publication, an update to the previous guidance (2009), was produced by leading endocrinologists specialising in support for transgender adults and adolescents from the US, Belgium, and the Netherlands.

The guidelines are endorsed by the world’s leading centres for evidence based practice: the American Association of Clinical Endocrinologists, the American Society of Andrology, the European Society for Pediatric Endocrinology, the European Society of Endocrinology, the Pediatric Endocrine Society, and the World Professional Association for Transgender Health.

In short, the Endocrine Society represents the global medical consensus on the clinical treatment of transgender adults and adolescents.

Here, we will respond in detail to this guidance in the following three sections:

Section A: A summary of the guidance as it applies to transgender adolescents, including factors underpinning gender identity; diagnosis; prescription; eligibility criteria; consent; age of treatment and risk factors.

Section B: We raise questions which are either unclear within the guidance or were not covered as out of scope.

Section C: Concludes with concerns in seven areas of the guidance and provides suggestions for amendment or further research.

Section A: Summary

i) Gender identity has a “durable biological underpinning”

From the position paper:

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

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder. Such evidence stems from scientific studies suggesting that: 1) attempts to change gender identity in intersex patients to match external genitalia or chromosomes are typically unsuccessful; 2) identical twins (who share the exact same genetic background) are more likely to both experience transgender identity as compared to fraternal (non-identical) twins; 3) among individuals with female chromosomes (XX), rates of male gender identity are higher for those exposed to higher levels of androgens in utero relative to those without such exposure, and male (XY)-chromosome individuals with complete androgen insensitivity syndrome typically have female gender identity 6; and 4) there are associations of certain brain scan or staining patterns with gender identity rather than external genitalia or chromosomes

In summary, although there is much that is still unknown with respect to gender identity and its expression, compelling studies support the concept that biologic factors, in addition to environmental factors, contribute to this fundamental aspect of human development.

Data are strong for a biological underpinning to gender identity”

ii) Treatment is medically necessary

“The Endocrine Society calls on policymakers to consider a biological underpinning to gender identity”

“These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary and should be covered by insurance”

iii) Counselling can support social transition

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

iv) Recommend puberty blockers

“We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development

These recommendations place a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm from early pubertal suppression.”

v) Start puberty before blockers

“We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty.”

“We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists.”

vi) Diagnosis

“For children and adolescents, an MHP [mental health professional] who has training/experience in child and adolescent gender development (as well as child and adolescent psychopathology) should make the diagnosis, because assessing GD/gender incongruence in children and adolescents is often extremely complex.

For adolescents, the diagnostic procedure usually includes a complete psychodiagnostic assessment and an assessment of the decision-making capability of the youth. An evaluation to assess the family’s ability to endure stress, give support, and deal with the complexities of the adolescent’s situation should be part of the diagnostic phase”

Table 2. DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:

A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)
A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

The condition exists with a disorder of sex development.
The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).

Table 3. ICD-10 Criteria for Transsexualism (F64.0) has three criteria:

The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments.
The transsexual identity has been present persistently for at least 2 y.
The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality

vii) Criteria for blockers

Adolescents are eligible for GnRH agonist treatment if:

1. A qualified MHP has confirmed that:

the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),
gender dysphoria worsened with the onset of puberty,
any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,
the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,

2. And the adolescent:

has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,
has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,

3. And a pediatric endocrinologist or other clinician experienced in pubertal assessment

agrees with the indication for GnRH agonist treatment,
has confirmed that puberty has started in the adolescent (Tanner stage $G2/B2),
has confirmed that there are no medical contraindications to GnRH agonist treatment.

viii) Criteria for gender affirming hormone treatment

Adolescents are eligible for subsequent sex hormone treatment if:

1. A qualified MHP has confirmed:

the persistence of gender dysphoria,
any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,
the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,

2. And the adolescent:

has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility),
has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,

3. And a pediatric endocrinologist or other clinician experienced in pubertal induction:

agrees with the indication for sex hormone treatment,
has confirmed that there are no medical contraindications to sex hormone treatment

ix) High satisfaction rates for cross-sex hormone treatment

“Follow-up studies in adults meeting these criteria indicate a high satisfaction rate with treatment. However, the quality of evidence is usually low. A few follow-up studies on adolescents who fulfilled these criteria also indicated good treatment results”

x) Cross-sex hormones by informed consent

“Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age.”

xi) Gradually increasing dose of cross-sex hormones

“In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.”

xii) Hormone treatment is safe

“Medical intervention for transgender individuals (including both hormone therapy and medically indicated surgery) is effective, relatively safe (when appropriately monitored), and has been established as the standard of care.

