Gender

WPATH 2024: Part Two

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On the 3rd full day of WPATH 2024, there was one session that I wanted to write up in slightly more detail, as it is very relevant to those working with or supporting trans children and young people. (My original WPATH 2024 blog is available here). The session was titled “New long-term research on adolescent gender-affirming medical care”, with 5 presenters, three from the US, and two from the Netherlands.

I wanted to share my notes on these presentations here. First a big caveat – my notes and interpretation may not be 100% correct, I have not confirmed this post with the presenters of these studies, and these studies have not yet been finalised, peer reviewed or published. Therefore, the data in this study may change before acceptance into the formal literature. At WPATH, within the trans room, there was a discussion on the challenges of knowledge that is of vital importance to trans communities and families of trans kids being paywalled behind expensive and hard to attend conferences. Recognising the very slow timelines of academic publishing, there was a discussion on a duty to share early preliminary results not only with the clinicians and researchers who are able to attend WPATH, but also with the very interested and directly affected trans and family of trans kids communities, currently trying to defend our healthcare from attack, for whom new research is most important. In the trans room at WPATH we talked about our responsibility and duty of care as trans researchers with half a foot in clinical spaces to share information with those who cannot access. As part of this commitment I’m writing this blog.  

First Dr Diane Chen (she/her) presented on trajectories for mental health in the four years following gender affirming hormone initiation. She highlighted the six existing studies that examine psycho-social outcomes in US-based trans youth receiving oestrogen or testosterone (Allen; Achille; Kuper; Tordoff; Chelliah; Chen). These studies have generally found that aspects of mental health improve following initiation of gender affirming hormones. These studies have limitations including that they only follow youth for average of one year after treatment initiation, that they only focus on (internalising) areas like anxiety or depression, and the one article (by the presenter Chen et al) that looked at individual trajectories found significant individual variation around the average change in outcomes. For that study the presenter showed graphs showing, on average, a steep improvement in appearance congruence, a shallow reduction in depression and anxiety, and a shallow improvement in positive-affect and life satisfaction over 2 years. The individual dots show significant variability, suggesting a focus on the average experience may hide difference trajectories between sub-groups. The new study being presented here aims to look at potential distinct trajectories between sub-groups.

The new study (by Chen et al, not yet published), looked at data for 217 youth, average age 16 (range 11-20), 60% trans-masc, 34% trans-femme, 4% non-binary, 80% socially transitioned at baseline, 7.6% received gender affirming care in early puberty (defined as puberty blockers at tanner 2 or 3 or HRT at tanner 3). The study looked at internalising data on (anxiety/depression), at externalising (aggression, risk taking), experiences of gender minority stress, and parental acceptance. Data were collected at baseline, year 1, year 2, year 3 and year 4 [They applied latent growth curve modelling / growth mixture modelling for statistical analysis]. They presented graphs distinguishing three sub-groups that follow distinct pathways across the 4 years. 25% of trans youth in their study were identified as a ‘consistently low’ group who had low levels of anxiety/depression/risk-taking behaviours at baseline who continued to have low levels of anxiety/depression/risk-taking behaviours. 56% were classified as having ‘declining’ levels of anxiety/depression and consistently low levels of risk-taking behaviours, with levels of anxiety and depression slightly above a clinical diagnosis at baseline, later declining to slightly below clinical thresholds. 18% were categorised as elevated, having persistently high levels of anxiety/depression/risk-taking behaviours at baseline and later in study.

From further data analysis they discovered:

95% of youth who accessed early affirmative care were in the categories of consistently low (53%) and ‘declining’ levels of mental health problems, with only 5% of these youth in the category of having persistently high levels of anxiety/depression/risk-taking behaviours.

[Talking about ‘low’ and ‘declining’ as positive descriptors in a study on mental health at times feels a little counter intuitive, given we think of high mental health, or improving mental health as a good thing, whereas here we want to see low and declining mental health problems).

The youth who had consistently good mental health, or improving mental health had the following characteristics in common:

Less loneliness

Less gender minority stress

Higher parental acceptance

Higher emotional support

The study highlights that provision of HRT is not a magic cure to the mental health challenges of trans youth who are isolated, unsupported and facing anti-trans hostility and gender minority stress inside and outside of their homes.

Among youth with high levels of anxiety/depression/risk-taking behaviours at baseline, those with higher levels of baseline parental support were more likely to see improvements in their mental health.

Protection from gender minority stress, reduced isolation, emotional and social support, and parental support are all protective factors for trans youth mental health.

18% of the sample continued to have high levels of anxiety/depression/risk-taking behaviours throughout the study and this portion of trans youth would benefit from more targeted mental health support as well as support to reduce gender minority stress and isolation.

Next Dr Laura Kuper (they/them) presented preliminary findings of 5 – 8 year outcomes of the trans youth longitudinal survey. The study began in 2014 including annual youth and parent report surveys. It looked at quality of life, anxiety, depression, body dissatisfaction. Recently added new measures of gender dysphoria, socio-political stress and decision regret scale.

Wider study now includes 738 youth. At baseline ages 6-18 (mean 15), 64% assigned female at birth, 34% assigned male at birth. A few youth are now in year 9 of the study, most are currently in years 2-7 of the study (new enrolments to the study are being added each year).

Presented data on 267 youth and 317 parents who completed survey on access to treatment. The study looked at those who had started and at some point stopped treatment with oestrogen or testosterone. [For this presentation exact numbers were not provided and the graphs were hard to read precisely so there is a likely margin of error in the percentages I’ve given below – you’ll need to wait for publication of the proper research for the accurate numbers]

10% of those who had ever started oestrogen had at some point stopped oestrogen. The reasons for stopping oestrogen were examined. 1 was because was satisfied with the changes and didn’t need further oestrogen; 2 experienced unwanted changes; 2 had a change in their experience or understanding of gender; 2 stopped due to difficulties accessing oestrogen; 1 for other reasons. Just under half who ever stopped taking oestrogen ended up re-starting taking oestrogen. Youth and parents were asked the question re starting taking oestrogen “It was the right decision”. Around 70% of youth strongly agreed, 5% agreed, 2% neither agreed nor disagreed, 2% strongly disagreed. 60% of parents strongly agreed, 20% agreed, 2% neither agreed nor disagreed, 2% strongly disagreed. Youth and parents were asked the question re starting taking oestrogen “I regret the choice that was made”, and “the choice did me/my child a lot of harm” with the same findings (vast majority strongly disagreed, with only around 2% strongly agreeing).

32% of those who had ever started testosterone had at some point stopped testosterone, significantly higher than the portion who ever stopped oestrogen. The reasons for stopping testosterone were examined. 16 were because were satisfied with the changes and didn’t need further testosterone; 8 experienced unwanted changes; 8 had a change in their experience or understanding of gender; 2 had legal barriers to access; 23 (the largest portion) stopped due to difficulties accessing testosterone; 19 for other reasons. Just under half who ever stopped taking testosterone ended up re-starting taking testosterone, with several going through multiple points of stopping and re-starting. Youth and parents were asked the question re starting taking testosterone “It was the right decision”. Around 154 of youth strongly agreed, 8 agreed, 2 neither agreed nor disagreed, 1 (hard to read graph) disagreed, 1 (hard to read graph) strongly disagreed. 145 parents strongly agreed, 32 agreed, 7 neither agreed nor disagreed, 2 disagreed, 3 or 4 (hard to read graph) strongly disagreed. Youth and parents were asked the question re starting taking testosterone “I regret the choice that was made”, and “the choice did me/my child a lot of harm” with the same findings (vast majority strongly disagreed, with only around 1% strongly agreeing).

Dr Kuper then moved on to present findings on a 5 year longitudinal study of trans youth receiving oestrogen or testosterone. The study currently includes data for 558 youth at baseline, 431 at year one follow up, 275 at year two follow up, 163 at year three, 115 at year 4, 59 at year 5. The declining numbers at later years of follow up is because new youth keep being recruited into the study (not linked to drop out). [They applied linear mixed effect modelling to the dataset for statistical analysis].

