transgender

AUSPATH KEY-NOTE SPEECH

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In late November I attended the AUSPATH (Australian Association of Transgender Health) conference in Tasmania, Australia. I had been invited as the key-note speaker on the first full day of the conference, given a 50 minute slot (followed by 40 min panel discussion with head of WPATH and head of PATHA (New Zealand Association of Trans Health). The audience was 555 people invested in trans healthcare, mostly trans healthcare professionals and advocates from across Australia, with a 50+ contingent from New Zealand. For transparency, as an invited key-note speaker I had my travel and accommodation paid by Auspath – I did not receive any other payments. A few people have asked if I can share my presentation – it was not recorded but I have captured a lot of the presentation content here, a mixture of my notes and memories combined with some of my slides.

Hi everyone, I’m absolutely delighted and honoured to be here today. I’ve already learned a lot about Australia in just a few days – I’ve learnt what a drop bear is. I’ve understood that my taste in Australian beer (VBs) is apparently bogan.

My name is Dr Cal Horton, I’m a trans and non-binary researcher from the UK. I’m also a parent of a trans kid. Being an advocate for and parent of a trans kid is not a particularly great position at the moment in the UK, so I will ask for no photos today please. I am currently based at both Oxford Brookes University and University College London. I am actively looking for routes out of the UK for my family, so if anyone is looking to hire a researcher, get in touch. I have no declared conflicts of interest – big pharma hasn’t come knocking yet – any day now, I’m sure.

Before I begin my presentation, I want to start with a reflection on the time and place at which I’m talking. In terms of place, I want to acknowledge the Muwinina and Palawa people as the traditional owners of this Land. I recognise histories of violent colonialism and brutal dispossession, and pay my respect to Aboriginal Elders past and present across Lutruwita. Sovereignty was never ceded, this was and is Aboriginal land. In terms of time, I recognise that we are speaking following two years of live streamed genocide in Palestine. In the UK we have a long and brutal history of colonialism and violence against marginalised groups. I note that this year the Lemkin Institute for Genocide Prevention raised a red flag warning for risk of genocide for trans and intersex communities in the UK.

Today my presentation is going to focus on how we move from pathologisation and violence to autonomy and rights in trans healthcare, with a focus on trans children. I’m using the term trans child to refer to everyone under the age of 18, though will sometimes reference more specific terms like trans adolescents where relevant.

When I talk about why the UK is so bad for trans people, why it is so bad for trans children, and for trans children’s healthcare, it is important to talk about the three Ps. Firstly Prejudice. We have a situation where individuals holding acute prejudice about trans people are in positions of influence or leadership over trans children’s healthcare. We have individuals in charge of the new children’s gender service who have never even attended WPATH, yet who have found the time to attend events organised by misinformation groups recognised as anti-trans hate groups.

The second important P is Pathologisation. In the UK you never even here the term ‘trans child’ in our NHS. It is all ‘gender questioning children’ or ‘children distressed by their gender’, ignoring the reality that the major reason that trans children are stressed and distressed is because of the violent persecution they are facing, including from the NHS. The language in the UK always focuses on describing trans children in pathologising terms, describing them as a group that are “complex” with extensive “co-morbidities”.

The third P, that impacts on trans children’s oppression in the UK, is Power. The current situation for trans children in the UK, the current situation for trans people in the UK, is impacted by the systemic exclusion of trans people from positions of establishment power, across and beyond the NHS. In my work, understanding why everything is stacked against trans children, I’ve started to increasingly focus on the concept of cis-supremacy.

PART 1: where the UK startedpathologisation & defensive practice
1A) Pathologisation Trans children’s care siloed in psychoanalysis A trans child as a problem The focus on understanding why a child is trans (what has gone wrong) No focus on supporting happiness & well-being in trans children Denial of recognition of a ‘trans child’ even as a concept
1B) WEAK Ethics and Accountability No routes to complaint for harmful practice Research without consent Interpretation bearing no resemblance to service user perspective About us yet definitely without us Growing levels of service user dissatisfaction Growing demand for affirmative care UK Clinicians becoming positioned as ‘the bad guys’
1C) CULTURE WAR HITS the UK Formation of anti-trans groups focusing on children Media fear mongering about trans children BBC anti-trans advocacy influencing public opinion Lobbying and court cases for removal of healthcare Culture war embraced by gender clinicians Positioned as ‘the sensible middle’ between anti-trans and trans radicals Encouraged rather than knocked down misinformation ‘complex’, ‘difficult’, ‘unknown’
1D) DEFENSIVE PRACTICE Agreeing with need for ‘caution’, emphasising how cautious they are Agreeing that it is ‘risky’, emphasing how much they care about risks Agreeing it is ‘unknown’ – we don’t even know what causes transness – it might be caused by child abuse Emphasising how much they are raising barriers to care Emphasising how much they are restricting care But: Cannot fight an anti-trans lobby movement through agreeing with its core messages
PART 2: where the UK is nowpersecution & state violence
1) State persecution Criminal bans on trans healthcare for under 18s Denial of legal recognition and protection to trans children and adolescents State and legislative attacks on basic rights to exist as a trans person Institutional threats to affirmative families
2) A hostile environment for healthcare Institutional, legal and regulatory barriers to informed consent healthcare services Affirmative doctors investigated and taken out of practice Media targeting of affirmative healthcare providers Absence of professional body advocacy in defence of rights-respecting healthcare providers.
3) A hostile environment for mental health and well-being Hostile and discriminatory school environments Bans on trans children participating in sports Barriers to childhood social transition Misinformation and hate from media and politics Co-ordinated, well-funded and influential campaigns against trans children’s rights
4) Pathologisation, control and conversion Services centred in mental health, diagnosis of identity, gatekeeping Mandatory, pro-longed and extensive psychological and developmental assessment Searching for a cause or other explanation for being trans Mandatory exploratory therapy or psychotherapy Stakeholders holding prejudice about trans children permitted to influence healthcare policy. Delays and conversion practices
5) Violence trauma and inequality Widespread denial of access to timely and individualised medical transition Discriminatory barriers for those who are neurodiverse, disabled or non-binary Coercive requirements that children are forced to endure to access care Intimidating multi-disciplinary teams Widespread institutional violence and trauma Disregard of bodily autonomy and consent

When I talk about why the UK is so bad for trans people, why it is so bad for trans children, and for trans children’s healthcare, it is important to talk about the three Ps. Firstly Prejudice. We have a situation where individuals holding acute prejudice about trans people are in positions of influence or leadership over trans children’s healthcare. We have individuals in charge of the new children’s gender service who have never even attended WPATH, yet who have found the time to attend events organised by misinformation groups recognised as anti-trans hate groups.

The second important P is Pathologisation. In the UK you never even here the term ‘trans child’ in our NHS. It is all ‘gender questioning children’ or ‘children distressed by their gender’, ignoring the reality that the major reason that trans children are stressed and distressed is because of the violent persecution they are facing, including from the NHS. The language in the UK always focuses on describing trans children in pathologising terms, describing them as a group that are “complex” with extensive “co-morbidities”.

The third P, that impacts on trans children’s oppression in the UK, is Power. The current situation for trans children in the UK, the current situation for trans people in the UK, is impacted by the systemic exclusion of trans people from positions of establishment power, across and beyond the NHS. In my work, understanding why everything is stacked against trans children, I’ve started to increasingly focus on the concept of cis-supremacy.

Cis-supremacy Cis-supremacy is a situation where cis people hold power over trans people, in cis dominated institutions, systems and societies. Cis-supremacy operates through the exertion of power over trans people, with trans people subject to control, systemic injustice and coercive violence
CONTRIVED Authority* Example 1: The Cass Review. Put a stamp of authority on policies that: 1) Closed-down existing healthcare 2) Erased the existence of trans children 3) Enabled transphobic policy to be labelled as ‘child protection’ 4) Enabled wider persecution of trans people without the question – but what about trans children? *Dr Natacha Kennedy
CONTRIVED Authority Example 2: The Commission on Human Medicine. Put a stamp of authority on policies that: 1) Defined puberty blockers as ‘dangerous’ (but not for cis people) 2) Criminalised private access to puberty blockers 3) Helped coerce young people into an abusive puberty blocker trial Policy-based evidence making
PART 3: TRANS KIDS in the UK
WHAT HELPS TRANS KIDS Social affirmation Affirmative healthcare Protection from medical violence Protection from prejudice & hate Protection from Gender Minority Stress Welcoming schools Supportive families
This slide shows the same text as the preceding slide, with red crosses next to each point.
HUGE rise in HARMS since CASS Schools Gender service Social services & GPs Forced medical detransition & forced puberty Self-harm and suicidal ideation School drop-out & social withdrawal Fear & pain & trauma
Healthcare Violence Significant harms experienced by trans children & supportive families in new UK gender clinics. Interviewed for 4 hours by panels of 4-6 clinicians. Invasive Abusive Pathologising Dehumanising Traumatic
Slide showing illustration of being asked inappropriate questions in gender clinic, labelled as 'holistic assessment'.
Pscyho-education Mandatory 2-day psycho-education course. Written by ‘alleged’ conversion practitioners. Misinformation Dis-education Conversive Pathologising Fake theories on causation
PATHWAYS STUDY 3,000-6,000 youth to be invasively questioned and studied without any medical care. 113 youth to receive puberty blockers following intensive assessment & approval process 113 youth to receive puberty blockers following additional 1 year delay
PATHWAYS STUDY Abusive & traumatic over-assessment: Extensive physical assessment, cognitive assessments, brain scans, bone scans, urine tests, blood tests, heart monitoring Over 314 different psychological assessment questions, repeated – using deeply pathologising and outdated questionnaires Domination: Full compliance required. Clinicians can deem ineligible on a whim. Approval reassessed every 12 months.
PATHWAYS STUDY Mandatory exploratory therapy: Full compliance with non-affirming and conversive talk therapy a requirement before and throughout the trial. Designed to fail: Key outcome measures are irrelevant and unclearly linked to expected impacts of puberty blockers. Study will not provide clear evidence of the usefulness of puberty blockers. Highly likely has been designed to show minimal or unclear utility.
Rising ANGER. Photos of protests by Trans Kids Deserve Better. “In the UK, we as trans young people don't have the right to access gender affirming care. We used to spend years on waiting lists for medical support, but now the doors are fully closed to new patients. The medical support we need is extremely time-sensitive, and many of us die waiting. Our supportive parents have been threatened with child safeguarding referrals, our pharmacies have been forced to hold back our medications, and our schools have been made battle grounds with us at the same time as weapon, aggressor, and victim. We refuse to live like this. We deserve better.”
Part 4: Autonomy & rights
Priority actions 1. Changing the narrative - Recognising systemic violence 2. Depathologisation 3. Rejecting defensive and conversive approaches 4. Confidently communicating 5. Removing clinical control 6. Centring rights
1. Changing the narrative: Recognising Systemic Violence Violent schools vs safe schools Violent families vs safe families Violent healthcare vs safe healthcare Role for medical authority (impossible to read screen shot of infographic on supporting trans kids in schools)
2. Depathologisation If we accept that being trans, at any age, is fine – do our systems and approaches really make sense? Do trans children & young people have a harder pathway to healthcare than cis children? Fundamental reforms Active depathologisation Resisting re-pathologisation Strategic effort will be needed
Pathologising LEGACY Measures Many current tools in current use can be considered Pathologising Legacy Measures. Authenticating Transness, Intrusion, Delegitimisation, Transnormativity, and Over-assessment. ‘Validation’ under pathologising practice is not valid. Tools for measuring gender, body image and multi-concept tools especially problematic. No role for PLMs in modern practice.
3. REJECTING DeFensive & Conversive Approaches Care designed in response to transphobic pressure does not centre the healthcare needs of trans children. Need to recognise & resist pressures to make care worse, & instead continue to push to make care better. Duty of care to avoid harmful questioning Avoiding identity probing or forced exploration Removing delays and barriers Removing MDT assessment
4. CONFIDENTLY Communicating Affirmative care works. We need to see confident communication on the importance of affirmative care. Schools & families & our media need to hear this from medical professionals. Communication needs to centre the dignity & rights of trans children – not centring the carefulness and control of clinicians. Communication needs to centre the healthcare of all trans youth – disabled, minoritised, neurodivergent, non-binary – no one left behind
5. Removing Clinical Control Dismantling power imbalances Informed consent for all Increasing accountability Centring rights
6. Rights (impossible to read screen shot of article on 'Child Rights in Trans Healthcare - a call to action')

Thank you for listening.

My wider reflections on AUSPATH are available here:

Reflections from AUSPATH

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Last week I had the huge privilege of being invited to give a keynote speech at this year’s Auspath (Australian association of transgender health) conference, held in Tasmania. I loved being at Auspath, met many awesome people, and enjoyed learning about Australian approaches and best practices, many of which I wish the UK would learn from. There were also a couple of things at Auspath that gave me pause. In this blog I’m going to briefly run through some of the things I liked best at Auspath, before a deeper dive into two areas of that left me thinking. I don’t claim to have all the answers, but am sharing my current thinking – I would love to hear other people’s takes, on their experience at Auspath, on their priorities for improving trans youth healthcare in Australia and beyond, and on their experience and perspectives on the two issues covered at the end of this blog.

Highlights

It was a rare joy to be around so many incredible people fighting hard for a positive future for trans kids. I really valued:

  • Hearing so many clinicians speaking with genuine compassion and respect about trans lives. Even where I took issue with a minority of clinical approaches, the professionals I heard at Auspath clearly cared for trans youth, clearly had a base level of respect for trans lives, clearly wanted the best. It is a very different world from the UK where I can count on one hand the number of NHS professionals I’ve met who I’ve heard speak respectfully about trans kids. I’ve focused the latter sections of this blog on critique rather than praise, because pretty good shouldn’t be the bar – Australia has the potential to be world leading in trans youth healthcare.
  • Hearing so many professionals, advocates, community members, parents, allies, speaking with determination about protecting trans kids and trans healthcare from the abuses spreading across the world.
  • Hearing an impressive and eloquent young person speak about their experiences, including obstacles and barriers to equal access to healthcare.
  • Hearing an impressive and eloquent parent share their experience on the difficult path advocating for a trans child in Australia.
  • Learning about Country and first people’s knowledge and experience. It would have been good to hear more on the topic of first people’s experiences and priorities.
  • Listening to a panel talk about the fight for trans kids in Queensland (I was crying through most of that panel).
  • Feeling really welcomed at the conference, some many people came up to me with kind and friendly words, and I also felt very welcomed as a non-binary person in that space.
  • Hearing a panel of young adults speak on their experience advising on trans health research projects, on the need to include young people who were unable to access paediatric services, the need to include rural youth, the need for fair pay, for both career development opportunities for those who are research inclined as well as keeping space for input from young people with no interest in working in research. The importance of disability justice informed approaches.
  • Meeting young adults who are willing to challenge establishment status quo approaches. I think this is really valuable. So much cis-supremacy and cisnormativity operates through the maintenance of outdated systems and approach that we don’t even question. Having young people speak up and ask these questions is super important. One such question was ‘do we ever need to collect and report on data on assigned sex/gender?’. It’s a really good question. My current answer is ‘I don’t know, but certainly very significantly less than we do at present. This is definitely a question I will carry with me. I’m doing a new piece of research at the moment on non-binary adults and in that survey we are including a specific question ‘do you want to see results from this research broken down by assigned sex/gender?’, along with open text boxes for people to share their reason for or against. These answers should likely be context specific and driven by the information needs of the people whose data it is. Certainly we should have already moved away from the approach I still saw some places in Auspath where a person was introduced as ‘patient A – AFAB – identifies as a boy’.
  • Meeting lots of awesome people from New Zealand, commiserating and strategizing on how to fight and support young people through state enforced discrimination.
  • Meeting lots of healthcare providers working outside of specialist gender clinics, who are working to develop alternative routes to respectful and informed consent care. Many of these are currently supporting adults – with confidence and advice the same care can be extended to under 18s.   