The data are strong for the relative safety of hormone treatment (when appropriately monitored medically)

Federal and private insurers should cover such interventions”

xiii) Fertility counselling prior to blockers

“We recommend that clinicians inform and counsel all individuals seeking gender-affirming medical treatment regarding options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults.”

xiv) Fertility

“Treating early pubertal youth with GnRH analogs will temporarily impair spermatogenesis and oocyte maturation. Given that an increasing number of transgender youth want to preserve fertility potential, delaying or temporarily discontinuing GnRH analogs to promote gamete maturation is an option. This option is often not preferred, because mature sperm production is associated with later stages of puberty and with the significant development of secondary sex characteristics.”

xv) Insufficient evidence to guide on minimum age for chest surgery

“We suggest that clinicians determine the timing of breast surgery for transgender males based upon the physical and mental health status of the individual. There is insufficient evidence to recommend a specific age requirement.”

xvi) Delay genital surgery until adulthood

“We suggest that clinicians delay gender-affirming genital surgery involving gonadectomy and/or hysterectomy until the patient is at least 18 years old”

xvii) Lack of support may interfere with positive surgery outcomes

“Literature on postoperative regret suggests that besides poor quality of surgery, severe psychiatric comorbidity and lack of support may interfere with positive outcomes”

xviii) Significant areas where further research is needed to optimise care, but this research will take a long time

“The gaps in knowledge to optimize care over a lifetime are profound. Comparative effectiveness research in hormone regimens is needed to determine:

The best endocrine and surgical protocols, as it is not yet known if certain regimens are safer or more effective than others;

Whether there are cardiovascular, malignancy, or other long-term risks from hormone interventions, particularly as the transgender individual ages.

The biological processes underlying gender identity

Strategies for fertility preservation

To successfully establish and enact these protocols requires long-term, large-scale studies across countries that employ the same care protocols.

Increased funding for national research programs is needed to close the gaps in knowledge regarding transgender medical care and should be made a priority” (Endocrine Society, Position Statement, 2017)

Section B: Questions on guidance

We have seven questions on areas in the guidance which are either unclear or were not covered as out of scope.

1 – Pre-pubertal children

“We recommend against puberty blocking and gender-affirming hormone treatment in prepubertal children with GD/gender incongruence.”

This recommendation is described as: “a strong recommendation in the face of low-quality evidence”, as “the task force placed a high value on avoiding harm with gender-affirming hormone therapy in pre-pubertal children with GD/gender incongruence”

Question area 1:

Surely no one is advocating for any medical prescription for pre-pubertal children in which case this statement is moot? Is this perhaps instead referring to prescription at the first onset of puberty? Further clarity is required here.

2 – Role of Mental Health Professional (MHP) in social transition

“We advise that decisions regarding the social transition of prepubertal youths with GD/gender incongruence are made with the assistance of an MHP or another experienced professional.”

Question area 2:

Can greater clarity be provided on which “other experienced professional” is suitable to “assist in decision making”? Is a MHP required, what is their role, and why are they necessary for making decisions on social transition? How would a MHP be defined?

We also note there is no evidence provided for such a requirement. Anecdotally many young children socially transition without any support to the child from a mental health professional (though we do see the value of support to the parent and wider family from a MHP or other professional to cope with conflicting emotions and stress of a ‘family in transition’. On this issue, we note the needs of parents, carers and family members are absent from this document).

3 – Monitoring onset of puberty

“Clinicians can use pubertal LH and sex steroid levels to confirm that puberty has progressed sufficiently before starting pubertal suppression. Ultrasensitive sex steroid and gonadotropin assays will help clinicians document early pubertal changes.”