Graphs were presented showing a significant and steady decrease in body dissatisfaction over 5 years time for both those on oestrogen and those on testosterone (with the same pattern for both). A graph of depressive symptoms showed a steady decrease in depression scores over the 5 years. The slope and change in depression was similar for both those on oestrogen and those on testosterone, but with those on testosterone having slightly higher depression at baseline and at current measure than those on oestrogen. Both groups were over the point for mild depression and near the level for moderate depression at baseline, and fell to at or just over the point for mild depression at current measure. Graphs showed some improvements in anxiety over time. Quality of life scores improved steadily over time for both groups.

Overall conclusions were:

Strong satisfaction with decision to receive treatment from youth and parents

Large improvements in body dissatisfaction, seen as the primary goal of treatment

Modest improvements in mental health and quality of life, which were also impacted by gender minority stress. They noted that this sample is in Texas where there are very significant socio-political stressors and state persecution, which is likely impacting on mental health measures.

This research also underscores the unsuitability of having mental health improvements as a key justifier for gender affirmative healthcare – especially for those youth who (through social support) have low levels of mental health at the start of puberty. Those youth do not see improvements in mental health, they see their good levels of mental health retained through medical transition. Reviews like the Cass review critiqued affirmative healthcare for not showing puberty blockers not having a significant enough boost to mental health – this is clearly the wrong variable to be tracking.   

Next Dr Kristina Olson presented on trans youth satisfaction with care. She presented existing knowledge on youth satisfaction with care, including the high levels of continuity of care, with the assumption that trans youth would not continue to take active efforts to continue healthcare that they did not want to continue. Also low rates of detransition to live as cis amongst trans youth who commence gender affirming healthcare. We also know there are cases of detransition / dissatisfaction, whilst noting that these two concepts are different and distinct.

This new study aimed to assess levels of satisfaction and regret following puberty blockers and HRT, and to assess continuity of care. Looked at trans youth project, more than 300 socially transitioned binary trans youth recruited between ages of 3 and 12 in years 2013-2017. Mostly US trans youth with some Canadians. Youth followed up every 1-2 years. Study has now been ongoing for 7 – 11 years. Youth have answered questions on average 3.8 times, and parents have answered questions on average 5.8 times. This study presents data from 2023 questionnaires, given to all youth who are currently 12+ and to one parent.

On average the cohort had socially transitioned at 6-7 years old. On average they had started blockers 5 years before the survey, at 11 years old. On average they had begun HRT 3.5 years before the survey, at 13 years old. This cohort, supported in childhood, has had good levels of mental health throughout childhood and into adolescence, with slightly elevated anxiety, matching well-being of cisgender peers.

269 were aged 12+ and had started gender affirming medical care and were eligible for this survey. 220 or 82% completed the survey. For the 18% who did not fill in this specific survey, the research team do have continuity of care medical records. Where data is provided by a youth and their parent, the data tables only show the youth report. Where youth data is not available, the parent reported data is provided.

215 reported on their experience with puberty blockers (160 direct from youth and 55 from parental report). Satisfaction was rated from 1 not at all happy to 7 extremely happy. Satisfaction was rated 6.4 average for youth and 6.7 average from parents. Regret was rated from 1 no regret to 7 strong regret. Regret was 1.5 for youth and 1.3 for parents.

170 reported on their experience with oestrogen or testosteone (119 direct from youth and 51 from parental report). Satisfaction was rated 6.5 average for youth and 6.9 average from parents. Regret was 1.4 for youth and 1.0 for parents.

Very high levels of satisfaction and very low levels of regret

Also asked participants if they would have preferred to receive healthcare treatment at a different time, with options: ‘wish earlier’, ‘correct age’, ‘wish later’, ‘wish never’. 2% of youth wished never to have received puberty blockers, 2% wished to have never received hormones, 1 parent in the sample wished never to have received puberty blockers. 18% of youth (4% parents) wished they had received puberty blockers earlier and 74% youth (86% parents) felt they had received them at the right time (in a sample receiving puberty blockers at average age 11). 34% of youth (19% parents) wished they had received oestrogen or testosterone earlier and 53% youth (75% parents) felt they had received them at the right time (in a sample starting oestrogen or testosterone at average age 13 years old.

From the overall sample, 97% have continued to access gender affirming medical care to this day. 2% have stopped accessing gender affirming medical care.

Overall – very high levels of satisfaction, very low rates of regret,

Only 9 individuals out of 220 sample (4%) experienced regret. 8 (3.6%) experienced regret for blockers, 3 (1%) experienced regret for hormones. From these 9 2 individuals (1%) expressed regret for both blockers and hormones. 4 of the nine stopped all treatment, 1 in the process of stopping treatment, 4 have continued to take blockers or hormones. From the nine expressing regret, about half regret ever starting treatment, about half regret a specific side effect or complication or regret not skipping straight to hormones without time on just blocker.

A majority of youth continue to express high satisfaction with care many years later. This cohort seems to align closely with their cisgender peers on mental health, well-being, and on rates of change of gender identity. Important to note that the access to gender affirming medical care that has accompanied this cohort, is harder to access today for their younger peers, with increasing barriers to trans healthcare across and beyond the USA.

Next Dr Marijn Arnoldussen from the Netherlands. The presentation was titled “gender related and psychological outcomes in adulthood after early gender related medical transition in adolescence”. Studies from the Netherlands tend be of interest, because they were an early supporter of a limited form of gender affirming care, with puberty blockers prescribed to a 13 year old trans boy starting in 1988, and with decades of follow up studies. Studies from the Netherlands also come with some significant baggage, in a highly controlled and potentially pathologizing and psychologically invasive model of care, where folks were expected to conform to a very defined stereotype of trans-ness to receive care. The narrowness of the model of expected transness has relevance to some of their outcomes. Knowing the UK children’s GIDS model sought to replicate the Dutch model, and knowing very closely just how abusive, invasive and harmful the UK approach to trans children has been, makes me approach data from the Dutch clinic with a significant degree of concern, especially where clinicians report data without asking centring the views of their patients, or where clinical control, coercion and pathologisation is apparent.

 The study aim was to describe long term gender outcomes, treatment regret, reflections on gender related medical care, and psychological outcomes for trans adults who received gender affirming medical care, including puberty blockers, during adolescence. The study focused on trans adults who took puberty blockers during adolescence and who started gender affirming hormones over 9 years ago. 145 service users were eligible, of whom 72 participated. This is clearly a pretty high drop out rate. In the UK service, high drop out rates are sometimes an indication of service users not having confidence in clinical research.

From the 72 participants, 51 (71%) were transgender men, 20 (28%) were transgender women. 1 (1%) non-binary. The binary focus of the cohort is perhaps unsurprising if, as was certainly the case in UK children’s clinics, non-binary transitions were not supported or permitted. Interesting that this  cohort who started medical transition in adolescence a decade ago, has significantly more trans men than trans women – when this phenomenon is noted in current youth it is blamed on tiktok which clearly did not exist a decade ago. This cohort started puberty blockers at an average age of 14.85 (range 11.47-17.97) and hormones at an average of 16.67 (range 13.93-18.46) and are followed up at average age 29.1 (range 25-36.29 year old). The oldest in this cohort are 36 years old. Hardly new treatment.  

94.4% had not experienced any change in their gender identity over time from starting blockers at  average age 14 to now being on average 29 years old.

83% (60 people) had not experienced any regret or doubt about their gender affirming medical.

17% (12 people) had experienced some form of doubt or regret – however:

For 2 people (3%) this was occasional thoughts what their life would be like if they hadn’t had medical transition, doubts rather than regrets.

3 people (4%) regretted the chosen surgical technique in genital surgery

4 people (5.6%) regretted either genital surgery or surgery to remove reproductive organs. This figure in particular need to be considered against two important realities – one, stating a desire for ‘full’ transition was in many places considered a key eligibility criteria for any form of medical transition, closing down possibilities for a less binary transition pathway, and two in the Netherlands until very recently surgical transition was deemed necessary for eligibility to change your legal gender and to access various state protections or rights as a trans person. I would assume that where there is pressure to engage in surgical transition, incidents of regret is arguably more likely.

