Dr Jo Olson-Kennedy on puberty, blockers and hormones

health image

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

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

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

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

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

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

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

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

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

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

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

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

What happens when puberty starts?

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

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

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

How do blockers work?

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

How do we know they are reversible?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In assigned males peak growth velocity occurs in tanner 3.

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

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

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

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

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

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

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

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

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

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

 

 

UK GIDS Failing Publicly

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

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

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

Introduction

The article is intended for “professionals” who:

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

Referencing fringe figures

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

Conflating behaviour with identity

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

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

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

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

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

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

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

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

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

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

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

Focus on rise in ‘birth registered females’ 

GIDS continue:

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

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

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

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

Inclusion of unsubstantiated speculation

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

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

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

And more:

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

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

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

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

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

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

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

Criteria for the diagnosis of Gender Dysphoria

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

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

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

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

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

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

  • A strong preference for playmates of the other gender.

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

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

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

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

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

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

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

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

Cisnormative and outdated terminology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cisgender

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

Appropriate assessments prior to referral

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

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

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

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

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

Autism

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

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

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

Assessment

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

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

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

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

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

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

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

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

Rates of referral to pediatric endocrine clinic

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

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

Polly was asked by the presenter Victoria Derbyshire:

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

Polly answered:

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

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

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

This is a gross abuse of their power.

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

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

What does their data actually show?

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

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

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

figure 2 Butler paper

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

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

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

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

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

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

6 year olds in this data set

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

9 year olds in this data set

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

12 year olds in this data set

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

15 year olds in this data set

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

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

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

Wait just one moment here!

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

When asked by the presenter Victoria Derbyshire

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

Polly responded:

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

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

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

Year  Number of 5 year olds referred

 Age in 2017

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

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

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

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

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

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

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

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

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

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

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

Misleading manipulation of data 

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

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

‘Desistance’ during early puberty

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

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

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

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

THEIR OWN DATA CONTRADICTS THEIR HYPOTHESIS!

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

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

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

Pubertal status

On the timing of puberty blockers, GIDS states:

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

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

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

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

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

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

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

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

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

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

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

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

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

<https://www.theguardian.com/society/2008/aug/14/children.youngpeople>

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

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

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

Persistence

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

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

FIG 2 DOES NOT SHOW THIS.

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

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

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

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

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

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

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

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

None of these factors are acknowledged in the article.

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

Pathologising language continues

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

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

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

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

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

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

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

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

Fertility preservation

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

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

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

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

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

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

Blockers

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

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

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

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

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

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

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

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

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

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

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

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

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

They have not provided a single reference for this claim.

This is unprofessional, unethical and OUTRAGEOUS.

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

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

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

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

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

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

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

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

Psychological benefits of GnRHa treatment

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

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

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

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

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

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

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

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

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

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

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

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

Here’s what the Endocrine Society actually says:

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

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

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

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

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

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

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

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

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

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

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

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

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

Gender affirming hormones and height

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

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

Over 90% go to adult services

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

 

Surgery for adults

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

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

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

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

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

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

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

Long-term outcomes

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

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

Conclusion

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

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

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

References – hold on, this is interesting

The references are perhaps the worst part.

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

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

Most references are from their colleagues in the Netherlands.

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

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

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

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

What references are not included

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

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

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

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

Peer review

The article was “Commissioned; internally peer reviewed”.

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

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

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

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

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

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

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

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

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

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

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

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

GIDS is a failing service stuck in defensive practice.

Our children deserve so much better.

GPs and trans children – BBC drama ‘Doctors’ and the UK Gender Identity Development Service

dr

BBC show Doctors included a trans teenager, and their mum meeting with a new GP. The show certainly had made an effort to provide an accurate and appropriate portrayal of a trans adolescent, so does score some points. It did also include some misleading stereotyping of trans children, and ignorance/misinformation on NHS protocols and timelines. I hope upcoming ITV drama Butterfly will do even better.

The first segment was the worst for misrepresenting the experience of parenting a trans child, and for perpetuating lazy stereotypes.

The child is described by the mum as ‘born a boy’ who ‘liked girly things’. The emphasis in the first segment is on the child’s interests, toy preferences, clothing preferences, not on the child’s gender identity. A later segment makes clear the child had identified as a girl her whole life, but this is not mentioned in the first segment.