Question area 3:

How frequently should LH and sex steroid levels be monitored? In which countries / locations is this carried out as standard? When does monitoring start? Can clarity be given on the correspondence between LH/sex steroid levels and tanner stage? At what level of LH/sex steroid do adolescents become eligible for GnRH agonists?

4 – Side effects of blockers

“Individuals may also experience hot flashes, fatigue, and mood alterations as a consequence of pubertal suppression. There is no consensus on treatment of these side effects in this context.

Acne, headache, hot flashes, and fatigue were other frequent side effects.”

Question area 4:

In countries without age based restrictions on cross sex hormone prescription, are blocker related side effects taken into consideration when making decisions on whether and when to proceed to cross sex hormones?

5 – Mental health professional (MHPs) to diagnose prior to gender affirming hormone treatment

“MHPs should diagnose GD/gender incongruence prior to gender affirming hormone treatment “to make a distinction between GD/ gender incongruence and conditions that have similar features. Examples of conditions with similar features are body dysmorphic disorder, body identity integrity disorder (a condition in which individuals have a sense that their anatomical configuration as an able-bodied person is somehow wrong or inappropriate) (66), or certain forms of eunuchism (in which a person is preoccupied with or engages in castration and/or penectomy for reasons that are not gender identity related)”

Question area 5:

It seems that the primary reason for a mental health professional led diagnosis is to distinguish GD/GI from these other conditions. What data is available on the numbers of children presenting for gender affirming hormone treatment who are instead diagnosed with one of these three other conditions?

6 – Blockers always required before cross sex hormone treatment

The criteria for sex hormone treatment refers to “subsequent cross sex hormone treatment”. The implication of this statement is that adolescents will proceed to sex hormone treatment only after having received GnRH agonist treatment.

Question area 6:

How are adolescents already at late stage of puberty treated upon referral? Is prescription of blockers on their own required before prescription of cross sex hormones even for youth already in late puberty?

7 – Medical Risks associated with sex hormone therapy

Table 10. Medical Risks Associated With Sex Hormone Therapy

Transgender female: estrogen

Very high risk of adverse outcomes:

Thromboembolic disease

Moderate risk of adverse outcomes:

Macroprolactinoma
Breast cancer
Coronary artery disease
Cerebrovascular disease
Cholelithiasis
Hypertriglyceridemia

Transgender male: testosterone

Very high risk of adverse outcomes:

Erythrocytosis (hematocrit . 50%)

Moderate risk of adverse outcomes:

Severe liver dysfunction (transaminases . threefold upper limit of normal)
Coronary artery disease
Cerebrovascular disease
Hypertension
Breast or uterine cancer

Question area 7:

To a lay reader, table 10 is not informative. It would be useful to know both the actual risk and two comparisons Eg when considering the risk of coronary artery disease for a transgender female it would be useful to understand i) what the level of risk is for a trans female on estrogen (eg 1/10,000) and how this compares both to ii) a trans female not on estrogen (eg 1/9,000) and iii) a cis female (eg 1/9,000). (The numbers in this example are fictitious). Is risk information in this format available?

Section C: Concerns with guidance

There are seven areas of the guidance that we find to be problematic as described below.

1. Reference to gender non-conforming children

The section on areas for further research mentions the need for further research on “The optimal approaches to gender non-conforming children”.

Concern 1:

The vast majority of gender non-conforming children have no need of input from an endocrinologist, so the inclusion of this statement is strange. Why not focus future research on optimal approaches for transgender children?

2. Harm of second social transition

If children have completely socially transitioned, they may have great difficulty in returning to the original gender role upon entering puberty (Source: Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011;16(4):499–516.

Concern 2:

The single source of evidence for this claim is unsound. Steemsa et al (2011) is a small sample, self-selecting, qualitative research study, based substantially on interviews with two children who did not in fact socially transition. This is not an evidence based statement. See: A plea for better transgender research on the perpetual myth of desistance and the harm of social transition.