2 people (2.8%) regretted becoming infertile and being unable to preserve sex cells

1 person regretted the hormones and surgery they received.

From the 72 patients followed into average age 29, only one stated a regret of hormones.

The cohort were asked about their ability to make decisions in adolescence. A significant majority, 50 people (69.4%) felt they were capable to make decisions at an even younger age then they were permitted to do under the Dutch model (where they received blockers at average age 14 and hormones at average age 16). 17 people (23.6%) felt they were at the right age for their decisions. 5 people (6.9%) felt they were too young, with these people particularly mentioning the impact on their fertility.

Overall, 98.6% of people were satisfied with their social and medical transition overall. 15% had some doubts or regrets, with this particularly related to aspects of surgical transition. 1 person regretted hormones and surgery. 93% felt, on reflection, they were capable to take decisions on medical transition during adolescence.

Finally in this session there was a presentation from Dr van der Meulen from the Netherlands entitled “sexual dysfunction after early endocrine treatment: long-term study in transgender adults”.

This session had elements of exoticisation and pathologisation of trans people that I found uncomfortable. I’ll share some of the results here. A study on 70 trans adults, comparing those who medically transitioned in early puberty (tanner 2 or 3) with those who medically transitioned in later puberty (tanner 4+). They were average age 29 during this research. For the 50 trans masculine participants, 18% medically transitioned in early puberty, for the 20 trans feminine participants 40% transitioned in early puberty.  

Amongst the groups of adult participants (average age 29), they were asked about experiences of sexual disfunction. For trans men 18% reported a problem with low sexual desire (80% reported no problem with sexual desire), and low sexual desire was reported for 22% of those who transitioned in early puberty compared to 17% for those who transitioned in late puberty. 16% of trans men reported too much sexual desire (64% reported no problem with too much sexual desire) and too much sexual desire was reported for 11% of those who transitioned in early puberty compared to 17% for those who transitioned in late puberty. 4% of trans men reported low sexual arousal (96% reported no problem with sexual arousal) and low sexual arousal was reported for 11% of those who transitioned in early puberty compared to 2% for those who transitioned in late puberty.; 24% reported difficulty orgasm (74% reported no problem orgasm) and difficulty to orgasm was reported for 33% of those who transitioned in early puberty compared to 22% for those who transitioned in late puberty.

For trans women 20% reported a problem with low sexual desire (60% reported no problem with sexual desire), and low sexual desire was reported for 38% of those who transitioned in early puberty compared to 33% for those who transitioned in late puberty. 0% of trans women reported too much sexual desire (100% reported no problem with too much sexual desire). 20% of trans women reported a problem with low sexual arousal (65% reported no problem with sexual arousal) and low sexual arousal was reported for 0% of those who transitioned in early puberty compared to 33% for those who transitioned in late puberty.; 35% reported difficulty orgasm (65% reported no problem orgasm) and difficulty to orgasm was reported for 0% of those who transitioned in early puberty compared to 58% for those who transitioned in late puberty.

Overall sexual disfunction was relatively low amongst these trans adults who medically transitioned in adolescence. There was no significant difference in sexual disfunction between those who medically transition in early puberty compared to those who sexually transition in late puberty. [Research on this topic surely, SURELY needs to better centre the voices and priorities of trans adults, and the multiple factors beyond early or late medical transition that likely impact on experiences – and surely some comparison to cis people’s experiences of sexual disfunction would make such research somewhat less exoticising and othering…]

A few follow up questions were held. One questioner stressed the importance of timeliness of publication of all the above new data – especially in contexts where healthcare is under attack. Another questioner asked about the mental health of neurodivergent populations, asking if datasets could be considered to see where autistic youth fitted on the mental health trajectories, noting the greater mental health challenges and [Is there a term like gender minority stress that applies to the stresses of navigating a neurotypical world?] that are carried by autistic youth that will not be ameliorated by gender affirmative care. There was also some discussion on what outcome indicators are best to track to monitor the impacts of gender affirmative healthcare, with panelists commenting that a narrow focus on mental health is probably not the right indicator.

I didn’t share any of my own research this time at WPATH, but given the WPATH content was very significantly dominated by US and Dutch research, I’ll end by sharing my contributions to the literature on puberty blockers here:

“I Didn’t Want Him to Disappear” Parental Decision-Making on Access to Puberty Blockers for Trans Early Adolescents – available here.

Experiences of puberty and puberty blockers: Insights from trans children, trans adolescents, and their parents – available here.

WPATH 2024

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At the end of 4 days of trans health presentations from researchers, clinicians and community advocates from across (parts of) the world, I wanted to capture some of my key learnings and reflections. The conference took place the last week of September, in Lisbon, Portugal. This is my first WPATH (a conference of the World Professional Association for Transgender Health). A majority of trans communities have no access to WPATH information, yet WPATH learning is important to many trans people and families. I’ve always appreciated those (especially Ruth Pearce) who try to make conference information available to those unable to attend. I note the significant barriers to attendance for those without an employer or institution to fund expensive attendance fees and travel, to those with disabilities or caring responsibilities unable to travel, for those without a visa to come to Europe, to those facing other barriers to attendance.

Overall vibe

The overall vibe was better than I had expected, although my expectations were drawn from hearing really poor experiences at past WPATH conferences. I found overall the tone of trans positivity, depathologisation, treating trans people as equals, centring research and healthcare ethics, was better than I had expected. However, there were still a portion of content and conversations where biases were clearly on display. I particularly noticed these biases in the very frequent exclusion of non-binary existence, on the continued pathologisation, mistreatment and exoticisation of trans children, and on a very significant domination of a US and white perspective, with notably limited representation from global majority populations. I gather only 3 attendees were from Africa (out of 1,445 registered in-person attendees). I also am scratching my head to think if there was even a solitary reference to the experiences of trans children in care in the presentations I attended – I don’t think there was.

The event had a trans chill out room where trans attendees could step away from the main event to decompress and reflect. It was noticeable that few trans attendees spent time there in the first days of the conference, with the fullness of the room growing over time, as trans researchers, clinicians and advocates encountered more challenging content and interactions. On the third day I heard one person reflect that despite WPATH improvements, it is noticeable just how many trans people are sat in the trans space burnt out by negative engagements by day three of four. I myself had a number of negative and hostile encounters, and a number of presentations that I could not sit through, finding some content taxing or upsetting, particularly where content demonstrated abusive clinical or research practices towards trans children. There were a number of other challenges at the conference, with no encouragement of sharing pronouns (apparently pronoun ribbons were lost in shipping), not being able to find gender neutral toilets on the first evening, and apparently some staff policing of toilet usage which was rather surprising in a trans health conference.

There were also a large number of encounters and presentations that were an absolute delight. I met a huge number of people from across different countries and disciplines who deeply care for improving equality and justice for trans people of all ages and situations. I heard some research that shows where we should be in terms of ensuring research and healthcare is centring the rights and needs of trans communities. One clear highlight was an opportunity to connect with TPATH, the trans professional association for transgender health, including an opportunity to connect with some Portuguese trans folks who were not able to attend the conference.

 Session structure

 The session included plenary speeches, symposia, oral abstracts and posters. I will write about each in turn.

Plenary sessions.