There were two points in Auspath where I heard completely different messages from different people, and that relates to the two topics that I’d like to do a deeper dive into in this blog: MDT assessment and comprehensive bio-psychosocial assessment. Some people came up to me and expressed concern that such things were happening in the UK, and that we should fight them being introduced in Australia. Other people came up to me to share their knowledge of these practices being experienced by trans children in Australia.

In my presentation I spoke about the harms of excessive questioning of trans kids. In the UK this 100% comes from a position of bad faith. Clinicians are encouraged to ask hundreds of questions, with an intention of probing, prodding and undermining trans identities. At Auspath I did not hear any explicitly and intentionally bad faith or actively transphobic intent. I did however, from some clinicians, hear approaches that, whilst coming from a better place, constitute the same excessive questioning. In Australia this excessive questioning was sometimes marketed and justified as ‘adding value’. Even from some brief conversations with service users I heard people share stories of having experienced this ‘added value’ as harmful. I would really like to call attention to the over questioning of trans kids even in nominally affirmative services. Being trans is normal, and trans kids shouldn’t be faced with extensive additional healthcare questioning compared to their cis peers. Any systems that normalise asking additional bio-psycho-social questions of trans kids compared to what is standard for cis kids is a problem. And here, our base comparator should not be the among of questioning that is standard for cis kids who need psychiatrist or psychologist support – our comparator should be an average cis kid who is not under psychologist or psychiatrist led care. Simply being trans, or accessing trans healthcare, does not justify invasive and excessive psychology centred questioning – this approach is a legacy of pathologisation. Two phrases were heard at Auspath more than I would like: Multi-Disciplinary Team Assessment, and Comprehensive Bio-Psycho-Social Assessment.

Multi-Disciplinary Team Assessment

In the UK it is presumed that a trans child needs to be assessed by multiple different professionals, often including a psychologist, psychiatrist, paediatrician, social worker, and that is before assessments with an endocrinologist or fertility specialist. These multiple levels of assessment are abusive and excessive. At Auspath clinicians listed a dizzying array of different professionals being involved in MDT assessment of trans kids. In Spain, in the highly respected Transit service in Catalonia, trans kids see one medical professional, usually a GP. The GPs role is to support informed decision making by a trans young person (and their family depending on age), their role is not to assess and decide upon access to healthcare. In this Spanish service that one medical professional, that one GP, can provide healthcare, including endocrine care for trans adolescents, without input from additional professionals. They do still operate in what they describe as a multidisciplinary team, having different colleagues within their service. This multidisciplinary team allows the GP to offer access to different additional services, optionally, in an opt-in approach. Young people can ask to additionally see a psychologist. They can ask to see a social worker or family worker, to support with school for example. But these additional professionals are additional optional services, a trans young person does not have to see, and certainly does not have to be assessed by, a whole multidisciplinary team of different professionals.

At times in Australia it was unclear to me what different clinicians mean when they refer to multi-disciplinary team working. I hope Australian colleagues can consider and articulate where they are working within an MDT that offers optional opt-in access to a range of different professionals, without mandating that a trans child see an overwhelming range of different professionals. I hope clinicians can be clearer in whether their approach forces trans young people into running a gauntlet of different stages of assessment by a series of different professionals. I hope more attention can be drawn to the harms of forcing trans children through multi-professional assessments where additional professionals are not desired or needed. WPATH SOC 8 recommends an MDT assessment for trans adolescents – I hope Australia can be part of building an evidence base for a better approach in time for SOC9.

Comprehensive Bio-Psycho-Social Assessment.

This is a term that I find really triggering. In the UK this term is used to define practices that are pathologising, intrusive, uncomfortable, and harmful for a trans child. When I first heard this term from clinicians in Australia I assumed it meant something else here. I initially hoped that it was being used as a defensive practice, by clinicians under anti-trans pressure, who are keen to emphasise the thoroughness of their care, using this term as a fancy descriptor for actions that I, as a non-clinician, would describe as ‘having a chat’, or ‘getting to know your patient’. A good GP can ‘have a chat’ with a patient, and quickly find out some useful information about them to better help them understand, build rapport with, and support their patient. This can include some brief questions to understand their life circumstance, their family support, their strengths, supports, stresses or concerns. This can be done rapidly in a first appointment as a non-intrusive, flexible, patient-centred and low stakes chat. This should not be defined as a ‘comprehensive bio-psycho-social assessment’.

I was chatting to one clinician, who described taking notes during such a ‘getting to know you’ chat, with those notes not affecting care pathways but being taken primarily to enable quicker rapport building at the next appointment. I commented that I find it really uncomfortable to have clinicians take notes when I am asked questions about my life and circumstance. This is clearly linked to my own institutional trauma in unsafe healthcare settings where answers to these questions are definitely being judged by clinicians, where answers might end up in a non-consensual case study report, and where these notes do impact on your (or your child’s) access to care. It is important for good healthcare professionals to note how much institutional trauma and distrust many trans people, including trans kids, carry into the clinic. Even young people I met in Australia spoke at length of trauma experienced in encounters with various healthcare professionals who were there to judge and control.

I had initially hoped that references to ‘comprehensive bio-psycho-social assessment’ were just a sign of defensive practice. I was dismayed and at one point upset to hear that actual comprehensive bio-psycho-social assessments are still a core part of care in locations across Australia, particularly in trans children’s healthcare, particularly in services delivered by mental health professionals. I was disappointed to see reference to incredibly detailed family tree mapping, filled with details entirely unrelated to a child’s access to trans healthcare services. I was disappointed to see wide-ranging body mapping exercises, children asked to draw themselves, notes taken on left or right handedness, even assessments of pen grip. Many of these unnecessary and pathologising over-assessments were marketed and justified by professionals as ‘adding value’. If we are seeing a trans kids, we ‘might as well’ assess whether they are having trouble holding a pen. We might as well investigate their full family system for areas of family disfunction. We might as well screen for ADHD, autism, anxiety, anger issues, dyslexia, poor family functioning, disordered eating, sexual health support needs, bullying support needs etc etc.

The list of things we ‘might as well offer’ as ‘added value’ while we are here grows ever longer, especially in trans children’s healthcare. Some of this emphasis on ‘added value’ is perhaps a symptom of some professionals realising that the original reason for their role is outdated, pathologising and unneeded. But why are ‘added value’ assessments brought into trans children’s healthcare? Why are trans children’s healthcare assessments so broad, ill-defined, all encompassing? The answer lies in services that are struggling to adapt from a pathologising model of care.

In terms of unnecessary questioning added on to trans healthcare, I am perhaps least worried about short screening questions that are designed to triage young people to additional support services that might well be beneficial. Some trans kids might also want an ADHD assessment. Some might want support for anxiety. But even then I’d rather this was done transparently, optionally, and with patient consent ‘would you like to do a few additional questions to help us see whether you might benefit from our optional mental health or neurodivergence services including related to anxiety, ADHD, eating disorders etc. For triaging child developmental concern, this can be similar ‘while you are here, would you like us to check your/your child’s pen grip, for dyslexia etc’. This transparency is important as it helps service users understand and have trust in the process, while also letting them tell clinicians when ‘added value’ services are not need, are already being managed by other professionals or are not wanted at this specific time. Crowding all types of assessment into a trans health assessment makes these extra long and stressful.

Then there are areas of a comprehensive bio-psycho social assessment that are clear remnants of past pathologising models. Questions on childhood toys, friendships, family gender roles, sexuality of parent or child, and many other unnecessary questions are inappropriate. At the conference there was one exchange that was particularly noteworthy. A clinician commented that they always ask trans young people about their romantic relationships. They noted that young people commonly respond by querying ‘why are you asking this?’. They said that they then tend to respond ‘Because it helps remind me that you are a full human, more than just your gender/transness’ (I didn’t take live notes and won’t be getting the statement 100% accurate).

I had three reflections on this answer. Firstly, it is important to recognise power dynamics in a clinical encounter. It is hard for any service user to question the approach of their clinician. It is particularly hard in a trans healthcare appointment, and especially so for a child. If young people are questioning our approaches, we would do well to take this as a significant potential indicator of discomfort. It is really hard for a child to question an authority figure, especially one whose approval they need. If we are asking questions that young people indicate some level of discomfort with, if there is not a very strong clinical need, surely we should not be asking those questions.

Secondly, I note that the young person’s question ‘why are you asking this’ was not provided a satisfactory answer. Clincians should not need private information on trans people’s lives in order to remember that we are more than being trans. I don’t think the speaker realised the impact of their words on some trans people in that room. I left the room at that point. There is a long history of trans people, especially trans kids, being asked invasive questions for no reason other than to satisfy clinician curiosity. Curiosity driven questions are entirely inappropriate – we shouldn’t have to humanise ourselves in order to access healthcare.

Thirdly, sexual orientation and relationships questions are often asked without clear purpose. In the UK these questions are deemed necessary based on anti-trans fake theories of childhood transness being a reaction to homophobia or sexual abuse. In the UK’s puberty blocker trial these are also justified through inclusion of a criteria excluding youth with any judged potential for having unprotected sex from eligibility to access the trial.

In less transphobic services these questions are sometimes justified by reference to a need to screen for unmet sexual and reproductive health information and support needs. I would tend to agree that trans youth may have unmet sexual and reproductive health information and support needs. Schools, regular resources and parents may all be ill-equipped to provide trans-inclusive education. But screening for unmet sexual and reproductive health needs can be done transparently, intentionally, none creepily and with consent. It does not need to be untransparently sneaked into a wider trans healthcare assessment, where historically youth have been forced to answer unwanted and intrusive sexual questions driven by clinician curiosity or clinician ignorance, unrelated to screening for sexual and reproductive health services. I would suggest that asking a young trans adolescents about their sexual and romantic relationships or desires is rarely an effective strategy in building rapport. When asking potentially irrelevant questions that are likely to make a young person uncomfortable it is not sufficient to give them an option not to answer. Some questions should not be asked. I’ve accessed specific sexual and reproductive health services as an adult without being asked any of the type of personal questions that psychologists and psychiatrists sometimes feel entitled to ask of trans children.

I would strongly question the appropriateness of insisting on a comprehensive biopsychosocial assessment in trans youth healthcare. I would ask clinicians to document much more clearly the questions they are asking and the purpose or clinical need for each question. I would suggest tat rapport building questions should be short, comfortable, flexible and non-intrusive. I would suggest that ‘added-value’ screening questions to triage to additional support services should be transparent, opt-in areas of questioning, strongly delineated from what is being assessed.

I hope we can quickly evolve away from assessment-based models of care for trans children and young people. And while assessment remains, we all have a shared duty of care to reduce the exceptionally excessive breadth and depth of questions that have become wrapped up in a comprehensive biopsychosocial assessment. Professionals who are able to deliver effective rights-respecting healthcare to trans children and young people in Australia without invasive psychological and psychiatric assessment as standard, please can you more clearly communicate what questions are actually clinically necessary, whilst also documenting the questions that you consider not clinically valid. (I’m happy to anonymously share examples on my blog).

Trans healthcare is not a psychological or psychiatric treatment, and we need to move trans children significantly further from being in positions of psychology/psychiatry-centred questioning and assessment. I’m not against jobs for psychologists and psychiatrists – we can channel those existing resources into helping trans kids with anxiety and stress related to living in a trans-hostile world, and into treating the adults around them who fall into anti-trans radicalisation. Trans kids in rights-respecting healthcare services across different parts of the world receive trans healthcare without a comprehensive biopsychosocial assessment, and we can aspire to this across Australia.

Flight home

After Auspath I tagged on a few holiday days in Tasmania, seeing some beautiful landscapes and wildlife, an incredible experience. I’m writing this blog whilst rather sleep deprived and time-zone confused on a long flight back to the UK. In the two weeks I was away, the UK has completely removed protection for non-binary people (in a legal case that made absolutely no sense); the UK has banned trans girls (and trans women as leaders) from girl guides; and banned trans women from the Women’s Institute. These are all severe blows. Girl Guides has long been one of the best allies for trans girls – an organisation whose inclusive policy we have long pointed to when asking for schools or other organisations to choose equality and inclusion. Having them bow to transphobic pressure is a blow not only for the impact on Girl Guides, but for what this means for the whole state of inclusion of trans girls in UK society.

I have felt so much lighter and safer being in Australia and fly ‘home’ with significant trepidation and fear for the future. At least I am re-energised from feeling safe and hopeful through my days in Australia and at Auspath. But the fight goes on.

Thanks to anyone who got to the end of a very long blog!

In cross-national solidarity,

Cal

Harming trans kids – Using art to capture the impacts of the Sussex ICB investigation

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When puberty blockers were banned in June 2024, the legislation included a clause stating that those currently on blockers would not be medically detransitioned, and could continue care if adopted by an NHS GP.

Only one NHS GP practice, WellBN in Brighton, agreed to take over this care, with trans adolescents and families from across Great Britain moving to their care. Patients have reported extremely high rates of satisfaction with this care.

In May 2025 ICB Sussex (ICB = Integrated Care Board, the level of bureaucracy above a GP practice and below NHS England) and NHS England launched an investigation into this care. The investigation has already caused a high level of harm to trans adolescents and families. Essential care is under threat of being taken away, with a threat of forced medical detransition. One person (I can’t share their identity) put this situation into a series of illustrations, capturing powerfully the current situation. This has been shared on instagram, but for those who don’t use it, they gave me permission to share here. I’ve added a bit of extra context.

Image one captures the ICB’s allegation of trans adolescents having been exposed to ‘potential harm’. What we instead have seen, is young people thriving and excelling through access to respectful affirmative healthcare.

[Description of image 1 “Potential Harm”: One trans young person is winning at sports; One is dreaming of a happy future relationship and marriage; one is hanging out with friends; one is doing their school work; one is playing the piano while proud parents watch; one is going shopping with a parent – while professionals write up reports of potential harm]

Image two captures the NHS’s approach to data collection. GP practice patients refused consent for the ICB taking their private patient data. GP practice patients, adolescents and parents, added notes to their files formally refusing permission to share their data. The GP practice did not want to share this data, and refused for several months. The GP offered anonymised data – the ICB was not interested in anonymised data. The ICB and NHS England stated that consent was not necessary due to ‘patient safety concerns’ despite no evidence of harm. The ICB finally threatened to cancel WellBN’s whole NHS contract, closing down a GP surgery with 25,000 patients, if they didn’t hand over patient data. WellBN at this point folded and handed over all trans children’s data. Information commissioner office complaints have been submitted.

[Description of image 2 “Data Pulling”: A house is being trashed with objects broken. Men in black suits (with the words Multi-disciplinary team on their top) are forcibly removing boxes of data, while adolescents and families try to keep hold of them. The boxes are labelled ‘private data’, ‘gender history’, ‘medical history’, ‘childhood history’.]

The third image covers the evaluation of patient harm. A patient harm investigation is being conducted without speaking to a single trans adolescent or family. It is being conducted purely based on clinical notes. The conclusion has been pre-determined with the investigation clearly considering affirmative care inherently a form of harm. Trans adolescents and families have prepared testimony on the reality that not only has there been no harm, their care has been excellent. Trans adolescent and family voices are not being heard.

[Description of image 3 “Desktop Review”: Adolescents and families are shut outside, using loud speakers to say ‘Please hear us, we were not harmed’; ‘children not harmed’, ‘no harm only care’. Inside, behind thick walls sits the head of the investigation team doing a ‘desktop review’ writing ‘harm is evident’.]

