Trans Rights are Human Rights – Interview with Ed Miliband

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

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

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

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

Take a listen here:


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


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

This week a new article came out:

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

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


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

The Unacceptable Transphobic Worst

The reference list includes three separate citations of the same non-peer reviewed paid-to-publish book, H. Brunskell-Evans & M. Moore (Eds.), Transgender children and young people: Born in your own body’. The first of these, a chapter ‘The transgender experiment on children’ by Stephanie Davies-Arai, the “founder” of Transgender Trend. An anti trans lobby group formed by a Davies-Ara, a sculptor with no real life or clinical experience of transgender children has been extensively criticized for its lack of rigour and transphobic bias. As Rachel Pain revealed, “of 57 sources cited in Stephanie Davies-Arai’s chapter, only seven are peer-reviewed research and these are cherry-picked and distort the wider medical and sociological evidence”.

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

The known to be flawed research cited without critique

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

In 2018, since writing the critique, three peer reviewed academic journal articles (by Elhrensaft, Pyne and Temple Newhook and others) have been published, analysing and exposing the failings in Steensma’s work on desistance. A response article by Steensma himself in 2018  outlined that he felt his own work had been misinterpreted and misapplied by others (“We have clearly described the characteristics of the included children (clinically referred and fulfilling childhood DSM criteria) and did not draw conclusions beyond this group, as has wrongly been done by others”).

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

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

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

“My work has been misrepresented”.

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

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

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

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

The citation of GIDS colleagues

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

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

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


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

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

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

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


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

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

The irrelevant:

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

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

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

Gender affirmative body of literature

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

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

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

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

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

Summary of references 

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

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

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

That was just the bibliography. Now to the paper.

First sentence:

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

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

Second sentence:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Educating parents

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

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

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

Back to the new GIDS paper

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

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

The Study Aim

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

The Sample

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

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

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

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

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

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

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

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

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

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

Other facts

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

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

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

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

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

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

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

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

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

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

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

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

Case Vignettes

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

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

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

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

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

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


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

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


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

Back to the paper

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

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

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

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

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

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

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

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

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

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

Conclusion as per the authors

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

Conclusion as per the evidence in the paper

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

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

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

First Day – Trans children on TV


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Final thoughts:

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

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

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

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


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

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

Red, A Crayon Story

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

Are you a boy or a girl?

Vincent the Vixen


Lily and Dunkin


Biological Sex is a social construct


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

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

They are wrong.

To unpick this we need to tackle several different issues.

Biological Sex

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

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

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

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

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

Social construct

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

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

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

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

Biology is complex

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There is a biological underpinning to gender identity

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

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

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

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

Endocrine Society

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

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

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

Trumpian Approach to Science, Trumpian Approach to Minorities

Sex traits are extremely complex. Not binary.

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

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

That is not how science works.

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

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

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

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

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

Are we saying that biology doesn’t matter?

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

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

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

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

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

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

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

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

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

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

Bigotry not biology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Zinnia Jones has written:

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

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

Science calls bullshit on your outdated bigotry.

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

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

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

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

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

Specialists agree

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

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

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

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


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

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

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

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

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

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

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

#ProtectTransKids #ScienceIsComplex #BiologicalSexIsNotBinary

#TransgenderPeopleAreBiologicalToo #BiologicalNotMythological #MinorityRights

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

Email- | Twitter-  | Facebook- IntersexUK

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


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

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

The Commissioner provided important context to the consultation

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

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

The Commissioner then outlined relevant international legislation:

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

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

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

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

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

The Scottish Consultation

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

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

The Commissioner’s answer was:


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

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

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

The Commissioner’s answer:

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

Other relevant questions:

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

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

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

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

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

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

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

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

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

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


Dr Jo Olson-Kennedy on puberty, blockers and hormones

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

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

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

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

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

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

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

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

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

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

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

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

What happens when puberty starts?

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

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

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

How do blockers work?

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

How do we know they are reversible?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In assigned males peak growth velocity occurs in tanner 3.

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

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

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

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

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

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

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

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

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

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



UK GIDS Failing Publicly

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

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

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


The article is intended for “professionals” who:

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

Referencing fringe figures

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

Conflating behaviour with identity

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

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

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

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

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

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

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

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

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

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

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

Focus on rise in ‘birth registered females’ 

GIDS continue:

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

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

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

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

Inclusion of unsubstantiated speculation

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

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

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

And more:

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

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

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

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

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

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

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

Criteria for the diagnosis of Gender Dysphoria

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

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

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

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

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

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

  • A strong preference for playmates of the other gender.