On each day there were two plenary sessions, that were hour long speeches to the full audience, from one or two speakers, with a moderator. The plenary speakers were appointed by the WPATH president. Three were related to surgery, which I won’t engage with here as its not an area I focus on or know a lot about. A broader reflection was that at times the plenaries overall were a source of pathologisation, erasure of non-binary people, dehumanisation, exoticisation, and demonstration of clinical control over trans communities. There were several sessions where, if one had a bingo card of common areas of biases and indicators of cis-supremacy, one might have ticked off many exemplars. The speakers also privileged a white, cis, US/European, abled, and clinical position. Of the plenary sessions, the one I enjoyed the most was the opening plenary, delivered capably by an American, the US state representative for Montana, Zooey Zephyr. It was a powerful and moving speech, capturing the challenges that we currently face. I particularly resonated by the words (that I am paraphrasing), that when anti-trans laws are passed, when communities face state persecution, the harm comes severe and fast, whilst processes to overturn such harms are drawn-out and slow. Those words certainly resonated with my experience in the UK, where the harms of recent criminalisation of adolescent healthcare has indeed been severe and fast. The speech and presentation was excellent, but very US centred for an opening plenary. I wouldn’t expect anything less than US centred content from a US state representative, so this US centring is more a question for WPATH leadership than for the presenter. Why would a WPATH opening plenary would be so US centred. The tendency for WPATH (the World association) to act as US-path on holiday does appear to continue to be on display. However, this opening plenary was at least very strongly trans-positive, centring trans rights, calling attention to the abuse, control and persecution of trans communities, including trans children. The other plenaries alas did not all maintain this important commitment on trans-positivity, rights and justice. Several centred a clinical perspective grounded in assumptions of clinician control over trans lives. The plenary on trans children was particularly problematic and disappointing, presenting to a wide audience some older concepts and research that are problematic and outdated, centring and justifying clinical control over trans children. There were times across the plenaries where trans community and service user voice and perspectives were absent, with speakers prioritising a cis, adult, white, global North, clinician perspective. 

I was disappointed to have the plenary on puberty blockers delivered by stakeholder from the Dutch clinics, whose model does not centre trans child and adolescent rights. The presentation itself summarised older research (some of which is problematic) and failed to update the audience on newer research findings from other countries. It was a really lost opportunity to update general attendees on the most up-to-date research on puberty blockers. I also wish we could hear more from Dutch trans communities and service users, particularly child service users, on the Dutch approach. My own research has centred the experiences of service users in the English Children’s Gender Service, which aimed to replicate the Dutch model. My own experience and my research with that service has demonstrated widespread clinical abuse and harms to trans children in that service. (My research, including on experiences in gender clinics, experiences of childhood social transition, experiences with puberty blockers, and on pathologisation and cis-supremacy in healthcare can all be found here).

I hope the next WPATH can better centre child rights, trans rights, an ethics of depathologisation and equality in future plenary sessions, ensuring that any presentations from clinicians centre some fairly basic ethical commitments.

Parallel sessions

Across the conference there were 14 different sessions (hour long time slots), during which attendees had to choose between 5 parallel options, 3 of which were usually symposia and 2 of which were oral abstract sessions. That meant there were a total of 70 hour long sessions, that we could attend only 14 of. The sessions we could attend are recorded and available to watch on catch-up, and I’ll certainly check in on some of the ones I missed in coming weeks. Here I’ll comment on some of the symposia of oral abstract sessions that I attended.

Symposia

On being a target

There was an excellent session on trans researchers being a target of hate and harassment. Unsurprisingly it featured two UK researchers, talking about the amount of targeted hate that comes with being a trans researcher in the UK. We need to find better ways of supporting trans researchers. And we need our institutions to step up, both to protect trans researchers from external abuse, and to ensure research spaces and universities are actually safe from organised transphobia.

Trauma-informed approaches to care

This session talked about trauma informed approaches. I’ve not heard much discussion of this before, and certainly not on how to ensure child and adolescent care is trauma informed. I noted particularly the discussion on how certain mindfulness techniques are inappropriate and triggering rather than relaxing for those living with trauma. I recognised this in myself (I find mindfulness unbearable), but wasn’t aware this was a more general phenomenon. There has been a big recent focus on mindfulness in schools in the UK, and I wonder how this is being experienced by children living with trauma, which will include a lot of trans children.

Evolution of gender expression care

This session focused on the support that trans people, and especially younger trans children, may benefit from in areas of their life not related to medical care. The presenters are including the term ‘gender expression’ care to capture support with social transition, gender expression and finding gender joy, as distinct from and running parallel to medical transition support.

New long-term research on adolescent gender-affirming medical care

This session was excellent, with three important presentations from the US, from Diane Chen, Laura Kuper and Kristina Olson. I will write up some more detail on these three presentations soon as they are very timely and relevant. This is now written up as a separate blog post here.

Preserving evidence-based trans healthcare for adolescents in Europe and North America

This included presentations on how clinicians are navigating care restrictions and challenges to care. It included a focus on the UK, USA, Croatia, as well as discussion on upcoming guidelines from Switzerland, Germany and Austria. It included discussions of clinical care on the defensive, and how to ensure services that are under attack are shifted to the most defensible positions. I would have liked a more significant focus on how to ensure ethical principles and child rights within services that are under attack. I would have liked more explicit discussion of the impacts on trans children of a shift into defensive practice, which often includes bringing in or maintaining approaches that are not in a child’s best interest. I would have liked more consideration of how to ensure child rights and prioritised while operating under defensive practice, and more explicit acknowledgement of the harms, and more proactive work to ameliorate such harms. I’d also like more discussion of how a shift to defensive practice can provide a cover for coercive and harmful practices beyond what might be 100% essential. And how those shifting to defensive practice need to be more rather than less accountable to criticism of their practices. We also need to consider whether shifting to the most defensible positions actually appeases or reduces criticism from trans-hostile actors – in the UK this was certainly not the case, every shift to the defensive led to more attacks on care. I think a ethical and rights based defense of care is stronger than any effort at appeasement. (This session clashed with another session on “Research-based, ethical, lifesaving: findings from a long-term satisfaction study on pediatric gender affirming care” that I hope to catch up on later.

Centring Gender Diverse Young Children’s Voices and Experiences in Clinical Care and Research

A tool developed by Zucker (1977) was presented, with discussion of its cisnormative flaws and failings. The presentation then talked about experience of modern research using this tool. I don’t understand using an outdated and inappropriate tool developed by Zucker with modern trans children. I didn’t stay for the full presentation so perhaps I misunderstood something. I worry about research practices that do not centre trans children’s well-being and do not protect from research related harms. In my experience every question asked to a trans child by a professional, of any type, is an example of that child being treated differently. Children notice when their identity is treated differently. They notice when they are being studied. All research needs to consider the potential for children feeling shame. I returned to the session later for a discussion on the use of dolls to help children display their gender. I was probably not in the best head space for the doll discussion. Again, I was prompted to ask myself how many cis children are asked to dress a doll in a meaningful outfit under adult stranger/professional scrutiny. How do those trans children feel. I’m sure this can be done in a really positive way, and I don’t doubt the researchers presenting who seemed lovely do this in a positive way. But there was also suggestion of sharing this approach and these dolls much more widely. I didn’t stay for the whole session. I hope there was also significant discussion on the many trans children who do not want to dress dolls while under adult scrutiny, on the children who don’t want to be treated differently just because they are trans. I hope there was discussion on the ways in which a doll dressing exercise can be done really badly by the wrong facilitator, how it could be experienced by a child as being a subject of adult curiousity of how different and weird they are compared to their siblings and peers who are not asked to do this task. I worry about any initiative that en masse treats trans children in a different way to cis children, and anything that is not individually determined and centred. The younger children who I have known most closely would have hated being asked to dress a doll to present themselves, especially at a point in time early in transition where their clothing and expression is being most extremely scrutinised and judged and commented on by those around them. For all of these tools, I guess the context and the intent is really important. In a really safe environment, where children are not already feeling hostility and judgement and shame, perhaps a doll dressing challenge could be a source of gender joy for some children. How do we know which environments are safe for this? How do we know which children will enjoy it? How do we offer this as one of very many, many, fun activities, and ensure children do not feel compelled to engage as part of defending their existence to the adults around them. Given the choice of a coordinated doll dressing activity and a game of tag or watching a movie, a majority of the trans kids I know best would choose tag or watching a movie. In my experience, younger trans children, especially those early in transition, are very very tuned in to any areas of their life where they are treated differently or scrutinised. How do we ensure that activities that treat them differently do not make them feel like there are being judged or assessed, or make them feel they need to perform to meet adult expectation or approval.

