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:

Episode 9. TRANSGENDER RIGHTS ARE HUMAN RIGHTS

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.

References

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 8^th 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.

Analysis

“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.

Voice

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.

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!

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.

WPATH Board

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- info@IntersexUK.org | Twitter- @IntersexUK | Facebook- IntersexUK

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:

AGREE

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 https://growinguptransgender.com/2018/01/18/scottish-gender-recognition-for-under-16s/

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