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

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

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

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

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

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

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

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

Cisnormative and outdated terminology

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Appropriate assessments prior to referral

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

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

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

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

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


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

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

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


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

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

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

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

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

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

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

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

Rates of referral to pediatric endocrine clinic

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

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

Polly was asked by the presenter Victoria Derbyshire:

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

Polly answered:

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

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

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

This is a gross abuse of their power.

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

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

What does their data actually show?

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

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

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

figure 2 Butler paper

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

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

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

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

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

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

6 year olds in this data set

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

9 year olds in this data set

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

12 year olds in this data set

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

15 year olds in this data set

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

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

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

Wait just one moment here!

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

When asked by the presenter Victoria Derbyshire

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

Polly responded:

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

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

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

Year  Number of 5 year olds referred

 Age in 2017

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

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

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

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

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

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

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

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

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

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

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

Misleading manipulation of data 

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

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

‘Desistance’ during early puberty

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

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

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

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


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

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

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

Pubertal status

On the timing of puberty blockers, GIDS states:

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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


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

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


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

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

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

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

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

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

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

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

None of these factors are acknowledged in the article.

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

Pathologising language continues

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

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

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

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

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

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

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

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

Fertility preservation

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

They have not provided a single reference for this claim.

This is unprofessional, unethical and OUTRAGEOUS.

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

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

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

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

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

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

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

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

Psychological benefits of GnRHa treatment

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

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

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

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

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

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

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

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

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

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

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

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

Here’s what the Endocrine Society actually says:

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

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

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

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

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

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

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

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

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

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

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

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

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

Gender affirming hormones and height

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

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

Over 90% go to adult services

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


Surgery for adults

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

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

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

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

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

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

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

Long-term outcomes

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

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


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

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

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

References – hold on, this is interesting

The references are perhaps the worst part.

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

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

Most references are from their colleagues in the Netherlands.

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

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

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

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

What references are not included

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

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

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

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

Peer review

The article was “Commissioned; internally peer reviewed”.

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

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

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

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

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

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

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

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

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

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

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

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

GIDS is a failing service stuck in defensive practice.

Our children deserve so much better.

Why does a biological underpinning to gender identity matter?


Biological essentialism vs social constructivism

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

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

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

Gender identity and the neurology of ‘trans brains’

Where then does gender identity fit in?

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

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

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

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

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

Rejection of biology

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

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

Pathologisation of diversity

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

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

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

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

Does it even matter why trans adults are trans?

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

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

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

Impact of denial on families

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

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

This particular recommendation makes me want to cry.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Who cares whether or not biology has any role?

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

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

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

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

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

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

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

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

Another way

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

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

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

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

Learning to reset my assumptions

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

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

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

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

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

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

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

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

Is there an alternative paradigm?

Holistic views of gender

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

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

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

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

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

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

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

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

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

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

Biological underpinning to gender identity

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

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

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

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

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

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

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

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

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

Do we have to reject biology?

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

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

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

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

Acknowledging biology without essentialism

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

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

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

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

We should embrace science

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

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

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

Trans children exist.

They know it.

Parents know it.

Science knows (a bit about) it.

Stand up for trans children



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



Anti-trans bigots dominate the conversation on trans youth (again)



The consolidated response from the NHS consultation on adult gender services has just been released. While there is some interesting data, the validity of the public survey method of consultation has been eroded due to the number of responses from organised transphobic lobbying groups. The impact of these responses is particularly pronounced on any questions which touch upon services for trans adolescents.

A great number of the responses from ‘individual members of the general public’ and from those who claimed to be ‘friends and family’, advocated transphobic positions, even arguing in favour of conversion therapy.

The volume of responses from those seemingly without personal knowledge or lived experience, is not surprising to anyone who has observed this lobbying tactic from prior public NHS and Government surveys. During the consultation, transphobic groups wrote and widely disseminated set template responses – alongside guidelines for how to complete. In doing so, they sought to swamp the consultation with their ill informed bigotry.

As usual, these highly organised hate groups prioritised spreading of misinformation about and denial of rights to trans children. This was a consultation on adult services, however the anti trans rights template responses focused their aim on the health care options for older teenagers, aged 17 and above.

Below are the key references to teenagers and youth in the consultation.

While in other areas of the consultation the balance is more pronounced between informed clinicians and the service users themselves, a lack of those voices speaking up for trans adolescents has led to the responses of transphobes being centred and highlighted in the report.

Note how the voices of trans seventeen and eighteen year olds are missing or invisible, note how the voices of trans adults (and allies) do not explicit defend the rights of trans youth, note how the voices of supportive parents of trans teens are missing and note how the dialogue on trans teens continues to be dominated by anti-evidence transphobes.