Oral abstracts

Engaging Family

There were several presentations on engaging with families. It is interesting to see the work that is being done with families who help them to better understand and support their trans children. One reflection that I had, was on how can support services better recognise a diversity of support needs amongst parents.

From my own experience I wonder about the targeting. In my experience the parents and carers who show up, who are reachable with interventions, are less likely to benefit from basic trans 101 education and support with things like ‘ambiguous loss’. As a trans person and a parent in such spaces, I have found some ‘support’ to be really upsetting, and I know plenty of cis parents who have felt the same – who have needed support in managing state oppression and the minority stress of being a family facing overt anti trans abuse and hate, who have found sessions focused on ambiguous loss or trans 101 a world away from the support that they actually need.

On the topic of ambiguous loss I also wonder how we can better recognise the way in which rhetorics of ambiguous loss provide some parents with a cushion that enables them to gain emotional support from trans-ignorant cis communities – for that parent, moving away from a rhetoric of ambiguous loss also means moving away from their available emotional support network. That support network needs to be replaced by a trans-positive support network, and I’d really be interested in seeing how support for parents can focus less on trans 101 or on dealing with ambiguous loss, and more on building trans positive emotional support networks, reducing the isolation of supportive parents/carers, and on providing meaningful support to help families facing state persecution, helping parent/carers emotionally stay afloat whilst engaging in constant advocacy for child rights and whilst facing harassment, isolation and abuse.

Especially in context where oppression is high and rising, I would love to see more focus on how to ensure supportive parents and carers can not fall apart under the strain. Of course, the trans-hostile and trans ignorant parents are also very important – I would just not assume that they are the parents who will voluntarily walk through the door. Unless you have other means of reaching such parents (eg direct referral from the GP, or targeted outreach with a less supportive parent building on a connection with a more supportive parent), I wouldn’t assume you are ever meeting those parents.     

I would also like to see more consideration within those facilitating and organising parent/carer support groups of how to ensure the spaces do not expose parents/carers to an excessive amount of anti-trans opinion. In my experience those spaces work best when they are a good mix of parents who have become strongly supportive and educated, who are actively fighting for trans children’s rights and those parents who are new and managing their own learning curve. I have noted a tendency for the facilitation of these spaces to have shifted towards younger, non-parent and trans facilitators. I have also noted a growth in space for parents to discuss at length their own transphobic assumptions, where facilitators perhaps want every parent to have their say and don’t feel able to police any minimum standards of respect. The last ‘support’ group I attended I was directly called a ‘traitor to feminism’ for being a non-binary person in a facilitated group discussion without any backup.

(as well as being a toxic work environment for a younger trans facilitator) this ‘let everyone speak their mind’ approach is also driving away those parents who are more supportive. The cis parents who are attending in search of a safe space away from a trans-hostile world are encountering yet more trans hostility in those facilitated support spaces, and many are stopping attending. I myself more often than not find such spaces traumatising rather than reinvigorating, and I know many cis parents who feel the same. If the more supportive parents, who are looking for support on trans advocacy and dealing with transphobia get deterred from support groups, then that is a huge loss to those new parents who usually learn a lot of trans positivity and how to better support their children from parents who have walked the same path. I would be interested to hear more research that recognises the diversity of positionality within parents groups (including the existence of trans parents in those spaces), how to ensure those spaces are overall safe spaces for all parents (whilst providing some space for parents sharing their worries), and a mechanisms for more targeted approaches where a trans 101 isn’t the starting point for all families, with an emphasis on the support required beyond trans 101.

I always find the topic of ‘ambiguous loss’ a bit triggering. Clearly some parents do experience it, and need some therapeutic support with it. I wish there was more recognition of the diversity of ambiguous loss. In my experience a majority of parents experience ambiguous loss, which when you dig deeper is about a loss of safety. Especially for white families in countries and areas not particularly affected by violence or conflict, parents have an expectation of safety for their child. When they realise their child is trans, parents can have a reaction of fear, that their child is not going to be safe, in the present or in the future. This loss of expected safety is something that parents can find emotionally upsetting. In a world where there isn’t much language, parents can fall to a language of ‘grief’ to explain this loss. For some parents who I know, the language of grief is a mis-application, describing something that is different to grief. I’d like to see more focus on loss of safety as a concept, including helping parents to re-examine and re-conceptualise what they are feeling, especially where their feelings are not really about grief.

Clearly some parents also feel something like grief. One presenter mentioned an initiative on creative writing to help parents process their emotions. They included a description of a parent writing a eulogy. I am not a counsellor and don’t know how best to help parents who feel that way. I do worry about how much acceptance or space we should give for a grief narrative in more general or plenary spaces. It is clearly offensive. I also worry about the impact of giving space to a grief narrative on those parents and carers who have actually lost a child. Parent support spaces should be a safe space for those parents too, and I think more care should be taken over how ‘ambiguous loss’ is dealt with, including ensuring there are spaces for parents who want to talk about a loss of safety without having to hear other parents talk about ‘grief’ for a still alive child.

Law, Policy and Ethics

This included a presentation on the reasons why a proposed NHS research trial on puberty blockers is unethical, as well as evidence on the negative impacts of US healthcare bans.

Community engagement

This was a fantastic session, centring trans led research including from India, centring trans-led community designed research, the roles of community initiatives in steering research or clinical practice, and the importance of gaining service user trust.

Other conversations

I had many other interesting conversations. In many countries it was shocking to me to hear just how very far ahead of the UK in terms of treatment and support for trans children and adolescents they are. Folks from many countries expressed concern and solidarity on just how bad the UK is right now, seeing it as so very far behind acceptable levels of care, law and policy. I heard about interesting upcoming work, about current practice in the US, Canada, Australia, New Zealand, about support for trans youth in countries like South Africa and Vietnam, about upcoming research on disassociation, about initiatives to support folks under state violence. I met many awesome people who I hope to stay in touch with.

Gender Dysphoria and puberty blockers

/ growinguptransgender / Leave a comment

In trans children’s healthcare there is so much intentionally bad science, so much science that fundamentally misunderstands (or chooses to misrepresent) trans experiences.

The quantity of bad science overwhelms – we challenge some, whilst other pieces of bad science slip through undetected.

I just this morning had my attention drawn to some fundamentally bad science (I read about it on the website transfemscience https://transfemscience.org/articles/puberty-blockers/ ) and realised that yet another bad faith move had somehow escaped my attention.

The Cass Review makes the claim that puberty blockers don’t reduce ‘Gender Dysphoria’. In recent discussions on this topic I have argued that this is likely both true and irrelevant. Puberty blockers shouldn’t be expected to reduce gender dysphoria, they don’t magically make trans kids feel better about their primary sexual characteristics. Instead they prevent the increase in gender dysphoria that can occur at puberty, if adolescents denied blockers are forced through the distressing development of unwanted secondary sexual characteristics. I have argued, including in recent media interviews, that puberty blockers shouldn’t be expected to reduce dysphoria, instead they prevent an increase in dysphoria at puberty.

HOWEVER. The term gender dysphoria has multiple meanings. One meaning refers to ‘physical gender dysphoria’, how we feel about our bodies, and particularly how we feel about the parts of our bodies that are impacted by sex hormones. A second meaning refers to ‘social gender dysphoria’, relating to our experiences navigating the world, including how we feel when we are mis-seen and misgendered. A third meaning references the diagnosis of ‘gender dysphoria’ from the Diagnostic and Statistical Manual of Mental Disorders, which has distinct definitions for children or for adolescents and adults, which operates as a proxy for a medical diagnosis of being trans.

In healthcare research a research question that is arguably valid and good faith is ‘does affirmative healthcare reduce physical and social gender dysphoria’. Asking this question about puberty blockers alone would be mis-placed (an error I thought the Cass Review was making) because puberty blockers don’t reduce physical and social dysphoria, they prevent it from getting worse.