A more measured assessment of the evidence base, which does not over-reach in its conclusions, is found in the new Australian guidelines, “The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

For further discussion See: Australian Gold standard for care of trans and gender diverse children.

This statement is not supported by robust evidence.

3. Social transition impacting persistence

“However, social transition (in addition to GD/gender incongruence) has been found to contribute to the likelihood of persistence.”

Concern 3:

Where is the evidence for this finding? What is the counter factual? Evidence that socially transitioned children are more likely to be transgender than children who do not socially transition, is not evidence that social transition makes children transgender who would not otherwise have persisted. It is very possible (probable in my opinion and experience) that only the most persistent, insistent, consistent children socially transition, so these children are unlikely to be the same children as those who do not socially transition. This statement is not supported by robust evidence.

4. Inclusion of debunked desistence statistics

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

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

Concern 4:

Much has been written on these flawed desistance statistics. See: A plea for better transgender research on the perpetual myth of desistance and the harm of social transition.

Within the guidelines the discussion of desistence is inconsistent. In one section the unreliability of the desistance rates evidence base is acknowledged, but in another section the 85% desistance figure is confidently stated without any qualification. Desistence rates have a extremely significant impact on public, media, community, practitioner and parental approaches to a transgender child. Desistance rates have a direct impact on policy (these flawed desistance rates are currently quoted in the consultation documents on whether to allow under 16s rights under the reformed Scottish Gender Recognition Act). Stating as fact desistance rates that are not based on robust evidence is unethical, and if, as many believe, these rates are incorrect, is harmful.

5. Can only assess persistence (and prescribe blockers) after an adolescent has experienced the first stage of natal puberty

“At the present time, clinical experience suggests that persistence of GD/gender incongruence can only be reliably assessed after the first signs of puberty.”

“Adolescents with GD/gender incongruence should experience the first changes of their endogenous spontaneous puberty, because their emotional reaction to these first physical changes has diagnostic value in establishing the persistence of GD/gender incongruence (85).” (Listed source: Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol. 2006;155:S131–S137.”

Criteria for prescription of blockers includes “gender dysphoria worsened with the onset of puberty”.

Concern 5:

The claim that persistence can only be assessed after a youth has experienced the first stages of puberty has one listed reference in the Endocrine guidance – de Waal and Cohen Kettenis 2006. However, de Waal’s paper does not contain this claim, nor any evidence for this claim. Instead, de Waal and Cohen Kettenis 2006 states that the suppression of puberty using GnRHa is a “very helpful diagnostic aid”, in that it allows time for open exploration. Notably there is no discussion in this paper of the diagnostic value of waiting for the first physical changes of puberty.

The endocrine guidelines contains no reference to any evidence that the early stage of puberty is diagnostic. Why therefore is this unsubstantiated recommendation included?

(We are aware of one deeply flawed and unreliable Steensma publication that over states conclusions on puberty and persistence, which will be the focus of our next research blog – this Steensma paper is not included in the references for the Endocrine guidance)

The belief that GD/GI can only be reliably assessed after a youth has experienced (and been distressed by) the first stage of puberty results in a requirement for transgender children to have to endure the first stage of puberty (and distress at these physical changes) before being deemed eligible for blockers.

It is presumably considered appropriate to cause harm to persistent transgender adolescents (forced to experience the distress of undergoing the early stages of natal puberty before eligibility for blockers) in order to benefit those youth for whom early puberty results in reduced dysphoria and a cisgender outcome (without need for blockers). We’ll put aside for now the clear prioritisation of the well-being of cisgender youth over the well-being of transgender youth.

For this approach to be at all valid, and for the harm to persistent transgender adolescents to be justified, it must be underpinned by robust evidence that significant numbers of children who are indistinguishable from them pre-puberty, desist during the very early stages (tanner 1-2) of puberty. Where is this evidence? This evidence is not provided in the Endocrine Guidance.