The focus on non-conformity is misplaced – many trans girls I know are not especially feminine or especially in to girly toys – trans girls are not the cliché of femininity the media leads you to believe.

The first segment suggests that the child one day stated ‘I want to be a girl’ and the parent switched pronoun. It mentions that two years later the child is on puberty blockers. It makes it sound so straight-forward. This unlikely scenario is a misrepresentation of the current NHS pathway for gender variant or trans children and does not match the experience of many families who I know.

Let’s look at a more realistic scenario.

A child, assigned male at birth, states ‘I am a girl’. Frequently. Consistently. Insistently. Persistently. (sure some children are less insistent, some are more fluid, some less clear – in my experience only the ones who are extremely insistent are likely to be supported to socially transition at a young age – it is a huge step in this gendered and transphobic world).

The parent spends months or often years telling their child that they can be a non-stereotypical boy, as non-stereotypical as they like, so long as not trans. Perhaps they say things they will later regret, like it is not possible to be trans, or that your genitals define who you are.

The parent spends months or years reading and learning, working through their own ignorance, fear and transphobia (I have met very few cis parents who did not have to first work through a lifetime of unconscious transphobia).

During this time while the parent finds the knowledge and understanding (and courage) to listen to their child, the child gets increasingly distressed and withdrawn – being rejected by your family is hard on a child.

The parent finally takes what feels like a monumental step of booking an appointment with their GP. The media may have led them to believe that things happen quickly from that point, so the parent may have delayed visiting their GP until the child is in puberty and increasingly distressed.

In, as a rough estimate, half of cases the GP refuses to refer the child to the children’s gender service, sending the parent on an unnecessary 12+ month delay via children’s mental health services. Or the GP tells the parent to come back in a couple of years. Or to come back at age 16. Or the GP flat out tells the parents that kids can’t be trans and they shouldn’t pander to a delusion. This happens a lot.

Parents with transphobic or ignorant GPs go away without any help, only returning to the GP when their child is extremely distressed, depressed, self harming or suicidal.

If they are lucky enough to get a referral from a GP to the sole Children’s Gender Service (In England and Wales), and the referral is accepted, the parents then wait in limbo for a further 14 months for a first appointment. 14 months. For an increasingly distressed child.

Once they get to the gender service the approach is extraordinarily slow and conservative, frequently breaking international guidelines that recommend puberty blockers at tanner stage two. It is often 1-3 years before approval for blockers (even for children who reach the service when puberty is well underway).

Clinicians have all the power and are quite keen to emphasise that the teenager and their parents have no rights whatsoever on whether the service will ever prescribe puberty blockers. Trans children feel this powerlessness, adding greatly to their stress and anxiety at what is already a very difficult time of progressing puberty.

Puberty blockers, let’s not forget, are a safe, reversible and proven effective treatment that has been in use for cis kids (in precocious puberty) since the 1970s, that in countries with a less transphobic health system are prescribed to trans kids (or gender diverse kids distressed about puberty) promptly at the start of puberty. A treatment that is recommended by the international experts on these issues – WPATH (The World Professional Association on Transgender Health) and the International Endocrine Society. A treatment that has been shown to be effective for trans children since the early 1990s.

If approval for puberty blockers is eventually granted by the (monopoly) children’s gender service there is a referral (and further wait) for the endocrine service, with several further appointments (each requiring further trips to London and further days of missed education (and lost earnings for parents) for yet more 1 hour appointments) before prescription of blockers.

Then the parents and child are left to manage a drawn out discussion between the NHS endocrine service and their GP about who will administer the puberty blockers (a simple injection) and who will take on responsibility for the ongoing prescription.

The NHS endocrine service says the NHS GP should do this. The GP usually refuses, claiming that this simple injection, that has been deemed necessary by NHS specialists, that they already administer to cis children, is ‘specialist’ knowledge that they are allowed to refuse to administer (just because the child is trans). Parents are left to sort out this incompetency between different wings of the NHS.