However, this isn’t what they are talking about at all,

Let’s take a 2021 UK GIDS (NHS children’s gender clinic) research article on puberty blockers as an example (GIDS research has tended to be so filled with flaws, methodological, analytical, ethical and interpretive, that it is exhausting to read or critique, which is one reason the flaw highlighted in this blog has escaped me until today).

The 2021 article is titled: Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK

The article talks about the purpose of blockers “used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes”. So we are talking about physical and social gender dysphoria, right? I’m pretty sure we’re not talking about identity…

The paper talks about measuring the intensity of Gender dysphoria. “The Utrecht Gender Dysphoria Scale (UGDS) is a self-report measure used to assess the intensity of GD validated for age 12+”. This is the only information on gender dysphoria provided in the article. If you don’t already know the Utrecht scale, you are left in the dark on what is being meant and measured here.

The article concludes that “Gender dysphoria changed little across the study”. Again, a finding that intuitively sounds predictable for physical and social gender dysphoria. I would expect them to remain the same (rather than worsen) if accessing puberty blockers. The idea we are talking about physical dysphoria appears to be reinforced by the next sentence “This is consistent with some previous reports and was anticipated, given that GnRHa does not change the body in the desired direction, but only temporarily prevents further masculinization or feminization”.

The article is not clear what is meant by gender dysphoria, and it includes several references to puberty blockers preventing secondary sex characteristics, so I do not blame past me for assuming we were talking about physical gender dysphoria.

BUT – then I went and looked at the measurement tool being used. The Utrecht gender dysphoria scale.

This is a simplified version of the Utrecht scale. It shows the measures that puberty blockers are being criticised for failing to improve:

1. I prefer to behave like my affirmed gender.
2. Every time someone treats me like my assigned sex I feel hurt.
3. It feels good to live as my affirmed gender.
4. I always want to be treated like my affirmed gender.
5. A life in my affirmed gender is more attractive for me than a life in my assigned sex.
6. I feel unhappy when I have to behave like my assigned sex.
7. It is uncomfortable to be sexual in my assigned sex.
8. Puberty felt like a betrayal.
9. Physical sexual development was stressful.
10. I wish I had been born as my affirmed gender.
11. The bodily functions of my assigned sex are distressing for me (i.e. erection, menstruation).
12. My life would be meaningless if I would have to live as my assigned sex.
13. I feel hopeless if I have to stay in my assigned sex.
14. I feel unhappy when someone misgenders me.
15. I feel unhappy because I have the physical characteristics of my assigned sex.
16. I hate my birth assigned sex.
17. I feel uncomfortable behaving like my assigned sex.
18. It would be better not to live, than to live as my assigned sex.

(The original, longer, and more misgendering version of the Utrecht is available here (trigger warning for a really outdated and offensive measurement tool). I would guess GIDS likely used the more offensive and outdated original version. I’ve put the simplified and more modern version above so readers don’t have to get the severe ick that comes from reading the original versions)

They are criticising puberty blockers for failing to show improvements across these 18 questions.

They are criticising puberty blockers for failing to cure transness.

How can we fight this level of bad science at every turn?

Why can’t they even be honest and clear? They could say ‘we expect healthcare to change young people’s answers to the above 18 questions. We consider it a shortcoming of puberty blockers that they do not lead to improved answers to the above 18 questions. We were hoping that puberty blockers would make people not trans. Without evidence of blockers making people not trans, we will not give them to trans youth. Our goal for trans healthcare is to make young people not trans’.

At least be honest about your anti-trans intentions, don’t hide it behind a measurement scale that only gender clinic measurement geeks will understand. Don’t hide beneath a term like gender dysphoria that has multiple meanings.

When stakeholders talk about the goal of NHS services being to ‘reduce gender dysphoria’, if they use the Utrecht scale, they mean, to make people not trans. When they say ‘to reduce gendered distress’ they mean make young people not trans.

When they measure gender dysphoria against the Utrecht scale, they are seeking to cure or reduce transness.

Puberty blockers are ineffective in making people not trans (reducing gender dysphoria according to the Utrecht scale). So, we need ‘talk therapy’, to make people not trans.

 It is conversion therapy all the way through. The conversion therapy is hidden in language of ‘gender dysphoria’ (a term that is used very differently in trans communities’). They know the term gender dysphoria has multiple meanings. It provides a perfect cover for conversive practices.

We need to reduce gender dysphoria they say.

We need to make children not trans they mean.

The level of bad faith, bad science and establishment transphobia is overwhelming. No amount of evidence that affirmative healthcare leads to reduced physical and social dysphoria will ever be enough – because this is not the measure they care about.

They just care about making trans kids into cis kids

This is all they ever care about.

Transphobia and transphobic bad science continues to enable harmful clinical policy and practice.

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

/ growinguptransgender / 4 Comments

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

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

 

teacher head in hands

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

Who are the authors? 

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

How am I meant to use it?

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

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

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

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

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

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

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

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

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

On to the publication in question

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

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

 

On Gender Stereotypes

/ growinguptransgender / 5 Comments

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

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

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

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

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

Can you not hear how that sounds?

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

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

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

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

This accusation is thrown at parents like myself daily:

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

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

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

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

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

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

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

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

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

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

Trans children are no more stereotypical than any other children.

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

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

On Media Tropes of trans children

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

  1. Media stereotyping
  2. Societal expectations
  3. Personal narratives (of children and families)

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

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

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

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

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

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

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

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

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

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

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

3. Narratives of the child and their parents

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

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

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

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

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

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

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

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

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

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

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

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

Research update: 12/04/2018

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

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

 

Too young to know their Gender? Constancy research in trans children

/ growinguptransgender / 2 Comments

 

TransGender_Symbol_Color

The perception that trans children are ‘too young’ to know their gender identity is used as a basis for denying them a suite of rights, and has long been a corner stone of arguments against social transition or timely provision of puberty blockers.

Cisgender (not trans) children are generally considered to know if they are a boy or a girl by a young age. But, not so for transgender or gender questioning children, according to the latest paper written by experts from the UK Children’s Gender Service, including the head of service Carmichael.

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

UK Children’s Gender Service experts’ view of Gender Constancy

The Costa (2016) paper has a section on gender identity development. It states that “research has shown that around the age of 3 years, children show a basic sense of self as male or female, owing to their inner experience of belonging to one gender”.

It goes on to note:

“Some research suggests that a developmental lag exists in gender constancy acquisition in children with gender variant behaviour” (reference number 16).

According to the paper “achieving gender constancy represents a cognitive-developmental milestone in gender identity development and is due to the understanding that being male or female is a biological characteristic that cannot be changed by altering superficial attributes, such as hairstyle or clothing”

The belief in trans children having a ‘developmental lag’ in gender constancy leads to this statement “treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults”

The belief in trans children having ‘a developmental lag” in gender constancy feeds directly into the Tavistock’s treatment protocols, such as proposing puberty suppression only be prescribed to those aged at least 12 “safely above the gender constancy achievement”.

Only one reference is provided for the claim that transgender children achieve ‘gender constancy’ later than cisgender children, reference 16, which is the source of this key statement:

“Some research suggests that a developmental lag exists in gender constancy acquisition in children with gender variant behaviour (reference 16)

If this single reference underpins the Tavistock’s belief that trans children do not understand their gender at the same age as cisgender children, and if this claim has direct implications on the Tavistock’s approach to treating trans children, then it is vital we review this paper.

The paper in question is:

Zucker, K. J. et al.(1999) Gender constancy judgments in children with gender identity disorder: evidence for a developmental lag. Arch. Sex. Behav. 28, 475–502 (1999).

 

Zucker (1999) 

Gender constancy in the Zucker paper is defined as “the understanding that ‘superficial’ or surface transformations in gender behaviour such as activity preferences or clothing style” do not change a person’s gender. The paper concludes that children referred to a Gender Clinic for ‘problems in identity development‘ have a ‘developmental lag in gender constancy‘. This conclusion merits further scrutiny.