The fourth image focuses on the ICB’s plan to close all WellBN Care and refer patients elsewhere. Trans youth who are under 17 are to be forced to into gender clinics that offer conversive talk therapies focusing on investigating trans identities. 17 year olds will join waiting lists for adult care that stretch into years and years long.

[Description of image 4 “Expedited Referral”: A scared young person is being pushed into a room. The room was labelled ‘conversion therapy’. The word conversion has been crossed out, and in its place the words ‘gender exploratory’ therapy are now scrawled. In another scene a slightly older adolescent sits at a computer where the screen states ‘Gender Identity Clinic waiting times: 75 years].

Image 5 covers the preferred NHS approach for trans youth, gender clinics that focus on invasive, traumatic and inappropriate questioning of trans youth.

[Description of image 5 “Holistic Assessment”: Worried looking parents embrace a worried looking adolescent on one side. Ahead of them is a barrier labelled ‘caution no treatment ahead’. Behind the barriers are six faces with word bubbles ‘how do you feel about your penis?’; ‘do you get erections?’; ‘how often do you masturbate?’; ‘Are you sure you’re trans’?’; ‘Do you like girls’ underwear?’; ‘are you gay?’].

Image 6 focuses on the ICB’s intention for ‘assisted withdrawal’ of affirmative healthcare. This is forced medical detransition. It is abusive and harmful.

[Description of image 6 “Assisted Withdrawal”: A trans girl is having her long hair cut and facial hair painted onto her face; a trans boy is having breasts added; a young girl musician is crying while a professional says ‘don’t worry you’ll be singing with the boys in no time’]

The ICB have stated that they expect the outcomes to be ‘stark’ for impacted trans youth ‘especially the younger ones’. This image powerfully captures the type of stark outcomes that the ICB is well aware of as possibilities, having included these risks in their own risk assessment.

[Description of image 7 “Stark Consequences”: The image shows various depictions of children and adolescents having serious mental health consequences, including school drop out, stopping eating, mental health crisis and death]

The eighth image captures the ICB and NHS England’s intended ‘robust tracking approach’. Now that they have full patient data on adolescent and supportive families, they intend to ‘robustly’ track these children and families, keeping their data for 20 years, and tracking what adolescents and families do next. They have stated that if they think families and adolescent will continue to access medication through private means, they will be reported by the ICB to social services. Families and adolescents feel extremely threatened, extremely unsafe. Many are trying to find ways to flee the country.

[Description of image 8 “Robust Tracking Approach”: A scary large figure with a magnifying glass stares down at a scared looking child, while parents try to pull the child away to somewhere safer]

The final image shows scared young people being pushed into a black hole.

[Description of image 9 “Improving Lives Together”: Scared young people, some of whom are crying are being pushed into a black hole. The adults pushing them in are saying statements like “just one of those stark outcomes”; “have to follow the guidelines”; “It’s not commissioned”; “the guidelines have shifted”; “there are trans kids?”; “the terms of reference sets this out quite clearly”.

Across all of the above images the artist has included ICB Sussex’s tagline ‘Improving Lives Together’.

Questioning trans kids

/ growinguptransgender / Leave a comment

The UK Government and UK research councils have contributed £10 million pounds to a series of research studies on service users of the newly established Children and Young People’s Gender Services.

These studies include the PATHWAYS study programme (Puberty suppression And Transitional Healthcare with Adaptive Youth Services) led by Kings College London in partnership with the NHS. This programme covers five different studies.

 1) ‘PATHWAYS HORIZON’ is a longitudinal observational cohort study of all children and young people (n~3600) attending CYPGS.

2) ‘HORIZON Intensive’, encompasses a sample of those from PATHWAYS HORIZON who are not approved to receive endocrine care who will be more intensively studied as a control group for PATHWAYS TRIAL;

3) PATHWAYS TRIAL, a study of those approved to receive puberty blockers (GnRHa) as part of a research study.

4) ‘PATHWAYS CONNECT’ a study of  cognition and brain development in CYP attending the services, including those who are and are not receiving GnRHa.

5) ‘PATHWAYS VOICES’ a longitudinal qualitative interview based study of CYP attending CYPGS. In this article we will focus only on the first study, PATHWAYS HORIZON.

Here I’m just focusing on the questions that will be asked under the first study, Pathways Horizon.

In this blog I want to do two things:

  • Highlight some big picture concerns with the questions asked in the PATHWAYS Horizon study, alongside some recommendations for families and young trans people engaged with the new NHS England and Wales Gender Clinics.
  • Outline in an accessible format all the questions that are being asked in that study, so that families and trans young people can be better informed on whether they choose to participate.

The PATHWAYS Horizon study hopes to gain the consent of 80% of young people and families to participate in it. I hope that number will be very much smaller. I do not believe it will add useful information to our academic understanding of trans young people, certainly not information that is worth the risks and harms inherent in the whole approach and service. I consider not participating in this study (or at least opting out of the more harmful tools) an act of harm reduction for trans children, young people and supportive families. When I was first given some of these exact same tools, many years ago, when I first attended a GIDS appointment as a naïve and unknowledgeable parent of a young trans child, I did not feel able to decline to participate in filling in questionnaires that made me feel really uncomfortable. I hope to empower others to make a different choice.

Big Picture Concerns

  • They are asking an excessive number of questions, which is itself abusive and unreasonable – over 314 questions are here listed.
  • A large number of these questions of more or less irrelevant or only tangentially relevant for trans kids – they are not clinically useful, necessary or meaningful
  • These questions will never demonstrate what healthcare benefits trans children.
  • The data collection shown here will be exhausting, time-consuming and expensive, a colossal waste of NHS and research resources whilst not delivering useful outcomes.
  • Many of the questions outlined below are deeply pathologising, invasive, trauma-inducing and inappropriate.
  • Several tools present trans children as a problem, potentially reaffirming parental biases, and potentially reinforcing trans children’s shame and self-hate.
  • I continue to recommend families to avoid the new service, as it holds very little potential of offering anything of value, and high potential to cause significant harm. For many families it may just end up being a significant waste of time.
  • If families choose to attend, hoping for the chance to be part of a puberty blocker trial, please think carefully before choosing to participate in this research. As an academic researcher specialising in this field, this planned research is not needed, will not lead to better care for trans youth, and in the wrong hands research of this nature can be distorted to further reinforce pathologisation, control and barriers to care. Participation in this research is not necessary to be eligible for the puberty blocker trial. Please know that you can decline participation. Please let your young person know they can decline participation.
  • If you do still choose to participate, please be aware of the potential for harm and trauma in several of the tools outlined below.
  • In particular I am concerned about the tools labelled the Child Behaviour Checklist (which is an awful tool to use for trans children, asking 118 questions on how much of a problem they are to the world), the Utrecht Gender Dysphoria Scale – Gender Spectrum (UGDS-GS) (which uses very outdated measures of gender dysphoria); Body Image Scale – Gender Spectrum (BIS-GS) (a horrific tool that asks children to assess how much they hate all their body parts); the ALSPAC Romantic Relations (which in spite of its name asks totally irrelevant and intrusive questions about the sex life of those aged 12-17). The SCOFF tool has a questionable name for a tool designed to screen for eating disorders.
  • I continue to be concerned about the questions that will be asked under the heading ‘medical history’, which by description is far wider a category with room to ask all kinds of irrelevant questions. I expect that component could include the typical gender clinic fascinations: many questions for parents on childbirth, parenting approaches, family deaths, family tensions, family gender roles and other irrelevant and trauma-uninformed lines of questioning. I expect there will be many questions for young people on defending and justifying their theoretical understanding of gender, and questioning them on proposed causes of gender confusion including social media, peer pressure, porn viewing, childhood trauma, parental homophobia or whatever is the latest transphobic focus in a search for anything other than transness to explain transness.
  • Throughout the years of the earlier GIDS clinic, there was a long and noble history of trans children, adolescents and supportive families putting the questionnaires that were offensive and harmful straight in the bin. Of asserting a right to not answer any question that feels off, that feels uncomfortable, that doesn’t seem relevant to the healthcare support being sought. Please continue this noble tradition in the new service. You should not answer any questions that make you or your young person uncomfortable. Bad questions always give bad data that will not benefit any trans young people. Research trauma is a serious concern. The NHS and associated researchers are not taking their ethical duty of care seriously, so we need service users to take this on. I’m writing this primarily to parents as I don’t think under 18s are likely to read this. But for any trans under 18s who do read this – please don’t feel pressured to answer questions that make you uncomfortable or seem strange or irrelevant. You do not have to answer and they cannot make you.
  • This is the non-intensive study – an additional ‘intensive study is also planned for those who will be in the puberty blocker trial and the control group for that trial). I repeat more than 314 questions for parents and more than 314 questions for children/young people is the non-intensive study.
  • These extensive, time and resource consuming, and largely irrelevant questions need to be understood in the context of a service that is trying to give the appearance of being busy, giving the appearance of doing something RIGOROUS, whilst failing to deliver any of the services that trans young people need and have a right to. It serves to keep service users distracted from the care that is not being offered. It provides baseline data on a host of largely irrelevant (or tangentially relevant) areas of mental health, generic well-being, neurodivergence etc, from which the service can seek to ‘further explore’ every one of those ‘issues’ or concerns, whilst denying or delaying affirmative healthcare. The type of intentional distraction and delay is a known component of modern conversive approaches.
  • Conversion therapy in the NHS never wears a badge saying ‘I will make you cis’. It comes much more subtly: Before we talk about the support that you need, FIRST we need to ask these hundreds of questions. Before we talk about puberty blockers or HRT, we first need to explore each of these areas of mental health or neurodivergence, or sexual attraction or family functioning or body image or sex life. We need to thoroughly explore what is going on holistically before we can do anything else. We need to be thorough. We need to avoid misdiagnosis. We need to rule out other causes. We need to Explore.
  • Not useful research: In spite of hundreds of questions, pages of spreadsheets and millions of pounds, this research will not answer questions that would be useful for a health service to know the answer to. Questions like: What are the things that make life harder for a trans child or adolescent? What are the things that improve things for trans children? The research isn’t answering these questions because we already know most of the answers. And our NHS and government and country does not like the answers to those questions. Cos they don’t care whether trans kids have a tough life. They don’t want to help trans kids at all. That is not the purpose of this service. It is a service to ‘study’ trans kids, to delay trans kids, and through delay to convert trans kids – pushing them to suppress their identity, to give up their fight, to think of themselves as a problem, as broken, pushing them to give up even thinking that they matter or have rights.

Number of Questions

ToolParent questionsChild/Young Person Questions
Kidscreen-52 (generic wellbeing)5252
CBCL (Problem behaviour)118118
Parental ‘About Yourself’ Questionnaire20
SNAP-IV tool (ADHD)180
Social Communication Questionnaire (SCQ) (autism)400
PATHWAYS Gender Identity Questionnaire02
Social Transition Questionnaire05
Adolescent Primary Care Traumatic Stress Screen (APCTSS) (trauma screen)55
Revised Child Anxiety and Depression Scale (RCADS) (anxiety and depression)2525
Utrecht Gender Dysphoria Scale – Gender Spectrum (UGDS-GS) (dated measures of gender dysphoria)018
Body Image Scale – Gender Spectrum (BIS-GS) (body image)033
Ask Suicide-Screening Questions (ASQ)44
SCOFF Questionnaire – Test for Detecting Eating Disorders55
Difficulties in Emotion Regulation Scale (DERS)  2918
Sexual Attraction01
ALSPAC Romantic Relations (sex life)014
Parental Attitudes of Gender Expansiveness Scale for Youth (PAGES)  1614
15 minutes questioning on ‘medical history’ that covers huge range of areas.  UnknownUnknown
Annual Health Update  UnknownUnknown
Total questionsOver 314 questionsOver 314 questions

Detailed Breakdown of the exact questions being asked

52 questions for parent & 52 questions for young person from the Kidscreen-52 tool (here the parent version)

  1. In general how would your child rate their health? (excellent; very good; good; fair; poor)

Thinking about last week (with answers: not at all; slightly; moderately; very; extremely or never; seldom; quite often; very often; always)

  • Has your child felt fit and well
  • Has your child been physically active (e.g. running, climbing, biking)?
  • Has your child been able to run well?
  • Has your child felt full of energy
  • Has your child felt that life was enjoyable
  • Has your child felt pleased that they are alive
  • Has your child felt satisfied with their life
  • Has your child been in a good mood
  • Has your child felt cheerful
  • Has your child had fun
  • Has your child felt that they do everything badly
  • Has your child felt sad
  • Has your child felt so bad that they didn’t want to do anything
  • Has your child felt that everything in their life goes wrong
  • Has your child felt fed up
  • Has your child felt lonely
  • Has your child felt under pressure
  • Has your child felt happy with the way they are
  • Has your child been happy with their clothes
  • Has your child been happy with the way they look
  • Has your child felt jealous other the way other children look
  • Has your child wanted to change something about their body
  • Has your child had enough time for themselves
  • Has your child been able to do the things they want in their spare time
  • Has your child had enough opportunity to be outside
  • Has your child had enough opportunity to meet friends
  • Has your child been able to choose what to do in their free time
  • Has your child felt understood by their parents
  • Has your child felt loved by their parents
  • Has your child been happy at home
  • Has your child felt that their parents had enough time for them
  • Has your child felt that their parents treated them fairly
  • Has your child been able to talk to their parents when they wanted to
  • Has your child had enough money to do the same things as their friends
  • Has your child felt they had enough money for their expenses
  • Does your child feel they have enough money to do things with their friends
  • Has your child spent time with their friends
  • Has your child done things with other children
  • Has your child had fun with their friends
  • Has your child and their friends helped each other
  • Has your child been able to talk about everything with their friends
  • Has your child been able to rely on their friends
  • Has your child been happy at school
  • Has your child got on well at school
  • Has your child been satisfied with their teachers
  • Has your child been able to pay attention
  • Has your child been enjoying school
  • Has your child got along with their teachers
  • Has your child been afraid of other children
  • Have other children made fun of your child
  • Have other children bullied your child.