In our realistic example, the parents are now trying to keep safe a desperate teenager  who has been waiting for years for the medically necessary treatment that they need and have a right to. Reports of self harm are common. These parents sometimes have to teach themselves how to administer an NHS prescribed injection as they can’t find any NHS workers locally willing to do this for trans adolescents. A simple injection that has been prescribed by NHS specialists which the local GP and nurses refuse to administer. Stressed adolescents are injected by a parent who has never before given an injection as their GP surgery has neglected their patient.

This is for a treatment that is already given as standard to 6 year old cis kids in precocious puberty. Because we can’t have a 6 year old cis girl with periods and breasts but that is fine for a 14 year old self-harming trans boy. Because we can’t have a 6 year old cis boy with a beard but that is fine for a 15 year old trans girl.

It is basic anti-trans children discrimination in health care.

The BBC show ‘Doctors’ includes a further brief reference to sex hormones. The mum states that the only way of getting hormones pre-age 16 is to go to the US. The GP shows a face heavy with scepticism and talks about safe-guarding. It would have been appropriate here to mention to Gillick competency, a concept familiar to all doctors. Across all areas of medicine adolescents are able to consent to complex irreversible medical interventions if they are deemed Gillick competent. The same benchmark should be applied to transgender adolescents.

The segment on sex hormones omitted to mention that provision of hormones before the age of 16 is deemed medical best practice in many clinics in the USA and elsewhere in certain circumstances – based on the benefits of peer concordant puberty (going through puberty at the same time as peers), due to recognition that children with a long track record of fixed trans identities are not going to suddenly change gender identities at age 15.

A well-informed GP would have also mentioned the global Endocrine Society’s 2017 guidance stating: “We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years”.

The mum in the BBC drama also makes a reference to “the operations” – a statement which is not clarified. There is so much ignorance about trans children in the UK that the fact that surgery is not considered for trans girls until adulthood does need stating.

One thing the show did portray convincingly is the parent pretty much begging a not-transphobic and slightly clued up GP to care for and advocate for her child. The programme ends with the GP in an ethical dilemma about whether to agree to be this child’s GP, and whether to be willing to state medical facts about accepted best practices for trans children’s care in a family court. Why is this an ethical dilemma? If the family were following any other medical specialist recommended health care, the GP would not consider it an ethical dilemma to defend this in family court.

The real ‘debate’ and ethical dilemma when it comes to GPs and trans children is why is there still such varied and poor practice? Why are desperate families encountering ignorance and transphobia from GPs? Why are GPs allowed to opt out of administering medically needed treatment that has been prescribed by an NHS specialist? Why are GPs treating trans children so much worse than cis children and why does no one care?

And if you want to a good indication of the wider institutional transphobia across the NHS that allows this poor healthcare for trans children to go unchallenged, look no further than the nonsense hokum that is “Rapid Onset Gender Dysphoria”. NHS children’s specialists have referenced ‘Rapid Onset’ in a presentation in a way that did not make it clear to service users and the general public that it is junk science.

In Canada, meanwhile, specialists working with trans children have endorsed a condemnation of Rapid Onset Gender Dysphoria as junk science, bunkum and quackery.

Where is the similar condemnation from the UK Gender Identity Development Service? I won’t hold my breath.

Given the poor state of the UK specialist service, whose protocols are outdated and not fit for purpose (with a 14+ month wait for current first appointments), we need GPs to step up and do more. GPs cannot continue to refuse basic care for trans children and adolescents. GPs cannot continue to claim that simple health care for trans adolescents is ‘too specialist’. It is discrimination clear and plain.

 

Update:

In episode 2 the GP goes to see a psychotherapist who tells him that the majority of socially transitioned 14 year olds change their minds. This is an outright falsehood.

Even the discredited Zucker/Steensma studies showed 14 year olds were extremely likely to maintain a trans identity.

The latest studies (Olson 2015 and Fast 2017) show that trans children have a clear identity at a very young age, that their identity is as valid and consistent as any other child’s.

The latest stats from Australia showed “From 2003 to 2017 96 percent of all patients assessed and diagnosed with Gender Dysphoria continued to identify as transgender or gender diverse into late adolescence”.

The ‘expert’ knows scarcely a thing of the latest evidence-based scientific consensus on care for transgender children.