Zucker et al.’s study focuses on a group of children who were referred to the Toronto Gender Clinic between 1978 and 1995.

The majority of the Gender Clinic children in this study were assigned males (207/236 = 88%). There were a small number of assigned females in the sample (12%). In order to simplify this blog post I have decided to focus the examples throughout on assigned males (noting that this editorial simplification perpetuates historical erasure of trans boys / assigned females).

The children registered at the Gender Clinic I will hereafter refer to as the ‘clinical sample’, to contrast with the study’s ‘control sample’ (a sample of children of the same age who were not registered at the gender clinic and were not known to have any gender issues).

It is known (and acknowledged in Zucker’s paper) that some of the clinical sample of assigned males were non-conforming boys rather than trans girls. How many were gender non-conforming (GNC) rather than trans is unknown as historical diagnoses focused on behaviour and interests more than on identity and Zucker did not believe in distinguishing between young gender non-conforming boys and trans girls.

The children in the clinical sample, together with a control group (aged 4-8 – average age 6 and a half) were put through three different types of test, which they either ‘passed’ or ‘failed’.

Zucker 1999, the tests

We will now look at the three tests, and see whether they do provide convincing evidence that transgender children (or children treated in the gender service) have a ‘developmental lag’, and understand their gender identity later than cisgender children.

Zucker 1999: Test 1: Slabey & Frey test

Test 1 Part A focused on Gender Discrimination 

The children were shown dolls and photographs depicting a boy, girl, man, woman and asked to identify them. The children ‘passed’ if they got at least 12 out of 16 ‘correct’. 93% of the clinical sample ‘passed’ this test, compared to 98% of the control group.

Test 1 Part B:  Gender Identity

The children were asked their own gender. The assigned-male-at-birth (amab) children ‘passed’ the test if they answered ‘boy’.

93% of the clinical sample ‘passed’ this test compared to 98% of the control group.

(The very high ‘pass’ rate for the clinical sample at first glance seems high as transgender children like my daughter would certainly ‘fail’ this test.

Perhaps the high ‘pass’ rate may add weight to suggestions that a large proportion of children referred to the Toronto gender clinic in the 1970s, 1980s and early 1990s were there for gender non-conformity (proto-gay cure….) rather than children with a gender identity different to their assigned sex.

The fact that a trans girl was considered to have ‘failed’ in her understanding of gender identity if she said she was a girl is an indication of the bias of the researchers.

Test 1 Part C: Gender Stability

The children were asked if their gender can change over time, for example if they were a different gender when they were born to their current gender. The children ‘passed’ if they said gender can never change over time.

80% of the clinical group ‘passed’ compared to 92% of the control group

Test 1 Part D: Gender Consistency

The amab children were asked questions like ‘if you wear a dress, are you a girl?’ ‘If you played with a doll would you be a girl?’. (the exact script, and the exact phrasing, is not provided so we cannot be sure exactly how the questions were worded)

66% of the clinical sample ‘failed’ this test, by stating that playing with dolls makes you a girl.

46% of the control group also ‘failed’, also thinking that playing with a doll made you a girl.

The fact that nearly half the control also think playing with a doll makes you a girl seems more an indication of the segregated and gendered restrictions on toys of Canadian children in the 70s, 80s and early 90s than any conclusion about gender identity. Given very few of the clinical group identified as trans in this study, it also brought to mind the limited freedom for boys to be feminine or play with perceived girls toys, and made me wonder how many assigned males had been told to ‘stop being a girl’ when playing with dolls or putting on a dress.

Zucker 1999 Test 1 – Conclusion

The data from test 1 parts A-D, and the fact that the clinical sample had a slightly lower ‘pass’ rate than the control sample, was interpreted by Zucker et al. as evidence that children at the gender clinic were more ‘confused’ about gender.

The researchers then take a further leap of faith, into a conclusion that the lower pass rate of the clinical group compared to the control group implied a ‘developmental lag’ in understanding of gender. However, the clinical sample and the control sample were the same age (ages 4-8, average age 6.5), and the clinical sample were not re-tested at a later point in time. How therefore can they claim a developmental lag? It is simply not possible to claim a ‘developmental lag’ based on this data. The assertion of a ‘developmental lag’ (with the implication that the clinical sample reach a similar level of understanding but at a later age than children not referred to a gender clinic) is pure speculation/fabrication.

Test 1 provides zero evidence that transgender children (those with a consistent, insistent, persistent identity different to their assigned sex) have a delayed understanding of gender.

Zucker 1999: Test 2 Boy-Girl Identity Test

The assigned male children were then shown a drawing of a boy. They were asked to give the child in the drawing a name. If they chose a girl’s name for the drawing they were corrected and given a boy’s name, eg ‘this is Tom’.

Zucker 1999 Test 2 Part 1:

The children were asked ‘If Tom really wants to be a girl, can he be a girl?’.

The children ‘fail’ this test if they say yes Tom can be a girl.

32% of the clinical sample ‘fail’ this task by stating Tom can be a girl vs 21% of the control group

(Interestingly there is not a huge difference between the clinical group and the control group, with 21% of the control group, children with no gender issues, thinking that yes, Tom can be a girl – Canadian 5 year olds from the 1970s, 1980s and early 1990s showing more sophisticated understanding of gender than their specialists…)

The children are asked to give a reason for their answer, and are defined as having reached ‘operational constancy’ if they justify their answer ‘No Tom can’t be a girl’ answer with the justification ‘because he was born a boy’.

This unethical line of questioning Zucker et al put trans children through is a form of coercive persuasion, tantamount to brainwashing, where the ‘wrong answer’ is corrected with the ‘right answer’ – ‘BECAUSE TOM WAS BORN A BOY’ until the child submits and agrees.

Zucker 1999 Test 2 Part 2:

A dress and or long hair is added to the picture of ‘Tom’ and the children are asked ‘If Tom puts on a dress, is he a girl?’ The expected ‘correct’ answer is ‘No’ and the expected justification is ‘because he was born a boy’.

71% of the clinical group ‘fail’ this test, as do 64% of the control group.

Again the control group is pretty similar to the clinical group in their openness to the possibility of Tom being a girl.

Zucker 1999 Test 2 Conclusion

Zucker 1999 Test 2 provides no evidence of a ‘developmental lag’ in understanding gender for trans children.

Zucker 1999 – Test 3 looks at ‘sex-typed behaviour’

Zucker 1999 Test 3 Part 1 asks children to draw a person, and then asks them if the person they have drawn is a boy or a girl.

The assigned male at birth children ‘pass’ if they opt to draw a boy and ‘fail’ if they opt to draw a girl.

66% of the clinical sample ‘fail’ by drawing a girl (in case of the assigned males). 54% of the control sample also ‘fail’ this test by drawing a girl (in case of the presumed cis boys).

Again the results of the control are fairly similar to the clinical group.

Again there is no evidence of trans children having a developmental lag in understanding gender.

Zucker 1999 Task 3 Part 2 has the children watched through a 1-way mirror in a room with ‘gender specific’ toys and or clothes and the researchers assess the amount of time the children spend with ‘appropriately gendered toys or clothes’. They are deemed to have ‘failed’ if they play too much with the ‘wrong’ gender toys or clothes.

This task has no place in today’s society in which children are not constrained by outdated gender stereotypes.

Zucker 1999 Task 3 Part 3 assesses what it calls ‘affected confusion’, assessing a child’s ‘desire’ to be a boy or a girl (rather than their identity). It asks assigned males (who have been referred to a gender clinic for non-conforming behaviour) questions like ‘is it better to be a boy or a girl’ and ‘do you ever wish you were a girl’. Assigned males are deemed ‘deviant’ if they state any wish to be a girl (perhaps because they are a trans girl or perhaps because they are a non-conforming boy who wants to be able to play with his dolls in peace without being taken to Dr Zucker every month/week…). Assigned males are also deemed ‘deviant’ if they acknowledge anything positive about girls or think that there are any ways in which it is better to be a girl than a boy.