“2.3.4 Assessment process

Service users felt that the requirement to undergo two core diagnostic assessments before treatment commences is excessive

Other respondents emphasised that the mental health of service users should be assessed in greater detail at the initial assessment. This was particularly emphasised in relation to the assessment of young people

Specialised, specific psychological interventions

Some respondents welcomed the service specification’s explicit rejection of conversion therapy. Others, feared that it would leave counsellors and therapists in a position where they can only ‘affirm’ a young person gender identity without exploring potential psychological causes

Loss of fertility

A few individual members of the public believed that under 18-year olds should not be allowed in law to undergo surgery that could result in infertility since under 18-year olds cannot fully appreciate the life-long implications of such a permanent procedure

Gender dysphoria and mental health

Some respondents from these groups disagreed with the NHS’s stance that gender dysphoria is not a mental health condition. Instead, they regarded gender dysphoria to be a mental health problem of a similar kind to body dysmorphic disorder (BDD).

Many respondents from these groups voiced their concern that the current treatment pathway priorities medical over psycho-social interventions. They believed that therapy and counselling should be mandatory before medical interventions are performed. This was seen to be particularly pertinent for young people who are still undergoing a period of identity formation. The concerns arising during this process of identity information, including those related to the gender, sexuality and body image, should be investigated in talking therapies as opposed to medical interventions.

Young people aged 17 years and above will be referred to an adult Gender Identity Clinic

83% of service users supported the proposal, 71% of clinicians, who are mostly GPs, supported the proposal

14% of individual members of the public supported the proposal, 30% of family and friends of service users supported the proposal

Respondents felt that 17 years is too young to make a decision regarding hormonal replacement therapy or surgery. This was particularly a concern given that many interventions were considered irreversible. Reasons for this were:

– That the brain of a young person is still developing at 17 years old and they are therefore more prone to risk-taking behaviour and imperfect decision making

– That young people are also still developing their personality and through this young people may explore aspects of their gender identity. Respondents were worried that during this period young people hold onto readily available “labels” and groups to satisfy their need of belonging, and they considered the “trans” community to be one such group. Often, however, expressing their (gender) identity in a certain way may just be a “phase” for young people that passes with time.

– That 17 year olds may be too young to make decisions about interventions offered to adults. Respondents were particularly worried that this proposal was seen to “fast track teenagers into the adult clinic where they will be treated like adults”. (Individual Member Of The Public).

Respondents said that the diagnostic assessments at Gender Identity Clinics were insufficient for young people given the specific challenges young people face. Respondents felt that more intensive psychological assessment and ongoing support were required.

Respondents also stated that there was a lack of evidence around hormone replacement therapy and surgery. This concern was primarily expressed by individual members of the public. For example, the affects that puberty blockers can have on a young person’s physical and socio-emotional development. Respondents also suggested that a number of young people want to reverse the transition they have undergone

Social pressures

Many individual members of the public suggested that wider societal factors and trends should be considered when assessing those presenting with gender dysphoria. They suggested that young people, and young women in particular, are subject to “social pressures” which may lead them to identify as trans:

  • It was felt that young people may be at risk of “social contagion” and “indoctrination” by trans lobby and peer groups online. It was suggested that young people may identify as trans as it gives them entry into a social network where they feel accepted. Respondents worried that any long-term decisions made as a result of trying to “fit in” as a teenager may lead to future regret.
  • Respondents identified a set of social “social pressures” faced by young women in particular. They felt that some teenage girls may be transitioning to “escape” the role of a woman in the context of “misogyny” and “sexism” in society. They suggested that the latter may lead to body dysmorphia in women, which can then be falsely understood as gender dysphoria. The perceived increase in the number of teenage girls attending young people’s gender identity services was seen as evidence that this was a societal phenomenon.

Respondents from these groups wanted more research on what “causes” gender dysphoria. They perceived this to be necessary in the light of the “social pressures” on young people and women outlined above”

Adults and Allies – Please Stand Up For Trans Children and Youth

Transphobic haters incessantly attack the rights of trans children and trans youth. They spread misinformation and fear so successfully that concern about potential abuse of children is their number one asset in their fight against trans equality. Note how Sarah Ditum focused on spreading misinformation and fear mongering about trans children in the recent Channel 4 ‘Gender Quake’ debate.

Anyone who wants to see a social shift in acceptance for trans people needs to speak up and stop letting transphobic hate groups dominate the conversation around trans children and trans youth. The fact that hate groups inundated this adult services consultation with fearmongering and misinformation about trans youth should be a surprise to no-one.

Trans children and trans youth need effective, proven, evidence-based affirmative care. They need protecting from harmful, abusive, conversion therapy, or from rigid age-based denial of medical expert endorsed affirmative care.

Transphobes see how weak trans children and youth are. They see how few allies are willing to speak up for trans children and young people.

Trans allies and advocates need to Stand Up for Trans Children and Young People.

Trans Children Exist.

#SomeKidsAreTrans #StandUpForTransKids #LetThemSoar