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

 

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 (= 36) did not differ from controls matched on age and expressed gender (= 36), or siblings of transgender and gender nonconforming children (= 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 onchildren 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.”

Puberty Blockers (GnRHa)

sherlock data

Safe and reversible

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

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

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

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

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

Adolescents are eligible for GnRH agonist treatment if:

1. A qualified MHP has confirmed that:

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

2. And the adolescent:

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

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

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

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

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

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

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

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

“puberty suppression medication is reversible”

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

 

Criteria for adolescents to commence puberty blockers

1. A diagnosis of gender dysphoria in adolescence

2. Medical assessment including fertility counselling

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

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

Australian References:

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

  1. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study, de Vries et al (2011)
AIM: To compare psychological functioning and gender dysphoria before and after puberty suppression in gender dysphoric adolescents.

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

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

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

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

 

  1. Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment, de Vries et al, (2014)
BACKGROUND: In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.

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

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

Recent claims from the UK Gender Identity Service

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

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

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

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

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

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

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

Slide text:

“Rationale for the blocker: Are all aspects reversible?

The blocker as a diagnostic aid

The blocker as time to explore, understand, consolidate

The blocker as reversible treatment

Experience some puberty? Tanner stage 2

Stage of puberty not age

Transcription of audio  for this slide:

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

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

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

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

Next slide text:

Balancing evidence and Practice

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

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

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

Transcription of audio  for this slide:

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

Next slide text:

Number Mean Age Age Range
Mean age young people at EI clinic 162 12.82 8.99-15.1
Natal Males 70 12.89
Natal Females 92 12.97
Mean age at started blockers 119 13.59 10.5-15.5
Natal Males 54 13.64
Natal Females 65 13.54
Mean age at start CSH 25 16.18 16-16.5
Natal Males 10 16.21
Natal Female 15 16.17

2 stopped treatment

Transcription of audio  for this slide:

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

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

Next slide text:

Summary

T1 Outcomes show

Overall no change in psychological functioning (YSR and CBL)

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

No change in self-harming thoughts or behaviours

No change in Gender Identity or Gender Dysphoric feelings

No change in perception on primary or secondary bodily characteristics

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

Transcription of audio  for this slide:

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

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

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

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

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

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

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

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

How are GIDS backing up their hunch?

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

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

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

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

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

i) Cohen‐Kettenis et al (2008) 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Benefits and Risks of treatments for AGIO

Puberty delaying hormones. These have the following benefits:

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

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

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

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

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

“My work has been misrepresented”

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

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

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

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

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

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

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

“There is a passage in your blog:

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

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

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

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

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

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

In summary

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

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

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

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

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

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

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

So what have Tavistock GIDS published on puberty blockers?

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

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

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

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

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

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

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

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

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

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

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

“Despite a limited number of studies, the existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence.”

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

 

 

References:

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

Cohen‐Kettenis, P. T., Delemarre‐van de Waal, H. A., & Gooren, L. J. (2008). The treatment of adolescent transsexuals: changing insights. The journal of sexual medicine5(8), 1892-1897.

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The journal of sexual medicine12(11), 2206-2214.

Costa, R., Carmichael, P., & Colizzi, M. (2016). To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nature Reviews Urology13(8), 456-462.

De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine8(8), 2276-2283.

De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics134(4), 696-704.

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

Giovanardi, G. (2017). Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents. Porto Biomedical Journal2(5), 153-156.

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

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

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

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., … & T’Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism102(11), 3869-3903. https://doi.org/10.1210/jc.2017-01658

Korte, A., Goecker, D., Krude, H., Lehmkuhl, U., Grüters-Kieslich, A., & Beier, K. M. (2008). Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies. Deutsches Ärzteblatt International105(48), 834.

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

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

Murchison, G. (2016). Supporting and Caring for Transgender Children. Human Rights Campaign11.

Stein, E. (2012). Commentary on the treatment of gender variant and gender dysphoric children and adolescents: Common themes and ethical reflections. Journal of Homosexuality59(3), 480-500.

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

Winter, S., Diamond, M., Green, J., Karasic, D., Reed, T., Whittle, S., & Wylie, K. (2016). Transgender people: health at the margins of society. The Lancet388(10042), 390-400.

