The Erasure of Trans Children

transgender children erasure

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

This got me thinking of the erasure of trans children.

All too often trans children are completely erased from discussions.

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

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

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

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

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

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

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

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

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

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

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

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

 Submissions that referred to children more than twice:

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

These can be roughly divided into three categories:

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

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

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

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

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

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

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

 

Conclusion

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

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

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

Stop the erasure of trans children!

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

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

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

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

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

We must do better for trans children.

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

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

Trans children exist and they desperately need support.

Don’t leave them voiceless and invisible.

#SomeChildrenAreTrans #GetOverIt

Follow us on twitter @FierceMum and @DadTrans

 

Further info on the findings

Methodology

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

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

Limitations of the research findings:

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

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

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

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

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

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

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

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

Table: Organisations that refer once or twice to transgender children

Organisation Reference to transgender children
The Albert Kennedy Trust “The right of the parent to support a child through their assignment is important.”
Genderagenda “Typically, 1 child per class will come out to me and another will say I know someone trans/non-binary and ask for help supporting them.
The Government Equalities Office has one reference to trans children, quoting Ofsted “Ofsted’s Common Inspection Framework, which takes effect in September 2015 and covers standard inspections of early years, schools and further education and skills providers, requires inspectors to pay particular attention to the outcomes of a number of specific groups, including transgender children and learners.”
A young trans adult makes one reference “I feel that children are discovering what trans means through the internet rather than in a classroom environment, and I fear that as a result, either children would grow up with a slight bias, or children who are trans would not realise this until many years later, when it is more difficult to transition. “
LGBT consortium “Medical interventions for children and adolescents have been inadequate and do not meet international best practice standards”
LGBT Youth Scotland “Further, transgender young people are aware of their gender identity and begin living in their acquired gender far earlier than the age of 16. We recommend implementing provision which would enable parents and carers to give consent for a child or young person to receive a GRC under the age of 16”
National LGB&T Partnership

 

Medical interventions for children and adolescents have been inadequate and do not meet international best practice standards
Outreach Cumbria ‘Fourthly there is no local support for children and adolescents with gender identity difficulties with the nearest (and only) gender clinic being the Tavistock and Portman Clinic in London
A volunteer with the Albert Kennedy Trust “Early access to transitioning and being accepted from a young age is vital to the emotional and mental well being of a trans person and therefore families, social services and the NHS should work with all trans children and trans youths to be able them to decide their future and how they wish to live.”
Support U “Most of the above issues all apply to young trans people, although more education of peer groups of trans children would help”
Terry Reed “Numbers presenting for treatment have grown at ~23% p.a. over the last couple of years. In the children and young people group, the growth is even faster.

inclusion of transgender people: adults, adolescents and children, in sport.”

Trans Media Watch “Louis Theroux’s recent documentary on trans children for the BBC also received much acclaim
UK Trans Info Provide a method for children and teenagers who are below the usual age requirement to obtain gender recognition with the consent of their parents or guardians, or without their consent through the courts where it is in their best interests.
Anonymous “Ensure that those working in proximity with minors are aware how potentially transgender children can and should be helped.
Equalities Officer, on behalf of UNISON Bournemouth Higher & Further Education Branch Ensure the implementation of compulsory, trans-inclusive PHSE curriculum in order that children are made aware of the issues facing trans persons, help trans children access support, and tackle transphobic behaviour before it begins.

Without access to educational information and resources on gender identity, trans children may be placed under undue stress, confusion, and harm. Through the provision of compulsory gender identity education within the PHSE curriculum, work can be done to make trans children aware that they’re not alone, that discriminatory behaviour they may face is not acceptable, and of the support available to them.

University of Leeds Particularly vulnerable groups include intersex bodied people and trans children under 18
Scottish Transgender Alliance With growing social acceptance, the annual number of children and adolescents coming out as transgender has increased five-fold over four years
Anon There is a need for a more robust communication / awareness programme to help parents who believe their children may be gender dysphoric , and how they can help and cope
Anon A close family friend has a trans child who, age 8, told his teachers that he wanted to be a boy and have ‘boy parts’. The school reported his parents to the social services, assuming that the child had been abused, based on no other evidence
Individual Studies indicate that the majority of trans people know they are trans by the age of 7, and many experience distress throughout their childhood. A growing number of children are transitioning, and the lack of any legal recognition until a child is 18 is starting to cause problems, for example with names in school systems and examination certificates.
Individual Inclusion of trans history as a compulsory element of the UK schools national curriculum, linking it to organisational support for trans children, adolescents, their families, and their friends
Individual We need to be intervening sooner, so that trans-children grow up with a chance of fitting in to society and being truly inclusive, and non-trans children will grow up with understanding and tolerance, rather than behaving in a segregatory manner and ostracising trans-people

 

 

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.

 

Diagnostic importance of starting puberty?

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

Here’s the Endocrine Guidelines 2017

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

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

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

gender dysphoria worsened with the onset of puberty”.

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

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

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

We will therefore look at this in detail.

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

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

It offers as a conclusion:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  1. social divisions
  2. pubertal physical changes and
  3. sexual orientation

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

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

1. Social Divisions

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

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

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

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

2. View of puberty

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

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

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

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

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

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

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

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

The desisters were not even distressed about anticipated puberty.

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

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

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

3. Sexual attraction

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

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

This finding is problematic on multiple levels.

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

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

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

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

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

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

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

Summary

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

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

What the Steensma et al. 2011 study actually proves:

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

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

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

What policy recommendations this study makes:

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

What policy recommendations this study can justifiably make:

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

Tanner 2?

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

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

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

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

Summary:

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