We would argue that there is a significant difference between an approach that says “for transgender children we will suppress puberty as soon as it begins if a child with a consistent, persistent transgender identity expresses distress at the idea of natal puberty”, and an approach that says “all transgender children will be required to go through at least some of their natal puberty, and only once clinicians notice their increased distress at actual physical changes will we consider them eligible for puberty blockers”. The latter approach surely can only be justified if there is robust evidence for this – otherwise a) it perpetuates the idea that children cannot be considered trans until after puberty b) it imposes stress on children and families as they receive no reassurance that blockers will be offered and c) it imposes distress on trans adolescents who are forced to undergo the early physical changes for no purpose.

6. Cross sex hormones prior to age 16

“We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/ gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years.”

Concern 6:

The phrasing above is curious. It mentions “compelling reasons”, but there is no elaboration or discussion on what those reasons may be. In the same sentence it is stated that published data is minimal prior to 13.5 years. But what about for ages 13.5-15.5? We note that in the referenced study (de Vries et al, 2014) the cohort were given cross sex hormones at mean age 16.7, with the youngest age 13.9 years. This study contained no evidence of harm in the younger catchment (though data numbers are small). The references provided do not provide any evidence for negative impacts of cross sex hormone prior to 16 years old, and do provide evidence of the negatives of waiting so long:

“Currently available data from transgender adolescents support treatment with sex hormones starting at age 16 years. However, some patients may incur potential risks by waiting until age 16 years. These include the potential risk to bone health if puberty is suppressed for 6 to 7 years before initiating sex hormones (e.g., if someone reached Tanner stage 2 at age 9-10 years old). Additionally, there may be concerns about inappropriate height and potential harm to mental health (emotional and social isolation) if initiation of secondary sex characteristics must wait until the person has reached 16 years of age. However, only minimal data supporting earlier use of gender-affirming hormones in transgender adolescents currently exist (63). Clearly, long-term studies are needed to determine the optimal age of sex hormone treatment in GD/gender-incongruent adolescents.”

In the absence of evidence for delaying until age 16, we would advise this statement could be more clearly be written as “there is a paucity of studies on prescribing hormones before 16 years old – the few studies available provide no evidence of harm”. We agree more long term study is needed to establish an optimal age for hormone treatment, and appeal to those working in this field to publish existing data.

We also note the lack of any detailed consideration given here to the benefits of peer-concordance, that is, having the same puberty, at the same time, as the adolescent’s peer group in order to reduce both physical dysphoria and wider social stigma.

Conclusion and recommendations:

We welcome this much needed update to the ‘Endocrine clinical guidelines for the treatment of transgender adolescents and adults’.

The finding that there is a “durable biological underpinning to gender identity” represents an important shift from a historical stigmatising psychiatric approach, towards the current affirmative model which acknowledges of a biological basis for gender identity, and respects and affirms an individual’s identity.

In section B we have outlined 7 questions, areas where detail is lacking and guidance unclear. In section C we have outlined 6 areas of concern, where the important recommendations are not grounded in robust evidence. We would welcome any clarifications or responses the authors could provide.

Nonetheless, and in spite of some important concerns, the guidelines are a hugely positive shift from the 2009 document, and represent a step forward in transgender health care.

References:

De Vries, Annelou LC, et al. “Young adult psychological outcome after puberty suppression and gender reassignment.” Pediatrics134.4 (2014): 696-704. http://dx.doi.org/10.1542/peds.2013-2958

Endocrine Society, Position Statement; 2017. https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

Growing up Transgender, Australian gold standard of care for trans children; 2017. https://growinguptransgender.wordpress.com/2017/10/01/australian-gold-standard-of-care-for-trans-children/

Steensma, Thomas D., et al. “Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study.” Clinical child psychology and psychiatry 16.4 (2011): 499-516. http://journals.sagepub.com/doi/abs/10.1177/1359104510378303

Vitale, A. “Rethinking the gender identity disorder terminology in the Diagnostic and Statistical Manual of mental disorders IV.” HBIGDA Conference, Bologna, Italy, 2005.

Citation: Growing up Transgender (2017, November 18). Expert consensus of a ‘durable biological underpinning to gender identity’: A response to Endocrine Society Clinical Practice Guideline for transgender health; Growing up Transgender. Retrieved from growinguptransgender.wordpress.com