64% of the clinical group are labelled ‘deviant’ due to their answers in this part, as are 50% of the control group (reminder the control group are ‘random’ children not being seen by the gender clinic and who are not known to have any gender issues and yet half are deemed by this test to be ‘deviant’).

Zucker 1999 Test 3 Conclusion

What on earth is going on, and how the heck is this research still being quoted in a 2016 journal article by the leading experts at the UK’s Children’s Gender Service!

The high ‘failure’ and ‘deviancy’ rate’ not only in the clinical group but also in the control group is perhaps indication that Canadian 5 years olds in the 70s, 80s and early 90s were did not have such ingrained stereotypes of gender, nor sexism, nor misogyny, as the ‘gender specialists’ who subjected them to such awful tests.

The Zucker 1999 article ends with a ‘blame the parents’ conclusion, proposing that parents of gender non-conforming boys or trans girls must have ‘actively’ encouraged ‘cross-dressing’ or appeared to ‘tolerate’ cross-gender behaviour. It highlights a view that “parental reinforcement of same-sex play was positively related to gender constancy in pre-schoolers”. It is pure ‘drop-the-barbie’ Zucker, more focused on installing out-dated gender conformity in non-conforming boys than any concern for how to help children who may be transgender.

Zucker 1999 in summary

To summarise, the Zucker 1999 research is deeply outdated, transphobic, stereotyped, homophobic, normative and unethical.

The clinical sample is known to contain at least some children who are non-conforming rather than trans and no effort is made to focus specifically on trans children.

The difference in answers between the clinical group and the control group are very small (the paper conducts regression analysis on a wide number of variables until it finds some that are considered statistically significant – this is an unsound approach to valid statistical analysis).

The study looks at a range of things that do not relate to gender identity (including toy preferences).

And most critical of all – the paper looks at the children at one moment in time – comparing the clinical group to a control group of children the same age (age range 4-8). There is no follow up at a later age and no comparison of children of different ages. Any claim to transgender children having a developmental lag (which I interpret to mean achieving a similar understanding of gender at a later age) is pure fabrication.

Given the obvious weaknesses of the the Zucker paper – why is it a core reference in the 2016 Costa paper from leading experts of the UK Children’s Gender Service

UK Children’s Gender Service

There are three major problems with the Tavistock’s view of gender constancy as shown in the Costa 2016 paper.

Problem 1 – Quoting fabricated conclusions as though evidence

The Costa 2016 paper states “Some research suggests that a developmental lag exists in gender constancy acquisition in children with gender variant behaviour”, referencing the Zucker 1999 paper.

As we’ve seen above, the Zucker 1999 research does not provide any evidence for this claim.

Problem 2 – Broadening the relevance of those unsound conclusions and applying them to clinical practice

The Zucker paper mentions a ‘developmental lag’, but does not mention any age at which transgender children reach ‘gender constancy’.

The Costa 2016 paper moves beyond even the conclusions claimed in Zucker 1999, taking a series of assumptions to extrapolate wider conclusions (for which no specific reference is provided). They move from the idea of ‘a developmental lag in gender constancy’ to the claim that “children with gender dysphoria are more likely to express an unstable pattern of gender variance”. They move from that unsupported statement to the claim that “treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults”. And they shift further to arrive at the final statement that puberty suppression is unwise until at least age 12 “safely beyond the age of gender constancy”. It is important to recall that Zucker 1999 provides no information on the age at which trans children ‘achieve gender constancy’ and focuses on children aged 4-8 (where the Costa paper get the age 12 figure from for gender constancy is anyone’s guess).

The Zucker 1999 research bears no relevance to the question of whether trans children understand their gender. Yet Costa et al 2016 use this study as their basis to suggest that transgender children do not know their gender. They use it to support an argument that transgender children have ‘unstable gender variance’ up until puberty, and they extend this to argue against pubertal suppression for those starting puberty under the age of 12.

Problem 3 – Omitting reference to critical recent research

The third, and perhaps the biggest error, is one of omission. The Costa 2016 paper, in its section on gender identity development / gender constancy in transgender children, only mentions the Zucker research, omitting mentioning any other research on transgender children’s gender identity.

The Zucker 1999 research paper is now 19 years old. Surely in the last two decades there has been some other research on the gender identity of transgender children, ideally research that makes an effort to focus on transgender (rather than gender non-conforming) children, and research that focuses on the children’s gender identity rather than toy preference? The answer is a clear yes. There are important studies on this topic that the Costa 2016 paper fails to even mention.

So let’s take a brief review of recent research on this topic which are noticeable by their absence:

New research on transgender children’s gender identity

Olson 2015

Olson, K.; Key, A.; Eaton, N. (2015) Gender Cognition in Transgender Children Psychological Science OnlineFirst, published on March 5, 2015

The introduction to the Olson el al 2015 paper describes historical (and current) scepticism to the idea of transgender children knowing their gender:

“This scepticism takes many forms: concerns that these children are “confused” and that they therefore need therapy, that these children are “delay[ed]” in their understanding of gender in part because of the behaviour of their parents (Zucker et al., 1999: Gender constancy judgments in children with gender identity disorder: evidence for a developmental lag), or that these children are merely saying they are the “opposite” gender, much as they might say on any given day that they are a dinosaur or princess.”

Olson et al.’s research aimed:

“to investigate whether 5- to 12-year-old prepubescent transgender children (N = 32), who were presenting themselves according to their gender identity in everyday life, showed patterns of gender cognition more consistent with their expressed gender or their natal sex, or instead appeared to be confused about their gender identity.”

Results:

“When the transgender children’s responses were considered in light of their natal sex, their responses differed significantly from those of the two control groups on all measures. In contrast, when transgender children’s responses were evaluated in terms of their expressed gender, their response patterns did not differ significantly from those of the two control groups on any measure.”

Conclusion:

“Using implicit and explicit measures, we found that transgender children showed a clear pattern: They viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender (nontransgender) control groups. These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.

Our findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.

The data reported here should serve as evidence that transgender children do indeed exist and that their identity is a deeply held one.”

 See here for background and further details

Fast 2017

Fast, A & Olson, K. (2017) Gender Development in Transgender Preschool Children, Child Development

Abstract:

“An increasing number of transgender children—those who express a gender identity that is “opposite” their natal sex—are socially transitioning, or presenting as their gender identity in everyday life. This study asks whether these children differ from gender-typical peers on basic gender development tasks. Three- to 5-year-old socially transitioned transgender children (n = 36) did not differ from controls matched on age and expressed gender (n = 36), or siblings of transgender and gender nonconforming children (n = 24) on gender preference, behavior, and belief measures. However, transgender children were less likely than both control groups to believe that their gender at birth matches their current gender, whereas both transgender children and siblings were less likely than controls to believe that other people’s gender is stable.”

 

Summary

So what do we know about gender constancy/ gender identity in transgender children?

We know that some claims are balderdash (junk science):

  •  The Zucker 1999 study holds no value in informing us about the gender identity development or constancy of transgender children.
  • The statement “a developmental lag exists in gender constancy acquisition in children with gender variant behaviour” is unsubstantiated and shouldn’t be quoted in future articles
  • Conclusions in the Costa (2016) report on “children with gender dysphoria are more likely to express an unstable pattern of gender variance” and “treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults” are unsubstantiated and should be disregarded
  • Policy recommendations in the Costa (2016) report on withholding pubertal suppression until “at least the age of 12, safely beyond the age of gender constancy” are unsubstantiated and should be disregarded

 

We know that recent research (Olson 2015 and Fast 2017) shows that:

  • “Transgender children do indeed exist and their identity is a deeply held one.”
  • “Three- to 5-year-old socially transitioned transgender children did not differ from controls or siblings on gender preference, behaviour, and belief measures.”
  • “Transgender children aged 5-12 viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender control groups.”
  • “These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.”
  • Research “findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.”