(the default questions use he/she and boys/girls language – I’m assuming they will adapt to use they and child as written above)

118 questions for parent & 118 questions for young person from the Child Behaviour Checklist

For each questions the available answers are:

0=Not true (as far as you know); 1=Somewhat or sometimes true; 2=Very true or often true

  • 1.Acts too young for his/her age / I act too young for my age
  • 2. Drinks alcohol without parent’s approval / I drink alcohol without my parent’s approval
  • 3. Argues a lot / I argue a lot
  • 4. Fails to finish things he/she starts  / I fail to finish things I start      
  • 5. There is very little that he/she enjoys / There is very little that I enjoy
  • 6. Bowel movements outside toilet / I like animals
  • 7. Bragging, boasting / I brag
  • 8. Can’t concentrate, can’t pay attention for long / I have trouble concentrating or paying  attention
  • 9. Can’t get their mind off certain thoughts/obsessions (describe) / I can’t get my mind off certain thoughts/obsessions (describe)
  • 10. Can’t sit still, restless or hyperactive / I have trouble sitting still
  • 11. Clings to adults or too dependent / I’m too dependent on adults
  • 12. Complains of loneliness / I feel lonely
  • 13. Confused or seems to be in a fog  / I feel confused or in a fog
  • 14. Cries a lot         / I cry a lot
  • 15. Cruel to animals / I am pretty honest
  • 16. Cruelty, bullying or meanness to others  / I am mean to others
  • 17. Daydreams or gets lost in his/her thoughts  / I daydream a lot
  • 18. Deliberately harms self or attempts suicide / I deliberately try to hurt or kill myself
  • 19. Demands a lot of attention   / I try to get a lot of attention
  • 20. Destroys his/her own things       / I destroy my own things
  • 21. Destroys things belonging to his/her family or others        / I destroy things belonging to others
  • 22. Disobedient at home      / I disobey my parents 
  • 23.Disobedient at school      / I disobey at school
  • 24. Doesn’t eat well / I don’t eat as well as I should
  • 25. Doesn’t get along with other kids  / I don’t get along with other kids
  • 26. Doesn’t seem to feel guilty after misbehaving        / I don’t feel guilty after doing something I shouldn’t
  • 27. Easily jealous / I am jealous of others
  • 28. Breaks rules at home, school, or elsewhere   /     I breaks rules at home, school, or elsewhere  
  • 29. Fears certain animals, situations or places other than school  / I am afraid of certain animals, situations or places other than school          
  • 30. Fears going to school   / I am afraid of going to school     
  • 31. Fears he/she might think or do something bad / I’m afraid I might think or do something bad
  • 32. Feels he/she must be perfect         / I feel that I have to be perfect
  • 33. Feels or complains that no one loves him/her  / I feel that no one loves me      
  • 34. Feels others are out to get him/her / I feel that others are out to get me
  • 35. Feels worthless or inferior         / I feel worthless or inferior
  • 36. Gets hurt a lot/accident prone / I accidently get hurt a lot
  • 37. Gets in many fights     / I get in many fights
  • 38. Gets teased a lot  / I get teased a lot
  • 39. Hangs with others who get in trouble         / I hang around with kids who get into trouble
  • 40. Hears sound or voices that aren’t there     / I hear sound or voices that  other people think aren’t there             
  • 41.Impulsive or acts without thinking        / I act without stopping to think
  • 42. Would rather be alone than with others / I would rather be alone than with others
  • 43. Lying or cheating  / I lie or cheat
  • 44. Bites fingernails / I bite my fingernails
  • 45. Nervous, high-strung, or tense    / I am nervous or tense
  • 46. Nervous movements or twitching (describe) / parts of my body twitch or make nervous movements
  • 47. Nightmares / I have nightmares
  • 48. Not liked by other kids  / I am not liked by other kids
  • 49. Constipated, doesn’t move bowels / I can do certain things better than other kids
  • 50. Too fearful or anxious         / I am too fearful or anxious
  • 51. Feels dizzy or lightheaded   / I feel dizzy or lightheaded
  • 52. Feels too guilty         / I feel too guilty
  • 53. Overeating   / I eat too much
  • 54. Over-tired, without good reason   / I feel overtired without good reason
  • 55. Overweight / I am overweight
  • 56. Physical problems without known medical cause:
  • a) Aches or pains (not stomach or headache)
  • b) Headaches
  • c) Nausea, feels sick
  • d) Problems with eyes (not corrected by glasses)
  • e) Rashes or other skin problems
  • f) Stomach aches
  • g) Vomiting / throwing up
  • h) Other (describe)
  • 57. Physically attacks people        / I physically attack people       
  • 58. Picks nose/skin/other part of body (describe) / I picks my nose/skin/other part of body (describe)
  • 59. Plays with own sex parts in public         / I can be pretty friendly
  • 60. Plays with own sex parts too much         / I like to try new things
  • 61. Poor school work         / My school work is poor
  • 62. Poorly coordinated or clumsy / I am poorly coordinated or clumsy
  • 63. Prefers being with older kids    / I would rather be with older kids than kids my own age
  • 64. Prefers being with younger kids   / I would rather be with younger kids than kids my own age
  • 65. Refuses to talk / I refuse to talk
  • 66. Repeats certain acts over and over; compulsions (describe)  / I repeat certain acts over and over; compulsions (describe) 
  • 67. Runs away from home        /  I run away from home
  • 68. Screams a lot        / I scream a lot
  • 69. Secretive, keeps things to self /  I am secretive or keep things to myself
  • 70. Sees things that aren’t there   / I see things that other people think aren’t there
  • 71. Self-conscious or easily embarrassed         / I am self-conscious or easily embarrassed        
  • 72. Sets fires         / I set fires
  • 73. Sexual problems       / I can work well with my hands
  • 74. Showing off or clowning     / I show off or clown
  • 75. Too shy or timid / I am too timid or shy
  • 76. Sleeps less than most kids         / I sleep less than most kids
  • 77. Sleeps more than most kids during day and/or night (describe) / I sleep more than most kids during day and/or night (describe)
  • 78. Inattentive or easily distracted        / I am inattentive or easily distracted       
  • 79. Speech problem (describe) / I have a speech problem (describe)
  • 80. Stares blankly         / I stand up for my rights
  • 81. Steals at home         / I steal at home
  • 82. Steals outside the home   / I steal from places outside the home
  • 83. Stores up too many things they don’t need (describe) / I stores up too many things I don’t need (describe)
  • 84. Strange behaviour (describe) / I do things other people think are strange
  • 85. Strange ideas         / I have thoughts other people would think are strange (describe)
  • 86. Stubborn, sullen, or irritable / I am stubborn       
  • 87. Sudden changes in mood or feelings       / My moods or feelings change suddenly
  • 88. Sulks a lot      / I enjoy being with people
  • 89. Suspicious       / I am suspicious
  • 90. Swearing or obscene language     / I swear or use dirty language   
  • 91. Talks about killing self    / I think about killing myself
  • 92. Talks or walks in sleep (describe)     / I like to make others laugh
  • 93. Talks too much         / I talk too much
  • 94. Teases a lot       / I tease others a lot
  • 95. Temper tantrums or hot temper      / I have a hot temper   
  • 96. Thinks about sex too much        / I think about sex too much
  • 97. Threatens people      / I threaten to hurt people
  • 98. Thumb-sucking / I like to help others
  • 99. Smokes, chews, or sniffs tobacco   / I smokes, chew, or sniff tobacco               
  • 100. Trouble sleeping  / I have trouble sleeping (describe)                
  • 101. Truancy or unexplained absence   / I cut classes or skip school
  • 102. Underactive, slow moving or lacks energy / I don’t have much energy
  • 103. Unhappy, sad or depressed / I am unhappy, sad or depressed
  • 104. Unusually loud    / I am louder than other kids  
  • 105. Uses dugs/alcohol for nonmedical purposes      / I use drugs for non-medical purposes  
  • 106. Vandalism      / I like to be fair to others
  • 107. Wets self during the day / I enjoy a good joke
  • 108. Wets the bed / I like to take life easy
  • 109. Whining / I try to help other people where I can
  • 110. Wishes to be of opposite sex / I wish I were of the opposite sex
  • 111. Withdrawn, doesn’t get involved with others  / I keep from getting involved with others
  • 112. Worries         / I worry a lot
  • 113. Please write in any problems your child has that were not listed above.

2 questions for parents on Parental ‘About Yourself’ Questionnaire

  1. Do you identify’ as: ‘woman/girl’, ‘man/boy’, ‘transwoman/transgirl’, ‘transman/transboy’, ‘non-binary/genderqueer/agender/gender fluid’, ‘don’t know’, ‘prefer not to say’, ‘other’.
  2. What was your sex assigned at birth?  ‘female’, ‘male’, ‘don’t know’, and ‘prefer not to say’.

18 questions for parents on SNAP-IV tool, assessing symptoms of ADHD

(not at all; just a little; quite a bit; very much)

  • 1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks
  • 2. Often has difficulty sustaining attention in tasks or play activities
  • 3. Often does not seem to listen when spoken to directly
  • 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties
  • 5. Often has difficulty organizing tasks and activities
  • 6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort
  • 7. Often loses things necessary for activities (e.g., toys, school assignments, pencils or books
  • 8. Often is distracted by extraneous stimuli
  • 9. Often is forgetful in daily activities
  • 10. Often fidgets with hands or feet or squirms in seat
  • 11. Often leaves seat in classroom or in other situations in which remaining seated is expected
  • 12. Often runs about or climbs excessively in situations in which it is inappropriate
  • 13. Often has difficulty playing or engaging in leisure activities quietly
  • 14. Often is “on the go” or often acts as if “driven by a motor”
  • 15. Often talks excessively
  • 16. Often blurts out answers before questions have been completed
  • 17. Often has difficulty awaiting turn
  • 18. Often interrupts or intrudes on others (e.g., butts into conversations/ games

40 questions for parents on Social Communication Questionnaire (SCQ) for assessing autism (I haven’t updated the language to make gender neutral here)

  • 1. Is she/he now able to talk using short phrases or sentences? If no, skip to Question 8
  • 2. Do you have a to-and-fro “conversation” with her/him that involves taking turns or building on what you have said
  • 3. Does she/he ever use odd phrases or say the same thing over and over in almost exactly the same way (either phrases that she/he hears other people use or ones that she/he makes up).
  • 4. Does she/he ever use socially inappropriate questions or statements? For example, does she/he regularly ask personal questions or make personal comments at awkward times
  • 5. Does she/he ever get her/his pronouns mixed up (e.g. saying you or she/he for I).
  • 6. Does she/he ever use words that she/he seems to have invented or made up herself/himself; put things in odd, indirect ways; or use metaphorical ways of saying things (e.g. saying hot rain for steam)
  • 7. Does she/he ever say the same thing over and over in exactly the same way or insist that you say the same thing over and over again.
  • 8. Does she/he ever have things that she/he seems to have to do in a very particular way or order or rituals that she/he insists that you go through
  • 9. Does her/his facial expression usually seem appropriate to the particular situation, as far as you can tell
  • 10. Does she/he ever use your hand like a tool or as if it were part of her/his own body (e.g. pointing with your finger, putting your hand on a doorknob to get you to open the door)#
  • 11. Does she/he ever have any interests that preoccupy her/him and might seem odd to other people (e.g. traffic lights, drainpipes, timetables)
  • 12. Does she/he ever seem to be more interested in parts of a toy or an object (e.g. spinning the wheels of a car), rather than in using the objects as it was intended.
  • 13. Does she/he ever have any special interests that are unusual in their intensity but otherwise appropriate for her/his age and peer group (e.g. trains or dinosaurs)
  • 14. Does she/he ever seem to be unusually interested in the sight, feel, sound, taste, or smell of things or people
  • 15. Does she/he ever have any mannerisms or odd ways of moving her/his hands or fingers, such as flapping or moving her/his fingers in front of her/his eyes
  • 16. Does she/he ever have any complicated movements of her/his whole body, such as spinning or repeatedly bouncing up and down.
  • 17. Does she/he ever injure herself/himself deliberately, such as biting her/his arm or banging her/his head
  • 18. Does she/he ever have any objects (other than a soft toy or comfort blanket) that she/he has to carry around
  • 19. Does she/he ever have any particular friends or a best friend
  • 20. Does she/he ever talk to you just to be friendly (rather than to get something)
  • 21. Does she/he ever spontaneously copy you (or other people) or what you are doing (such as vacuuming, gardening, or mending things)
  • 22. Does she/he ever spontaneously point at things around her/him just to show you things (not because she/he wants them)
  • 23. Does she/he ever use gestures, other than pointing or pulling your hand, to let you know what she/he wants
  • 24. Does she/he nod her/his head to indicate yes
  • 25. Does she/he shake her/his head to indicate no
  • 26. Does she/he usually look at you directly in the face when doing things with you or talking with you
  • 27. Does she/he smile back if someone smiles at her/him
  • 28. Does she/he ever show you things that interest her/him to engage your attention?
  • 29. Does she/he ever offer to share things other than food with you
  • 30.  Does she/he ever seem to want you to join in her/his enjoyment of something
  • 31. Does she/he ever try to comfort you if you are sad or hurt
  • 32. If she/he wants something or wants help, does she/he look at you and use gestures with sounds or words to get your attention
  • 33. Does she/he show a normal range of facial expressions
  • 34. Does she/he ever spontaneously join in and try to copy the actions in social games, such as The Mulberry Bush or London Bridge Is Falling Down
  • 35. Does she/he play any pretend or make-believe games
  • 36. Does she/he seem interested in other children of approximately the same age whom she/he does not know
  • 37. Does she/he respond positively when another child approaches her/him
  • 38. If you come into a room and start talking to her/him without calling her/his name, does she/he usually look up and pay attention to you
  • 39. Does she/he ever play imaginative games with another child in such a way that you can tell that each child understands what the other is pretending
  • 40. Does she/he play cooperatively in games that need some form of joining in with a group of other children, such as hide-and-seek or ball games?

2 questions for young people on PATHWAYS Gender Identity Questionnaire

  • 1. What best describes your gender identity?’

 ‘definitely a boy’, mainly a boy’, ‘in the middle’, ‘definitely a girl’, ‘mainly a girl’, ‘neither a boy or girl’, ‘not sure’ and ‘none of the above’.

  • 2. Are there other words that you use to describe your gender identity? (select all that apply), ‘cisgender’, transgender’, ‘non-binary’, ‘agender’, ‘genderfluid’, ‘genderqueer’, ‘two-spirit’ and ‘other’.

5 Questions for Young people on Social Transition Questionnaire

“Have you socially transitioned in any of the following settings?”, followed by a checklist of five settings: Home, School, With Friends, Online, and Any Other Setting (e.g., holiday).

5 Questions for Parent and 5 questions for young people on Adolescent Primary Care Traumatic Stress Screen (APCTSS) (here the young person version)

In the past month have you:

  1. Had bad dreams about scary experiences or other bad dreams?
  2. Had upsetting thoughts, pictures or sounds of scary experiences come into your mind when you didn’t want them to?
  3. Tried not to think about or have feelings about scary experiences?
  4. Been mad at yourself or someone else for making the scary experiences happen, not doing more to stop it, or to help after?
  5. Felt jumpy or easily startled, like when you hear a loud noise, or when something surprises you?

 25 Questions for parent and 25 questions for young people on Revised Child Anxiety and Depression Scale (RCADS)

Children or parents rate how often symptoms occur, using a four-point scale: 0 (Never), 1 (Sometimes), 2 (Often), or 3 (Always). 

The tool asks 25 different questions written for either a child to self-complete (the version below) or with slightly rephrased questions for an adult to complete (where question 1 is “My child worries about things”.

  • 1. I feel sad or empty.  
  • 2. I worry when I think I have done poorly at something.
  • 3. I would feel afraid of being on my own at home.  
  • 4. Nothing is much fun anymore.  
  • 5. I worry that something awful will happen to someone in my family.  
  • 6. I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds).  
  • 7. I worry what other people think of me.  
  • 8. I have trouble sleeping.  
  • 9. I feel scared if I have to sleep on my own.  
  • 10. I have problems with my appetite.  
  • 11. I suddenly become dizzy or faint when there is no reason for this.  
  • 12. I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order).  
  • 13. I have no energy for things.  
  • 14. I suddenly start to tremble or shake when there is no reason for this.  
  • 15. I cannot think clearly.  
  • 16. I feel worthless.  
  • 17. I have to think of special thoughts (like numbers or words) to stop bad things from happening.  
  • 18. I think about death.  
  • 19. I feel like I don’t want to move.  
  • 20. I worry that I will suddenly get a scared feeling when there is nothing to be afraid of.  
  • 21. I am tired a lot.  
  • 22. I feel afraid that I will make a fool of myself in front of people.  
  • 23. I have to do some things in just the right way to stop bad things from happening.  
  • 24. I feel restless.  
  • 25. I worry that something bad will happen to me

18 Questions for young person on Utrecht Gender Dysphoria Scale – Gender Spectrum (UGDS-GS)

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

33 Questions for Children/Young people on Body Image Scale – Gender Spectrum (BIS-GS)

Each questions asks: a) How happy are you with [insert name of a particular body part]?: With answers i) very happy ii) happy iii) neutral iv) unhappy v) very unhappy vi) don’t have.