 

NHS Failing Transgender Children

Another day waking up to a national broadsheet newspaper accusing me of child abuse. Painting my child as mentally ill and a threat to others when she is neither.

“Under the banner of transgender equality children are being subjected to a form of child abuse by an adult world that is failing to treat or even wilfully exacerbate an often transient confusion” Melanie Philips, The Times, 3rd October 2017

The fact that we live in a country where these lies, this hate, this prejudice is regularly printed in a national daily broadsheet defies belief. I cannot imagine any other area where parents following evidence based best practice to support their children are so accused. Surely there would be an outcry if columnists accused parents of child abuse for vaccinating their children? These lies damage transgender children. These lies are themselves a form of child abuse.

Worse still than the fact that ill-informed bigots can write lies in the national press, is the knowledge that these lies will go unchallenged. Bigots in the media know that transgender children cannot speak up. They know that parents of transgender children dare not speak up. We just bow our shoulders, avoid looking people in the eye, wonder which of the judgemental faces on the playground have read the latest attack piece and believe we are abusing our child.

Where are our allies standing up for transgender children?

Where are the NSPCC, articulating the evidence based consensus that supporting transgender children is in their best interests, and that to reject and stigmatise transgender children is a form of child abuse? Where are the journalists who were so vocal when Trump was calling out for Trans service people to be kicked out of the US military? Where is the Stonewall poster saying:

“Some Children Are Trans: Get Over it”.

somechildrenaretrans

Where is the challenge from the experts in the NHS?

The NHS Gender Identity Service (GIDS) understands that public ignorance and prejudice is the number one barrier to the happiness and wellbeing of transgender children. The NHS Gender Identity Service is, as per its own guidelines, supposed to advocate for transgender children. In other countries, such as America and Australia, Gender Experts devote a portion of their time to public advocacy, defending and educating about transgender children – publically challenging lies and misinformation. They do this because they are all too aware of the impact of societal stigma, created, developed and perpetuated by a media of misinformation and fake news.

In the media appearances of UK NHS Gender Specialists, more care is given to defending their Gender Service to sceptics and transphobes, emphasising how some children are not really trans, emphasising how much caution they have, how slow and conservative their support is. They fail in their moral and legal duty of educating the public and advocating for transgender children. When media lies, misinformation and prejudice appears, instead of ignoring or fuelling this, they need to be challenging it clearly, fiercely and publically.

In response to today’s Times piece they should:

  1. Put a statement on their website in an clear area where parents and journalists can see it
  2. Put out a press release
  3. Write to the Times expressing their concern
  4. Write to the Independent Press Standards Organisation outlining that lies about evidence based NHS support for transgender children is damaging and harmful

I’ll even write it for them:

 

Press release:

“Transgender people exist. Transgender people always have existed, in countries all around the world. Being transgender is widely recognised as a normal part of human diversity. Transgender people are not a threat, or mentally ill, or confused. There is a durable biological underpinning to gender identity – this is not a choice and transgender people cannot be converted. Attempting to convert transgender people into a different identity is considered unethical and ineffective and has been outlawed by all competent evidence based professionals.

Transgender children exist. Medical consensus is that transgender children thrive if acknowledged and supported to live in their identified gender. Transgender children suffer high levels of depression, self-harm and suicidality if forced to live a lie. This is not a choice. Parents who support transgender children are following evidence-based guidance and are doing what is best for their child. Spreading lies, ignorance and prejudice about transgender children is a serious threat to their well being. Media bigotry, exemplified by today’s piece in The Times, is a form of child abuse that causes significant harm and suffering to vulnerable transgender children.”

Here’s a Tweet to go with it:

tavistep up

All the evidence shows That transgender children pre-puberty who are supported at home and at school have normal levels of mental health and well-being and do not require regular appointments with medical professionals. The single biggest support that the NHS Gender Identity Service can offer to these children is clear, confident advocacy on behalf of transgender children to an ignorant and ill-informed (and often hostile) media.

Every single media communication from the UK Gender Identity Service should be designed to serve the best interests of transgender children. This is currently not happening.

Parents are fast losing patience with an NHS service that is failing our children. The NHS must do better. Clear, confident communications supporting, normalising and de-pathologising transgender children is where they need to start.