Each question is followed up with: Would you want to change that body part if it was possible through medical or surgical treatment? i) Yes ii) No

  • 1) Nose:
  • 2) Shoulders
  • 3) Hips
  • 4) Chin
  • 5) Calves
  • 6) Breasts
  • 7) Chest
  • 8) Hands
  • 9) Adam’s Apple
  • 10) penis
  • 11) clitoris
  • 12) testes
  • 13) ovaries
  • 14) scrotum
  • 15) vagina
  • 16) Height
  • 17) Thighs
  • 18) Arms
  • 19) Eyebrows
  • 20) Waist
  • 21) Buttocks
  • 22) Biceps
  • 23) Hair
  • 24) Feet
  • 25) Muscles
  • 26) Facial Hair
  • 27) Face
  • 28) Voice
  • 29) Weight
  • 30) Body figure/shape
  • 31) stature
  • 32) Body hair
  • 33) Appearance

4 Questions for parent and 4 questions for child/young person on Ask Suicide-Screening Questions (ASQ) (here the child/young person version)

  • 1. In the past few weeks, have you wished you were dead? Yes No
  • 2. In the past few weeks, have you felt that you or your family would be better off if you were dead? Yes No
  • 3. In the past week, have you been having thoughts about killing yourself? Yes No
  • 4. Have you ever tried to kill yourself? Yes No
  • If yes, How? When?

5 questions for parent and 5 questions for young person on the SCOFF Questionnaire – Test for Detecting Eating Disorders (here the child/young person version)

  • 1. Do you make yourself Sick because you feel uncomfortably full? Yes No
  • 2. Do you worry you have lost Control over how much you eat? Yes No
  • 3. Have you recently lost more than One stone in a 3 month period? Yes No
  • 4. Do you believe yourself to be Fat when others say you are too thin? Yes No
  • 5. Would you say that Food dominates your life? Yes No

29 questions for parents and 18 questions for children/young people on Difficulties in Emotion Regulation Scale (DERS)

(here the child/young person shorter version)

Statements are presented that need to be answered as Almost Never, Sometimes, About half the time, Most of the time, Almost always

  • 1. I pay attention to how I feel.
  • 2. I have no idea how I am feeling.
  • 3. I have difficulty making sense out of my feelings.
  • 4. I am attentive to my feelings.
  • 5. I am confused about how I feel.
  • 6. When I’m upset, I acknowledge my emotions.
  • 7. When I’m upset, I become embarrassed for feeling that way.
  • 8. When I’m upset, I have difficulty getting work done.
  • 9. When I’m upset, I become out of control.
  • 10. When I’m upset, I believe that I will remain that way for a long time.
  • 11. When I’m upset, I believe that I’ll end up feeling very depressed.
  • 12. When I’m upset, I have difficulty focusing on other things.
  • 13. When I’m upset, I feel ashamed with myself for feeling that way.
  • 14. When I’m upset, I feel guilty for feeling that way.
  • 15. When I’m upset, I have difficulty concentrating.
  • 16. When I’m upset, I have difficulty controlling my behaviors.
  • 17. When I’m upset, I believe that wallowing in it is all I can do.
  • 18. When I’m upset, I lose control over my behaviors.

1 Question for children/young people on Sexual Attraction

(question for 12 years+)

  1. Who are you attracted to?

Options: ‘Prefer not to say’, ‘Males’, ‘Females’, ‘Males and females’, ‘Neither’, ‘Not sure’

14 Questions for children/young people on ALSPAC Romantic Relations

(question for 12 years+)

In the past 30 days:

  • 1. Have you hugged anybody?
  •  2. Have you held hands?
  • 3. Have you spent time alone?
  • 4. Have you kissed?
  • 4a. Have you been kissed by anybody?
  •  5. Have you cuddled?
  • 6. Have you lain down together?
  • 7. Has someone put their hands under your clothing?
  • 8. Have you put your hands under someone else’s clothing?
  • 9. Have you been undressed with your genitals showing?
  • 10. Have you touched or fondled someone’s private parts?
  • 11. Has someone touched or fondled your genitals?
  • 12. Have you performed oral sex?
  • 13. Has someone performed oral sex on you?
  • 14. Have you had sex?

16 questions for parents and 14 Questions for children /young people on Parental Attitudes of Gender Expansiveness Scale for Youth (PAGES)

(1= strongly disagree; 5= strongly agree

  • 1. I am proud of my child        
  • 2. I am ashamed of my child  
  • 3. I try to hide my child’s gender identity       
  • 4. My child can be him- or herself around me             
  • 5. I advocate for the rights of my child            
  • 6. I protect my child and defend my child against others’ prejudice against gender-nonconforming/transgender people
  • 7. I have problems with my child’s gender expression
  • 8. I encourage my child to wear clothing and accessories consistent with their birth-assigned gender
  • 9. I use toys, treats or other rewards to pressure my child not to gender transition and to live as his or her birth-assigned gender
  • 10. My child can talk about romantic relationships and dating
  • 11. I worry about how my child’s gender identity will affect our family’s image
  • 12. I feel like a bad parent because I have a child that is gender-nonconforming/transgend
  • 13. I think my child is gender-nonconforming/transgender because of something I did wrong
  • 14. I feel like I am losing a son/daughter, or as if my child were dead             
  • 15. I am supportive of my child’s gender transition  
  • 16. I am worried that my child’s gender identity is a bad influence on my other children

Child/Young person version

  • 1. My parents are proud of me
  • 2. My parents are ashamed of me
  • 3. My parents try to hide me
  • 4. I can be myself around my parents
  • 5. My parents advocate for my rights as a gender-expansive/trans* child
  • 6. My parents protect me and defend me against others prejudice against gender-expansive/trans* people
  • 7. My parents have problems with my gender expression
  • 8. My parents use rewards or treats to pressure me to live as my sex assigned at birth
  • 9. I can talk to my parents about romantic relationships and dating
  • 10. My parents worry about how my gender identity will affect our family’s image
  • 11. My parents probably believe they are bad parents because I am gender-expansive/trans*
  • 12. My parents probably believe that I am gender-expansive/trans* because of something they did wrong
  • 13. My parents are supportive of my gender transition
  • 14. My parents are worried that my gender identity is a bad influence on other kids in my family

15 minutes questioning on ‘medical history’

This component is the least clear. It mentions covering the following vast topic areas that are defined as ‘Medical History’ Domains:

  • 1. Family Context
  • 2. Developmental History
  • 3. Physical Health
  • 4. Mental Health and Risk
  • 5. Adverse childhood experiences
  • 6. Safeguarding
  • 7. Gender Development and Experiences
  • 8. Sexual Development, Knowledge and Sexual Orientation
  • 9. Education, Peer Relationships, and Social Context
  • 10. Additional Information.
  • Clinical Judgements – Impact assessments and clinical evaluation for various aspects of the CYP’s development and wellbeing;
  • Parental Support – Judgements on the level of positive parental support and any conflicts between parents/carers/legal guardians or between parents/carers/legal guardians and the CYP.

Would be good to find out exactly what data is collected and why.

Annual Health Update

A questionnaire was designed to assess:

  • CYP’s current height and weight,
  • current prescribed medications
  • diagnoses including neurodevelopmental, mental health and physical health, received in the past year. number of GP appointments
  • planned surgeries or procedures
  • A&E attendances or other unplanned admissions in the past year.
  • The reasons for the GP appointments and A&E attendances
  • Length of hospital admission for planned surgeries or procedures and admissions following an A&E attendance

Experiences of therapeutic options

Data will also be collected on rates of referral to, uptake of and completion of:

  • Psychological therapy
  • Occupational therapy
  • Speech and language therapy,
  • Clinical nursing
  • Youth work support
  • School/College support
  • Non-endocrine pharmacological treatments

Compensation

Children/young people and parent/carer/legal guardian completing informant measures will each receive shop vouchers worth £20 for each data collection episode.

Stonewall: Pragmatism or selling out

/ growinguptransgender / Leave a comment

Pragmatism or selling out the weakest?

Last week Stonewall shared their latest strategy. Reading it you’d barely notice that trans children are facing an acute escalation in  targeted persecution. Life is dire for trans kids in the UK right now. Here’s a very short list:

  • Healthcare – criminalised
  • Trans teens being medically detransitioned
  • Forced conversion practices disguised as therapy
  • Forced identity investigation
  • Social transition denied
  • Segregated and humiliated at school
  • Excluded from sports
  • Can’t even go on a school or DofE camping trip
  • Bullying and violence
  • Supportive families facing social services and police
  • Can’t change institutional records
  • No chance of protection from transphobic parents
  • Barred from trans positive social media connections
  • Fights to ban trans books from school and county libraries
  • Schools teaching transphobia
  • Lessons on the ‘sex-based right to be transphobic’
  • Transphobic and scientifically illiterate lessons on bodies and puberty
  • Ban on school resources about trans lives, esp for younger ages
  • No education for their peers on trans lives or trans rights
  • No action on transphobic bullying
  • Gov refuses to even recognise trans kids

From a policy angle, I can’t think how things can be worse? (don’t tell me how)

Stonewall’s strategy does not mention a crisis. It does not mention trans children facing the worst situation for their rights and wellbeing this century.

If you don’t even acknowledge the problem, how are we meant to believe you are a trusted ally in helping us solve it?

They describe their role as to be “pragmatic conveners”. I always worry when folks use the word pragmatic. It’s a bit like describing yourself as the sensible grownup in the room. It is often a way of talking down to those of us who ask for more, as though it is not possible to hold steadfast to certain principle and then act in pragmatic ways. Too often pragmatic is the word used to defend something else – selling out those who are less important to you.

“Turbulence” is another buzz word that Stonewall is using. It is a term that glosses over the reality that we are not all in the same boat, and this isn’t a bit of rocky weather, but a very clearly targeted and incredibly well funded attack on the weakest parts of our communities.

Our enemies are incredibly strategic and tenacious. Our ‘friends’ appear without strategy.

Stonewall – from foes to friends and back again?

Over a decade ago Stonewall was being protested for its transphobia.

In 2015 they chose to start working for trans people

In 2017 I critiqued their then strategy for failing to have anything to offer for trans children.

Under Nancy’s leadership they were suddenly reliable strong on advocating for trans children.

At the same time as Stonewall got better at sticking up for trans kids, they apparently lost political capital. Perhaps they stopped getting the ear of government. Perhaps they stopped being in the rooms of the powerful.

Does that mean that sticking up for trans kids was the wrong strategy?

Should trans kids be sacrificed in the name of political capital and influence?

Should we operate under this fascist logic?

Should advocacy for trans kids be blamed for Stonewall’s unpopularity amongst a media and political elite in the throngs of rampant transphobia?

Should advocacy for trans kids be blamed for being on the losing side of a culture war?

Would those culture warriors have bowed out and quit if Stonewall had been more pragmatic?

Consensus

The part of the strategy that really stuck in my throat is this sentence.
“We will seek common ground and consensus”.

  • Billions of pounds have gone into the global anti-gender movement.
  • In the UK we have had 8 years of incessant misinformation, lies, propaganda and fearmongering about trans kids
  • Transphobic politicians created the illegitimate and prejudice riddled Cass Review that has greenlit all kind of persecution and discrimination against trans kids
  • Whole organisations have formed to advocate against trans kids rights. Organisations that are terrifying in their connections to those with power and funding.
  • Organisations fighting for trans kids rights have been weakened, have sold out, have been scared away
  • Public opinion has over the past 8 years got worse year after year on topics related to trans kids

We cannot get progress through common ground and consensus.

Common ground and consensus tells me that trans kids’ rights, trans kids’ lives are disposable, while you work on the areas where there is most consensus.
Grow a bloody backbone.

An organisation standing up for trans rights, for trans kid’s rights at this point in history needs to be brave, needs to be principled, needs to proactively reshape the narrative through standing up clearly and articulately and strongly for trans kids’ rights at every turn.

We should be telling everyone who will listen that the current status quo is deeply harmful. That it is unfair. That it is persecuting trans kids just for being trans.

I don’t believe we will see change through consensus. We will see change through clearly putting our marker in the sand, and speaking up again and again and again, leading with our principles.

In the room where it happens

Those who talk of pragmatism and consensus want to be in the room where it happens. They want to have the ear of those in power.

Great for them.

But what message will they be saying in those powerful rooms?

Are they going to hold the government to account on all of its horrendous failings?

Or are they going to play polite, make a couple of challenging points on the less controversial issues, while letting a whole heap slide?

Are they going to bask in the warmth of the powerful while trans kids are out in the cold?

Do they even recognise how bad it is? Do we even trust that they care about all the above violence being pushed by our government onto trans children?

I’ve been in rooms with several leading (cis, white, male) LGBT sector leaders and they have said to my face (in politer terms) that they don’t support trans children. That they are not actually bothered by trans children’s rights violations. That trans children make them uncomfortable. That they are quite on the fence. That its all a bit much isn’t it. That rights for trans children is a step too far. Perhaps even that rights for trans children is harming the wider LGBT endeavour. Trans kids can wait for next century, their time is not now.

For those defending ‘pragmatism’, I am sometimes left to wonder if they are naïve to the real agenda, to the real lack of conviction amongst some leaders.

Is it pragmatism, or is it selling out trans kids entirely?

The good activist

Let’s also be honest here – there is not a shortage of organisations and individuals queueing up to the be ‘reasonable LGBT activists’ who are allowed into the rooms of the powerful.

But at what cost? If you sell out your weakest members to get into those rooms, to stay in those rooms?

Moving the needle

I don’t believe we are where we are due to lack of articulacy.

Or due to not being invited to play the token LGBT friend.

Or due to being too demanding.

I don’t think we have done anything wrong.

We have faced overwhelming power differentials, and have lost because of the scale of those power differentials.

Taking away a lesson that we just needed to do X or we just need to be politer or work more for slow progress or consensus, is learning the wrong lesson.

Being in the room isn’t going to shift the needle when the game is rigged. We certainly can’t win the consensus game in our current media landscape.

Winning through consensus, through playing nice, will take us decades.

And that isn’t winning at all really. It is giving up any chances for the current generation of trans kids. And for the one after. And the one after that.

What can we do?

I see three roles that stonewall can do in this current context:

  1. Calling out persecution and injustice to embarrass those in power

    This role is not nothing. There are parts of the Labour party who do not want to be known as the baddies. Most trans people view them as out and out baddies. Conveying this message to a wider public can embarrass Labour, and empower those in Labour who want to be less terrible.

    2. Calling out persecution and injustice to embolden cis people

    This is for me the biggest priority. There are a ton of cis people across the country working out how to respond to trans kids. Individual school teachers. GPs. Governors. Scouts leaders. Many will by default fall into the path of least resistance, which currently means following gov policy and guidance to harm trans kids. But clear messaging from stonewall on how unacceptable all of this is can embolden people to consider a different act. Most of life does not take place based on detailed following of government decree – it is in the small and everyday decisions and actions of millions of us. Having clear communication from Stonewall that the current government policy harms trans kids can turn the needle on those everyday decisions. Having clear communication from Stonewall that specific actions and policies are part of systemic persecution and genocidal intent (see recent statement from the Lemkin Institute), is something that we can give to individual school head teachers, to individual social workers, to individual family members, to legitimise the messages that we are currently trying to convey.

    3. Calling out persecution and injustice to make us feel less alone

    Even if nothing else, feeling that our current pain and fear is noticed, that we are not abandoned, that we have staunch allies – that actually matters. Even in the face of ongoing and perhaps not easy to fix persecution – it can help us take one more step – help us stay in the fight.

    Today I saw photos of Stonewall smiling and celebrating at a 10 Downing Street ‘pride’ reception. I saw no public call outs of the horrific Labour policies that are destroying the chances of happiness for trans children across the UK. It felt a real kick in the teeth.

    Finding Hope

    The Stonewall strategy talks about being a “a beacon of hope”. I actually agree with this ambition. What does that hope look like? For me, I draw hope from knowing that organisations and individuals will be brave, will stand up and be counted, will call out oppression and persecution and ignorance and hate wherever they find it. This gives me hope. This can give hope to trans kids too – showing that their current atrocious treatment is noticed, showing that we recognise it for bigotry and violence, showing that we stand at their sides. The current Stonewall approach give me zero hope.

    What they have given me, this evening, is rage. I am beyond done with sell outs and folks who are part of the problem. We have enough problems.

    I know that Stonewall are not the real enemy. They are not the reason that life is so goddam hard. They are not the reason I am stressed and afraid.

    I know that it is easy to turn on each other when we feel so powerless and defeated.

    Maybe I should thank them for providing some rage.

    Rage is more motivating than fear.

    I just wish there were other things on the menu these days.

    Is hope really too much to hope for?

    Are a majority of non-binary people cisgender?

    / growinguptransgender / Leave a comment

    I keep coming across research, written by authors who are not non-binary, that includes the confident statement that a majority of non-binary people are not transgender, or that a majority of non-binary people are cisgender.

    I will start by saying that identity is complex and personal and every individual can identify how they please. Naturally. Personally, I am trans and non-binary. I both identify as trans, and I also consider ‘trans’ as an umbrella term that has space underneath it to capture non-binary identities in general [whilst recognising that some non-binary people, just like some binary-oriented people of trans experience/history, don’t like to be called or recognise themselves as trans].

    I personally feel stressed out and othered by language that defaults to ‘trans and non-binary people’ as though they are two distinct categories (I’m personally happier with a default assumption that the term trans will always include non-binary people, and where folks want to emphatically include non-binary people who reject trans as an umbrella I’m be ok with the cumbersome ‘trans and/or non-binary’. Of course humans are messy and no language will be perfect.

    A conclusive and confident statement about a majority of non-binary people being cisgender always pushes me to ask the question – where is the data coming from?

    In my personal experience, I’ve known many people who start out identifying as non-binary and ‘not trans’, who over time, embrace the umbrella label of trans [I’m not sure I’ve ever met anyone who has gone the other route]. I’ve known many non-binary people who initially feel that they cannot or must not take the label trans, that using such a label would be ‘appropriation’, if they have not medically transitioned enough, if they have not socially transitioned enough, if they have not suffered enough. With connections to trans communities I’ve known many such people come to adopt the label of trans. Whether an individual non-binary person finds meaning under the umbrella label trans is not a static binary and can change over time.

    There is also a curious double standard in some surveys wherein non-binary people can be labelled as cis if they do not actively identify with the word trans, whereas trans is considered a default marker for binary-oriented trans people even if they do not personally identify with the term.

    Lets look at the original report that is the root of the claim that a majority of non-binary people are cisgender and see whether there are any potential problems with that report.

    It is a 2021 report titled “Nonbinary LGBTQ Adults in the United States“

    It tells us confidently that “A greater percentage of nonbinary LGBTQ adults are cisgender rather than transgender”. I’ve seen this claim, that a majority of non-binary people are cisgender replicated in many publications.

    There are several points to give us pause about the reliability of this claim.

    Firstly the data comes from surveys conducted in the US in 2016-2018, that were designed in 2014. Identity language and knowledge amongst non-binary communities has been on a huge journey over the past decade. There are way more resources, groups and connections for non-binary people in 2025 than in 2016. Presuming that identity labels for non-binary people in the US in 2016 align with non-binary identity labels (worldwide!) in 2025 is a big assumption.

    Secondly, the surveys from which this claim are drawn were not designed to find out whether non-binary people identify as trans, and were not designed, as far as I’m aware, in collaboration with non-binary authors. The summary report is from the Williams Institute, a research institute that has a history of being critiqued for some failings in the way it considers trans people’s data.

    Take a look at this figure from the 2021 summary report and tell me if it might demonstrate some structural areas of ignorance or bias. As a non-binary reader this figure makes me dizzy. At best it begs some serious questions.

    I tried to find out what was the underpinning data, what exact questions were people being asked in 2016 that led to the above diagram and it is rather complex and confusing.

    The original sample comprised 1,369 LGB(T) people in 2016-2017 (people were asked if they were ‘lesbian, gay, bisexual, queer, or samegender loving’ and respondents needed to answer yes to be included).

    This sample was filtered into two different surveys based responses to these two questions, designed in 2014:

    1. On your original birth certificate was your sex assigned as male or female
    2. Do you currently describe yourself as i) man, ii) woman or iii) transgender.

    [In some versions of the survey a fourth option for part 2 was included “(iv) do not identify as female, male, or transgender”.]

    Respondents who did not pick the option ‘transgender’ above were filtered into an LGB survey called the Generations study. It was presumed to be a study of cisgender people (though respondents were never asked if they identify as cisgender). (27 respondents who clicked man or woman rather than transgender in a way that did not match with their assigned sex were excluded from the Generations survey).

    It is important to note that people only gain access to the Generations study if they click that their identity is ‘man’ or ‘woman’ in the initial filter question (making it harder to access, for say, non-binary people…).

    The presumed cisgender participants of the Generations study are then asked about their gender identity:

    “If you had to choose only one of the following terms, which best describes your current gender identity?” a) woman (744 answered this) b) man (665 answered this) c) non-binary/genderqueer (94 answered this). 15 did not respond.

    Note none of these participants have been asked if they identify as cisgender, they are simply LGBT identifying participants who did not click on ‘transgender’ in the initial screening. These 94 people in the US are deemed to be ‘cisgender non-binary people’. This group of ‘non-binary/gender queer’ individuals are further sub-divided into those who are deemed ‘cisgender LB women’ and those who are deemed ‘cisgender GB men’ based on whether they had ticked man or woman in the very first question. All non-binary people must be a man or a woman.

    People who clicked ‘transgender’ at the first question are steered to a separate survey called ‘transpop‘. Everyone in the second survey is classified as transgender, as they needed to specifically click the option ‘transgender’ for question one.

    People in the transpop survey were asked about their ‘gender identity’.

    They were asked two questions:

    1. Which of the following terms best describes your gender identity? a) man, b) woman or c) genderqueer/non-binary.
    2. Do you currently consider yourself a) man b) woman c) transgender.

    If it seems that the questions options are confusing and non-logical, it is because they are confusing and non-logical.

    Comparing the two surveys

    1518 individuals completed phase one of the Generations survey, of whom 94 identified as non-binary. Only 274 people completed the transpop survey across all waves of that survey, of whom 76 identified as non-binary. The total number of those deemed cisgender non-binary men and cisgender non-binary women in the Generations survey (=96) was greater than the number of non-binary people in the transpop survey (=74). This leads to the confident conclusion that ‘a majority of non-binary people are cisgender. Despite not one non-binary person having been asked ‘are you cisgender’? Despite no questions that specifically recognise a non-binary person’s identity before asking whether the word transgender or trans as an identity term or an umbrella term is meaningful to them.

    I do not find the above reliable or (globally) meaningful for providing insight into non-binary populations in 2025.

    Overall

    This survey from 2016-2017, designed in 2014, makes a range of questionable choices. I don’t think anyone would argue that these choices stand up in 2025 as a useful way of collecting information about trans and non-binary populations.

    Most importantly, it never specifically asks non-binary people ‘do you identify as transgender yes or no’. ‘do you identify as cisgender yes or no’, or the question ‘do you feel comfortable defining your non-binary identity under a broader umbrella as trans’.

    There are plenty of non-binary people who may not specifically identify with the word trans as a key self-descriptor, who nevertheless are happy under a broad ‘trans umbrella’.

    It is a double standard to define all binary trans people as ‘trans’ based on e.g. identification as a man while having assigned gender female even if that individual does not personally ‘identify as’ trans, but limiting non-binary transness to only those who ‘identify as’ trans.

    Overall I think identity and labels are messy, binaries are often false.

    I do not think any of the above is a robust basis on which to make confident claims that ‘a majority of non-binary people are cisgender’.

    Could we, maybe, actually ask non-binary people what we actually think?

    Could we stop relying on surveys such as this deeply flawed 2021 Williams Institute survey for understanding non-binary lives?

    EHRC Consultation: Are We Sure?

    / growinguptransgender / Leave a comment

    Are we sure?

    Today EHRC released its consultation on the segregation of trans people.

    There seems to be general trans community momentum behind an assumption that we want to get as many people as possible to respond to this consultation.

    I just want to ask…. Are we sure?

    1. Clarity of segregation

    The consultation is not a consultation on whether trans people should be segregated. It is a consultation on whether the recommendations are clear enough.

    Imagine the recommendation was “police should shoot trans people in the head”.

    A consultation on ‘clarity’ would quibble with what do we mean by shoot, does a cross bow count. What do we mean by head – is a grazing wound sufficient or is a kill shot needed.

    A consultation on clarity of discrimination gives no space to consider whether the recommendations are i) legal ii) fair and just and in keeping with equality and decency and what we expect from a modern society.

    • 2. EHRC is in charge

    The EHRC will write up the findings (or they will be written up by a consultant following the terms set by EHRC).

    There is no way of winning this.

    There is no way of submitting in a format that will lead to the EHRC saying that the consultation declared segregation a bad idea.

    At best it will lead to tweaks in the wording to make it clearer how and when we are to be segregated.

    We can add all the protests, all the pleas for human decency, all the testimony of real world harms we are already experiencing to the submissions. It will count for nothing.

    The consultation results will be written up in the way that suits EHRC.

    It will either say that the guidance is clear, or it will provide suggestions on how to clarify it further.

    All other content that does not relate to clarity will simply be discarded.

    It will never result in a report saying that the guidance is out of keeping with human rights and unpopular with public opinion

    • 3. Popularity contests are a losing battle

    Even if the EHRC were willing to capture the number of positive endorsements of their guidance versus the number of criticisms, it will never present this as public support for or against the guidance.

    The EHRC are in charge of the process.

    If there are a majority of positive endorsements of segregation, then this might make it into the EHRC summary.

    If there are a majority of criticisms of segregation, this will never make it into the EHRC summary. They will focus purely on the questions asked, the percentage of respondents who felt the guidance was a) clear b) not clear.

    We cannot win by playing this game

    • 4. The stakes are high

    Trans people (myself included) are bloody worn out. Panic attacks are common. People are afraid.

    People want to do something, whilst working with very little spare energy

    I looked at the consultation briefly today.

    It felt like an actual kick in the stomach to read it.
    It is very long and confusing – it would take me days to properly process it and formulate a response, and I’m an academic used to analysising such stuff

    But more importantly – it felt like an actual kick in the gut to read it.

    It has already caused me harm.

    Do we really want to ask all of our trans friends to do this?

    Knowing what it costs us? Even to read the detailed EHRC documents is a tick in the teeth – reading how the powerful plan to discriminate against us is not a neutral pastime.

    I think very carefully before sharing anything written by hate groups – let alone asking people to read hate group material.

    This material will traumatise some readers. It has left me in tears this afternoon.

    I don’t know why we’d ask our community to go and read that – to feel compelled and threatened into going to read that to protect their safety – when the consultation is not going to be the thing that leads to a life of safety.

    The potential benefits of community-wide filling in of this consultation are infinitesimally tiny.

    Do we also really want to ask our allies to do this?   

    Knowing that most allies will do very little, and if they do this then they will tick off their trans activism badge for the year – is this the single best use of ally time?

    Of course we can stream line the process – providing simple guidance etc. But even engaging with the consultation questionnaire is overwhelming and stressful and made me feel afraid and disempowered.

    Do we want everyone feeling further afraid and disempowered?

    Can we guarentee that the costs are worth the benefits?

    • 5. Charity momentum

    In the UK the ‘trans community’ is very disjointed. There are not any clear mechanisms for actually inputting into decisions on how ‘we’ should proceed.

    Instead we tend to have ‘leadership’ from trans charities.

    If trans charities say we should participate in a consultation, folks tend to follow on,

    If trans charities produce guidance, folks tend to think they should participate.

    But

    I’ve worked in a lot of charities.

    I know how they function.

    Responding to a government consultation is a very core part of being a charity

    It feels like an achievement.

    A box gets ticked. It goes on an annual report to supporters and trustees

    Leadership may ask junior staff to do the consultation response, on an assumption that of course a major trans charity will respond to a government consultation with relevance for their members.

    A charity might well get criticised if they do not respond.

    And once a charity decides to respond, well, it’s only kind to provide clear guidance for other community members to be able to respond.

    And thus charities push the trans community into participation in yet another consultation in which there is no trans power, no trans accountability.

    They push us into a game we literally cannot win.

    A lot of UK trans charities collaborated for many years with the Cass Review process.

    They were used by Cass.

    Their collaboration was used to justify the legitimacy of the process – a process that it was clear from the very start was illegitimate.

    I have not seen one of them publicly reflect upon that collaboration, publicly learn lessons about how trans participation in government ‘consultation’, time after time, is used to legitimise things that should hold no legitimacy.

    • 7. Boycott is an option

    I never hear proper discussion of an organised boycott of such things.

    Why not?

    If we cannot win. If we are guaranteed to lose – why play their game at all?

    Especially when playing is deeply harmful to our well-being.

    Why not stand back and clearly say as a community:

    Trans segregation is wrong.

    We are not interested in unpicking the clarity of the terms under which we are segregated.

    We refuse to be segregated.

    We refuse to engage with processes led by those who hate us.

    We refuse hate and fascism.

    We refuse.

    • 8. Better uses of our time

    Amongst trans communities spirits are low and there are a lot of very significant challenges we face.

    Why is this consultation a good use of any of our time?

    I would love to say to the trans people in my life – do yourself a favour – skip this consultation.

    I particularly don’t want the young trans people who I know to pour their heart out in submissions on the impact of this guidance on their life – in a consultation where that type of testimony will be ignored.

    I would argue we are much better off focusing on legal challenges – arguments that the guidance and the Supreme Court is breaking international and national law.

    I would argue we are much better off focusing on justice and equality and basic decency related arguments, writing public blogs and articles on how the guidance harms us, spending our limited time talking to our MPs, campaigning for actual justice, talking to our communities on the harms of segregation, supporting our trans children to get through the next months, finding the optimism that we and they need, advocating for their rights at school.

    Keeping the focus of our efforts not on telling EHRC on the clarity through which we are segregated, but on maintaining our own wellbeing and self-esteem, refusing to play their game.

    I also think refusal at this point, and refusal in solidarity would be a powerful message and example to underpin the wider refusals that need to continue.

    Through refusal we underpin that we do not accept the terms by which they want to rule our world. We show and practice defiance that we are not going to disappear.

    I’ve lost energy to finish this blog coherently.

    Everything in life takes energy.

    There is so much to be done.

    Above all we need to look after ourselves and our community

    Asking for the community to spend time on this consultation seems like voluntarily smashing ourselves in the face with a brick. It will harm us. It will not harm those who are trying to harm us.

    I don’t know everything.

    I only know I have now done 20 such consultations and every single one led to either no change or to a roll back in rights.

    And this consultation seems more hopeless than every one of those.

    I will go with the collective wisdom, including from those who are wiser than me. But before we all agree to collectively participate in – and to ask our friends and allies to at scale participate in – the consultation – can we at least ask:   

    Are we sure?

    Why I won’t be engaging with the UK’s puberty blocker study

    / growinguptransgender / Leave a comment

    Funding for the long awaited study on puberty blockers was announced this week, with £10 million pounds designated for a study running until 2031.

    The study team at a glance appears to be fully cis, with no trans leadership. At least one senior leader attended a conference of a known anti-trans hate group. None of the leaders of this study bothered to attend with the WPATH global conference on trans healthcare that happened at a similar time.

    The study aligns with and is embedded in new children’s gender services, designed in response to the Cass Review. Those services are deeply unethical and harmful, using staff selected for having no background in trans healthcare, trained according training materials steeped in pathologisation and misinformation.

    Those service are deeply unethical and harmful with us already hearing regular negative reports of intimidating approaches to care, children being assessed by 5 or six professionals.

    The research is by design unethical and coercive, with participation expected to be mandatory for all seeking to access healthcare.

    The trial is by design unethical and coercive, putting youth at random into wings of puberty blocker or denial of puberty blocker, when forcing a youth who is distressed about puberty through an unwanted puberty for the sake of an unneeded trial is deeply unethical and cruel.

    I expect more horrors will be revealed whenever we find out the inclusion criteria for the study. I expect the exclusion criteria will be used to exclude certain groups of trans youth. The fact it is being kept ultra secret is another red flag.  

    The trial is by design likely to fail, with a strong impulse for those in the non-healthcare wing of the study to drop out, either to access healthcare outside of the study, or because there is no benefit and significant ongoing harm to being a such a study without accessing healthcare.

    The study is certain to provide rubbish data – as per the Cass Review cis professionals with no experience and no inclination to listen to trans people or learn from existing research tend to focus on and measure the wrong things – measuring what is of concern to transphobic cis people rather than what is of use in improving outcomes for trans youth.

    The study is deeply unethical for having no trans leadership – cis professionals particularly in the NHS continue to fail trans communities.

    The study shows significant signs of having a semblance of youth engagement, with zero youth power. That is unacceptable.

    The whole thing is deeply harmful and unethical, drawing its basis from the Cass Review, already one of the most critiqued healthcare reports, which will one day be viewed as a flagship example of bigotry driving healthcare policy.

    Several people have asked if I will be volunteering to be on any lived experience panels or similar linked to this study. I have not been asked (and do not expect to be).

    My answer would be very clear.

    No.

    No I will not in any way collaborate with a deeply harmful and unethical process.

    No I have no faith at all that voices speaking up for trans youth healthcare rights will be listened to.

    No I will not be complicit in providing any veneer of ‘inclusion’ to a process that is deeply cis-supremacist, unethical and harmful.

    Others have asked me if trans youth or families should engage in the research governance, consultation and ‘accountability’ structures.

    My advice would be – No.

    Time and again I’ve seen people give the benefit of the doubt to processes like this, and be deeply burned. I’ve seen trans kids try their best to influence and be ignored and side-lined. Consultation without influence or power is not a genuine consultation.

    Folks want to hope for the best. They hope that they can make a difference. They think it is better to be in the room than out of it. I strongly disagree.

    Do not allow your hope, your faith in people being willing to learn, to persuade you to engage with a service and system set up intentionally to cause harm. Do not allow yourself to be a tool for their system.

    I have not been asked by trans and LGBT civil society whether they should engage.

    I was extremely disappointed throughout the Cass Review process to be continually reassured by figures in trans and LGBT civil society that engagement with the Cass Review was worthwhile, that they were having influence, that they were adding value.

    As many of us outside of positions of (relative) power said would happen from the start, trans engagement in the Cass Review process was callously utilised to provide a veneer of inclusion and consultation to a process that was by design cis-supremacist and toxic.

    The Cass Review has even been described as a process with ‘extensive’ youth and family and lived experience consultation. But consultation, as we saw with the Cass Review, as we saw with every NHS review related to trans healthcare I’ve engaged with for years, does not mean influence.

    I will have no patience for any folks who in 2025 naively stumble into roles that provide a veneer of trans engagement to this harmful NHS trial. At the start of the Cass Review a position of ‘giving the benefit of the doubt’ to a review designed to intentionally exclude trans people was barely tenable. Those giving reassurances and the benefit of the doubt in the latter years of the Cass Review were something other than naïve.

    There is no space for trans and LGBT civil society pretending to be naïve about the harm and unethical nature of this current study.

    I hope for at least some solidarity with trans kids.

    I hope that the least we can do is not engage with and lend any form of trans community support through participation in abusive practices.

    I hope we can focus efforts on resistance from the outside. On supporting trans adolescents to continue to resist the harms that are foisted upon them, including resisting the harms of this trial and the associated study.

    That will be my focus. Damage limitation from the outside.

    Whilst continuing to speak up about the harms inherent in any process that is designed in this manner. Setting a clear expectation that crumbs and consultation from the outside is by definition not good enough.

    We need trans leadership in trans children’s healthcare, in all trans healthcare. Nothing about us without us, and that means with genuine influence and power across healthcare design and management structures, not relegation to ‘lived experience’ panels that have no power to change and hold to account the fundamental and intentional failings of the whole approach.

    We need depathologisation as a core principle. We need affirmative healthcare.  

    Research should uphold children’s rights. Research should not cause harm.

    Healthcare ethics Professor Simona Giordano testified recently to the Women’s and Equality Committee on the harms of this proposed study, noting that in this study “there is a risk that NHS England will violate fundamental principles contained in virtually all declarations and conventions on human rights as they apply to participation in research”.

    The Welsh Children’s commissioner recently flagged similar concerns.

    Not wanting to participate in research that breaks basic principles of healthcare and research ethics should not be a radical position. It should be the basic starting position for anyone who has any care for trans children.

    Puberty Blocker Ban: Invited Expert Submission

    / growinguptransgender / 1 Comment

    I was an academic expert invited to submit expert opinion & evidence to the Autumn 2024 closed consultation on the legal and criminal ban on puberty blockers. I’m one of the experts that Wes has claimed to have listened to in agreeing to make this ban permanent.

    Here is my submission:

    Proposed changes to the availability of puberty blockers

    Question 1: Do you agree with making it permanent?

    Strongly disagree.

    The current policy has had very significant negative impacts and consequences for trans children, adolescents and their families. It is not evidence based and does not centre the rights, health or well-being of the children and adolescents who are directly impacted.

    Question 2: Positive impacts

    Absolutely zero. It has had devastating consequences for many trans children, adolescents and families.

    Question 3: Negative impacts

    As an academic and researcher specialising in transgender children’s health and well-being, I need to highlight my grave concerns with the unevidenced and risky decision to criminalise access to puberty blockers. The law has already led to significant severe harms/negative consequences, with significant risks to the young people directly impacted. Three items are important to note 1) Consequences of denial of blockers 2) Higher risk of alternative medical pathways 3) Wider healthcare differentials.

    1. Consequences of denial of blockers

    The current criminalisation of puberty blockers has not considered the serious consequences of denial of blockers to trans adolescents who feel endogenous puberty would be intolerable. Recent research has been conducted with UK trans adolescents using and seeking access to puberty blockers, and their families. These articles were not considered by the Cass Review as they were published in 2022 (the Cass Review only looked at literature published pre-2021). At this point the government needs to take stock of all modern evidence, including that published post 2021. This more recent research highlights the reasons for trans adolescents and supportive families seeking access to puberty blockers. This research substantiates the importance of puberty blockers in safeguarding and protecting trans youth happiness, self-esteem, mental health, and in enabling trans youth to stay in school, socialise with their friends, enjoy their adolescence. It also touches on the known harms where trans youth are forced through a puberty they find intolerable, including drop out from school, not wanting to leave their room, disconnecting from friends, not wanting to leave the house, stopping wanting to speak in public, anxiety, depression, self-harm, losing hope, suppressing food intake to prevent pubertal development, no longer wanting to be alive.

    There are highly significant risks to the well-being and happiness of trans youth denied access to healthcare interventions such as puberty blockers. Being forced through a puberty that is deeply traumatic, when there is an effective and safe medication to prevent that, is a deeply significant interventions in a young person’s bodily autonomy, necessitating a very high barrier of justification, a justification that is simply not present in the case of puberty blockers. The known harms of forcing trans adolescents through endogenous puberty against their will have not been considered in making the decision to criminalise puberty blockers. Any policy in this area needs to draw upon effective risk assessments of the known dangers of not having access to puberty blockers.

    • Higher risk of alternative medical pathways

    When it comes to abortion, it is recognised that criminalisation does not prevent abortion, it merely prevents safe abortion, pushing individuals towards less safe routes to healthcare. There are clear parallels with criminalisation of puberty blockers, with clear evidence already apparent of adolescents and supportive families being pushed to less safe routes to healthcare. The risks of forcing individuals into less safe options have not been considered in making this law.

    Many adolescents and families impacted by the current ban feel that being forced through unwanted endogenous puberty is entirely intolerable and inconceivable, and will navigate any other option to ensure that does not happen. Some are looking to flee the country, literally being driven out of their home by a criminal ban on essential healthcare that is more draconian than anywhere else in the democratic world. Some are applying for asylum, due to being persecuted by their government just for being trans. Some are needing to travel abroad every three months in order to access healthcare outside of the UK. This is a significant financial burned on supportive families, and a significant burden and stress on those adolescents who should be able to access healthcare locally, who should be able to spend their weekends having fun with their friends rather than travelling outside of the UK to maintain their right to bodily autonomy and a happy adolescence. Others are likely accessing the Black market, with risks especially related to a lack of blood hormone monitoring and medical oversight. Many are switching from puberty blockers to non-criminalised alternative medication that has a similar impact on preventing puberty, medication that is known to have greater side effects than puberty blockers. In the decision to criminalise puberty blockers, a medication known to be safe, there has been zero consideration of the risks of the alternative medication that youth are now switching to. Other adolescents are going directly to oestrogen or testosterone, at an earlier age than they would have chosen to do if puberty blockers were available. The current criminalisation is having very significant impacts on the healthcare options and pathways that trans youth are accessing. It is not stopping trans youth from accessing affirmative healthcare, merely pushing youth towards options that are less safe.

    • Wider healthcare differentials

    A significant impact of criminalisation is a very significant rise in trans children, trans adolescent and supportive family distrust of healthcare providers including GPs. Adolescents and supportive families forced into less ideal paths to healthcare to avoid criminalisation also now have significant reasons to avoid engagement with their local GP. I am deeply concerned about the wider health impacts, both short and long-term, of having a population who are avoiding routine healthcare interactions with their GP and other healthcare providers, related to current criminalisation. This is and will continue to feed into wider healthcare differentials and poorer healthcare outcomes far beyond trans health.

    References on puberty blockers (peer reviewed journal articles)

    Horton, C. (2022). Experiences of puberty and ‘puberty blockers’ – Insights from trans children, trans adolescents and their parents. Journal of Adolescent Research.

    Horton, C. (2022). “I didn’t want him to disappear” Parental decision-making on access to puberty blockers for trans early adolescents. Journal of Early Adolescence.

    Question 4: Benefits

    It is extremely dangerous and damaging – making it permanent would magnify and entrench the current harms.

    Question 5: Risks and risk mitigation

    There is no way of mitigating the current risks. It is deeply dangerous and damaging.

    Question 6: Impact on protected groups

    It is evidently directly discriminatory against those with the protected characteristics of gender reassignment. The same medication, with the exact same purpose (preventing puberty), is considered safe and not criminalised when used by other groups. The argument that it is not discrimination because use for preventing puberty in trans youth has a separate (outdated) psychiatric diagnosis label is not a credible argument. The same medication, the same purpose (preventing puberty), fine for an individual who is not trans, a criminal offense if they are trans. Absolutely direct discrimination.

    Looked after children/children in care are being disproportionately negatively impacted by the current criminalisation. The impact of the current criminalisation is being unevenly carried. There are systemic inequalities in which adolescents are being forced to medically de-transition and forced through a endogenous puberty they find intolerable. I am particularly worried about those least able to circumnavigate current criminalisation, especially looked after children. Whilst many other youth with supportive families find some alternative route to avoid being forced through an intolerable puberty, looked after children, even those with supportive carers, are least able to find a route through. The burden of this criminalisation, and its heavy expected negative impacts on trans youth, is falling most heavily on those who are already disadvantaged through being in the care system. Criminalisation is a very blunt instrument for healthcare, and it is particularly blunt in its impact on trans youth in care who desperately need to avoid being forced through an endogenous puberty. There need to be pathways for individualised healthcare, without the law providing a blanket barrier to providing individualised healthcare to each child and adolescent.

    Question 7: Additional evidence

    As an academic and researcher specialising in transgender children’s health and well-being, I need to highlight my grave concerns with the unevidenced and risky decision to criminalise access to puberty blockers. In addition to the severe harms/negative consequences, and significant risks of criminalising access to puberty blockers outlined above, I will here highlight five serious flaws and miscalculations that have influenced this poor policy, relating to 1) puberty blocker effectiveness 2) safety 3) erosion of child rights and healthcare ethics 4) Pathologisation & mental health led approaches to trans healthcare 5) Government interference in healthcare.

    1. Puberty Blocker Effectiveness.

    Puberty blockers are extremely effective at their primary purpose – stopping puberty. Their effectiveness is well studied and not in doubt. Supposed concerns about a lack of evidence of the ‘benefit’ of puberty blockers fail to engage with a critical question. Are they effective at stopping puberty (answer – yes – this is beyond doubt). Trans healthcare scholars and gender service users are very clear that the key purpose of puberty blockers is to prevent endogenous puberty, preventing the progression of unwanted secondary sexual characteristics. Puberty blockers are not expected to resolve ‘gender dysphoria’, where gender dysphoria is a psychiatric diagnosis under the DSM-V that proxies being trans. Puberty blockers are not expected to lead to an improvement in mental health and well-being, they are intended to prevent the catastrophic decline in mental health and well-being that is known to occur when trans youth are forced through a puberty they find intolerable. Discussions on a lack of evidence of puberty blockers resolving gender dysphoria or improving mental health are, at best, a severe misunderstanding of trans youth healthcare. Their purpose is to prevent puberty, and at this they are undoubtably highly effective.

    • Safety

    Puberty blockers have been used and studied in different populations for many decades, including use in trans adolescents since 1988. There is no evidence of significant safety concerns when used in trans or non-trans patients. The medication does not work any differently in trans compared to non-trans patients, having the exact same purpose in preventing puberty. There can be different reasons for wanting to prevent puberty (for precocious puberty it is to delay puberty to align with ones peers, for trans adolescents it is for bodily autonomy and preventing progression of a puberty they find intolerable and incompatible with their bodily aspirations, for some cancer treatment it is to remove sex hormones that impact on their cancer). The reasons for stopping puberty are different, but the medication is equally safe. Here the medication is permitted for all uses to prevent puberty in cis (non-trans) people, and is only deemed unsafe for trans people. There is zero evidence that puberty blockers work in a different manner in trans versus cis bodies. There is zero evidence that the same medication, for the same purpose (preventing release of endogenous sex hormones), is somehow safe in cis people an unsafe in trans people. There has been no documented evidence of serious risk in use of this medication, certainly nothing to justify criminalisation.

    The known risks of puberty blockers can be monitored and minimised as part of standard endocrine care. Bone health can be monitored, with exogenous sex hormones provided before bone health is compromised, alongside recommendations for exercise and vitamin supplements. There is simply no evidence of any serious safety concern.

    The only current suggested harms of puberty blockers for trans youth fall into a category of ‘speculation and pseudoscience’. The Cass Review includes an unevidenced statement speculating that puberty blockers may change the outcome, preventing trans children from shifting into cis identities in adolescence. Trans scholars and healthcare professionals have raised very significant concerns about the Cass, as written in peer reviewed academic publications and scientific commentaries. The Cass Review’s unevidenced speculation on blockers potentially keeping trans children as trans is a gross misunderstanding of existing scholarship on this topic. There is no such evidence that trans children denied puberty blockers become cis youth, or that puberty blockers have any impact on identity. This speculation of a psychological impact of puberty blockers on identity is entirely unsubstantiated, and is in fact directly contradicted by modern evidence that shows trans children frequently grow into trans adults, regardless of healthcare provision or denial. There is zero credible evidence that puberty blockers, a medication used on cis children without any anticipated impact on their gender identity, will have any impact on identity in trans people.

    The second speculated ‘risk’ of puberty blockers, is the suggestion that there are ‘unknown’ impacts on brain development. Again, this is entirely unevidenced and speculative. Puberty blockers have been used for many decades, including for trans youth since 1988, with no recorded negative impacts on brain development. Speculation should not be substantiating a highly unusual decision to criminalise a medication. Especially when that speculation is only used to criminalise use of a medication in a highly persecuted minority, while leaving the same medication available to all other populations.

    • Erosion of child rights and healthcare ethics

    The current criminalisation of puberty blockers runs in the face of core concepts of child rights, bodily autonomy and healthcare ethics. Decisions on this topic need to bring ethics and healthcare rights into much greater focus. This also needs to consider the reality that puberty blockers are supposedly criminalised apart from for youth under a proposed NHS trial. This trial is not yet designed nevermind launched, with youth being forced to navigate alternative routes to healthcare while waiting for said trial. There are also very significant ethical concerns about the proposed trial, in a UK gender service that has long been critiqued for severe ethical failings. Many many families will not force their child through a service and trial that has significant ethical failings, and currently criminalisation is one tool being used to coerce children into such an unethical trial.

    I am also deeply concerned that the proposed criminalisation on puberty blockers is being pushed through without effective and meaningful listening to the adolescents most directly impacted, and their caregivers and Doctors. I am concerned that the latest policy proposal document dismisses the need for further stakeholder consultation, claiming that the Cass Review itself “include(ed) extensive stakeholder engagement with those with ‘lived experience’”. Any engagement with trans communities in the UK will quickly reveal a very widespread belief that Cass Review stakeholder engagement did not meaningfully inform the final report, with community, academic and professional critiques of the Cass process and outcomes extensive, well-documented and growing. Trans communities and trans adolescents have a right to a seat at the table in influencing trans healthcare policy, and this current criminalisation is yet another in a long series of processes where lived experience voices are not being heard or listened to. If the government has any care for trans children and young people, there needs to be a process of committed rebuilding of faith with trans communities, including a commitment to ensuring lived experience specialists are given a seat at the table in informing trans healthcare policy and legislation. 

    Current policy documents fail to even recognise the scale of the impact on trans youth. Several documents convey the impression that youth currently accessing puberty blockers are unlikely to be forced to medically de-transition. In reality, the vast majority (over a thousand) trans adolescents currently in receipt of puberty blockers at the point of the introduction of the ban found themselves immediately without any legal route to continue their prescription, and facing an immediate risk of medical de-transition, a forced medical de-transition known to have significant psychological and well-being risks. There has been no estimation of the scale of impacts on trans children who have entered into puberty in the months since the criminal ban, and no estimation on the psychological toll, fear and distress of trans children approaching puberty. The government has taken no effort to understand the experiences and impacts on trans children and adolescents.  

    • Pathologisation & mental health led approaches to trans healthcare

    I am also deeply concerned that the proposed policy document references the “importance of ensuring that children and young people impacted by the order can access appropriate support”. Noticeably this does not specify what ‘support’ is effective and appropriate for a child or adolescent who is being forcibly medically detransitioned or who is being coerced through a puberty they find intolerable. This oversight, and the failure to consider what is “appropriate support” in lieu of affirmative healthcare is a fundamental and deep rooted flaw in this whole approach. There is no approach to support for trans adolescents with more evidence of effectiveness than affirmative healthcare, including access to puberty blockers and HRT. The government is criminalising the best currently available healthcare. There is no evidence that alternative medication to treat the symptoms of denial of trans healthcare (including anti anxiety and anti depression medication, or psychotherapy) is effective for trans youth wanting to avoid distressing pubertal changes. I am deeply concerned that the government policy is paying lip service to “support” to those children and adolescents affected by criminalisation, whilst having no evidence-based support to offer.

    In managing the ‘risks’ to trans children and adolescents denied affirmative healthcare, the current consultation places significant emphasis on ‘access to mental health services’. There is significant evidence of pathologisation of trans identities in this approach. Trans children and adolescents, when supported and provided access to affirmative healthcare, may not ever need access to mental health services. The assumption that mental health services are needed by trans children and adolescents is worrying, especially when the mental health need to be managed, is the need directly caused by a UK government ban on essential healthcare. The NHS is supposed to have switched from the view of transness as a mental health disorder as categorised in older healthcare standards, through to acknowledgement that trans-ness is not a mental health condition but a natural part of human diversity, as categoried in the World Health Organisation’s ICD-11. The NHS is yet again failing in its supposed commitments to depathologisation of trans identities, proposing mental health led care for trans young people. This is an extremely dangerous and harmful approach.

    • Government interference in healthcare

    I am very concerned about political interference in healthcare, especially when targeting a persecuted minority. There needs to be an exceptionally high bar of justification for political interference in healthcare, especially for use of a blunt instrument like a criminal ban on a medication only when used by a minority population. Trans scholars and communities have long flagged the serious injustices, misunderstandings, and structural violence in navigating healthcare services that fail to provide equitable healthcare to trans people. Here, the government has taken a step to criminalise an aspect of healthcare that is strongly supported by many healthcare professional bodies worldwide. Doctors are being prevented from making individualised decisions with their patients. The law is a very crude tool and politicians stepping between Dr and patient need to be very confident that the risk clearly merits this intervention, bearing in mind also the expected risks of criminalisation. In this case the risk of puberty blockers is entirely unsubstantiated, indeed they are deemed safe for every other population group, and are deemed safe enough for an NHS trial. The statement in the equality and impact assessment that this criminalisation does not directly discriminate against people with the protected characteristic of gender reassignment is entirely uncredible. The policy very clearly directly discriminates against use of puberty blockers only when used by trans adolescents. Children using them for the exact same purpose (preventing puberty), are not criminalised, if they are not trans. The risks of criminalisation are already very clear and growing by the day, pushing trans adolescents towards routes that are known to be less safe than puberty blockers. The policy does not stand up to scrutiny as necessary or evidence based. It is not driven by any understanding of trans adolescents nor care for their rights and well-being. It is not informed by engagement with trans healthcare experts. It will certainly go down in history as an example of government persecution of trans communities. Healthcare should be individualised and evidence based, with no room for prejudice. Criminalisation of a medication only when used by trans adolescents is a very clear example of prejudice informed healthcare.  

    References

    On failings in the Cass Review (peer reviewed journal article)

    Horton, C. (2024) The Cass Review:  Cis-supremacy in the UK’s approach to healthcare for trans children. International Journal of Transgender Health

    On failings in the Cass Review (commentary)

    Horton, C. and Pearce, R. (2024) The U.K.’s Cass Review Badly Fails Trans Children, Scientific American

    Pearce, Ruth (2024) What’s wrong with the Cass Review: A round up of commentary and evidence. Blog post.

    Horton, Cal (2024). “Social transition, puberty blockers and the Cass Review”, What the Trans Podcast: https://whatthetrans.com/social-transition-puberty-blockers-and-the-cass-review-podcast-transcript/

    On ethical failings in trans healthcare services in the UK (peer reviewed journal articles)

    Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

    Horton, C. (2022). “Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies.

    Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

    On the need for child voice and child rights in healthcare research and policy (peer reviewed journal articles)

    Horton, C. (2024) The importance of child voice in trans health research: a critical review of research on social transition & well-being in trans children. International Journal of Transgender Health

    Horton, C., Pearce, R., Veale, J., Oakes-Monger, T. C., Pang, K. C., Pullen Sansfaçon, A., & Quinney, S. (2024). Child rights in trans healthcare – a call to action. International Journal of Transgender Health, 25(3), 313–320.

    On the need for depathologisation of healthcare (peer reviewed journal article)

    Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

    Question 8: Data gathering

    There is no way to gather meaningful data on those trans children, adolescents and supportive families directly harmed by this law without trust. Currently the UK government hold no such trust amongst impacted communities, who view this current criminalisation as a direct attack on trans children’s rights, lives and well-being. Without trust building, people will continue to be afraid to engage with government or NHS related data collection on this topic. Trust needs to be earned through removal of this harmful attach on trans children and adolescents, through ensuring lived experience experts are given an influential and respected seat at the table in government and NHS policy spheres, and through enacting policy that is actually guided by listening to and ensuring the best interests of trans children and young people.

    Question 9: Satisfaction with consultation

    Very little faith that this consultation will be listened to, or that the harms to trans children will carry weight in the eyes of those making decisions.

    Latest Evidence on Puberty Blockers

    / growinguptransgender / Leave a comment

    In 2020 I summarised the then published research on puberty blockers in a blog. That blog post remains a comprehensive overview of the pre 2020 literature, with relevance to discussions today.

    There has been a significant body of research on puberty blockers published since that 2020 blog, that I will summarise and keep updated here. I’ve been meaning to update that blog, 4 years later. I was given encouragement by the latest overstep by the Charity Commission.

    Yesterday the UK Charity Commission insisted that UK Charities revise their communication on puberty blockers with due regard for the findings of the Cass Review. This Charity Commission recommendation is problematic for two major reasons. Firstly, the Cass Review was heavily biased, an exemplar of prejudice impacting on healthcare policy, and has been widely condemned by trans communities, by healthcare experts worldwide and by academic researchers. The Charity Commission has no business stepping into this realm of academic criticism, and should not be preventing UK charities from highlighting the areas where the Cass Review deviated, for ideological reasons, from the evidence base. UK charities should not be coerced by the Charity Commission to endorse and disseminate medical advice they know to be deeply flawed. (Ruth Pearce has also done a blog on the Charity Commission’s latest advice to UK charities).

    Secondly, regardless of any view on the reliability of the Cass Review, the Cass Review presents a snapshot of scientific evidence review at one point in time. The Cass Review drew upon a systematic review that looked at evidence published before April 2022 (and omitted some evidence published before that). The Cass Review was very clear that the science and evidence base underpinning trans youth healthcare is evolving and growing, and that approaches need to be atuned to new evidence as it is published. Science does not stand still. We need to continue to track and report on new evidence as it becomes available. Charities and others advising and supporting trans youth need to ensure they are representing current literature and current knowledge on puberty blockers, including considering the numerous peer reviewed academic studies published since April 2022.

    This blog summarises all the literature published on puberty blockers since my last blog (written in early 2020). Many of the more recent of these articles were not considered by the Cass Review. The Cass Review examined articles published before April 2022 – articles published since that date are starred to highlight the evolving evidence base in this field.  

    (note: The April 2022 cut-off date was used variably by the Cass Review. April 2022 was stated as the cut-off date for inclusion of studies in the York systematic literature review – however the Cass Review did include more recent studies that were critical or ambivalent about gender affirmative care, whilst ignoring more recent studies that presented positive findings on gender affirmative care).

    On effectiveness

    Mejia-Otero et al. (2021) “Effectiveness of Puberty Suppression with Gonadotropin-Releasing Hormone Agonists in Transgender Youth”. Found that puberty blockers were effective at blocking puberty, and as effective in trans youth as in cis youth with precocious puberty.

    On mental health

    *Chen et al. (not yet published). This study was presented at WPATH 2024. It highlighted the different mental health trajectories of trans youth. It emphasised that for trans youth with childhood support, family support, affirmation, low levels of gender minority stress, they have good mental health from childhood, and that good mental health is maintained through puberty blocker and gender affirming hormone treatment. For these youth, puberty blocker treatment would not lead to an improvement in mental health but a retention and protection of that good mental health. This is a very important distinction and highlights that looking for ‘mental health improvements’ is the wrong metric for this cohort. Similarly it highlighted a group with persistent mental health challenges, throughout gender affirming treatment. It concluded that gender affirmative healthcare is an important component of healthcare, but not expected to eradicate mental health challenges, especially for trans youth facing hostility, hate and persecution, and for youth with co-existing challenges linked to elevated rates of mental health. Overall, amongst youth receiving gender affirming healthcare, good mental health was more likely in trans youth with less loneliness, less gender minority stress, higher parental acceptance and higher emotional support.

    * Kuper et al. (not yet published). This study was presented at WPATH 2024. It examined the outcomes for trans youth receiving testosterone and oestrogen. It noted that large improvements in body dissatisfaction were seen as the primary goal of treatment. This is an important clarification of a key goal of gender affirming care. It noted modest improvements in mental health and quality of life, which were also impacted by gender minority stress. They noted that this sample is in Texas where there are very significant socio-political stressors and state persecution, which is likely impacting on mental health measures. This study again emphasises that mental health does not operate in a vacuum, and that looking for improvements in mental health may be an unhelpful metric in a context where trans youth face severe and chronic stressors.

     *McGregor et al. (2024) “Association of Pubertal Blockade at Tanner 2/3 With Psychosocial Benefits in Transgender and Gender Diverse Youth at Hormone Readiness Assessment”. It compared 40 trans adolescents receiving blocker at tanner 2 or 3 to 398 trans adolescents who had not accessed a puberty blocker. It found those who accessed a puberty blocker had lower anxiety, less depression, less stress, and were significantly less likely to report any suicidal thoughts.

    *Horton (2022) [My article] “Experiences of Puberty and Puberty Blockers: Insights From Trans Children, Trans Adolescents, and Their Parents”. Three major themes are presented, relating to pre-pubertal anxiety; difficulties accessing blockers; and, for a minority who were on blockers, experiences of relief and frustration. It highlighted the increase of anxiety in the years before puberty, and the role of confidence that puberty blockers would be available in assuaging that anxiety. This is one of the only pieces of modern research that actually centres trans children’s voices and perspectives on puberty blockers.

    Chen et. al (2021) “Psychosocial Characteristics of Transgender Youth Seeking Gender-Affirming Medical Treatment: Baseline Findings from the TYC Study”. It compared the well-being of 95 trans adolescents just before accessing puberty blockers (mean age 11) to the well-being of 316 trans adolescents just before accessing HRT (mean age 16). A vast majority (93%) of the youth just about to start HRT had not been able to access puberty blockers. This study compared the two groups. Amongst the group about to access puberty blockers 28% showed depression, 22% anxiety, 23% lifetime suicidal ideation and 7.9% a past suicide attempt. Amongst the group about to access HRT group, the vast majority of whom had not been able to access puberty blockers 51% showed depression, 57% anxiety, 66% suicidal ideation and 24% a past suicide attempt. The study may indicate a decline in well-being over adolescence for trans youth who are not able to access affirmative healthcare, pointing to possible benefits of accessing gender-affirming treatment earlier in life. 

    *Tordoff et al. (2022) “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care”. The study looked at 104 trans youths. It found that receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up. Given this population’s high rates of adverse mental health outcomes, these data suggest that access to pharmacological interventions may be associated with improved mental health among TNB youths over a short period.

    Wittlin et al. (2024) “Mental Health during Medical Transition in a US and Canadian Sample of Early Socially Transitioned Transgender Youth“. Looked at anxiety and depressive symptoms among transgender youth at 3 stages: before youth had begun puberty blockers; after they had begun blockers; and after they had begun hormone therapy, comparing them to samples of cis youth. In this sample of transgender youth who sought and received gender-affirming medical care, participants experienced stable and relatively low levels of psychological distress across stages of medical transition and across time. There was one exception: transgender girls showed increased, followed by decreased, parent-reported depressive symptoms over time. In contrast, cisgender girls showed increases in internalizing symptomatology (with the exception of parent-reported anxiety) as they got older, and cisgender boys showed decreased self-reported anxiety and increased, followed by decreased, parent-reported depressive symptoms. By mid-adolescence, levels of anxiety and depressive symptoms among transgender girls and transgender boys generally fell between those of cisgender girls and cisgender boys.

    On quality of life & well-being

    Fontanari et al. (2020) “Gender Affirmation Is Associated with Transgender and Gender Nonbinary Youth Mental Health Improvement”. Survey of 350 Brazilian trans youth. Having accessed multiple steps of gender affirmation (social, legal, and medical/surgical) was associated with fewer symptoms of depression and less anxiety. Furthermore, engaging in gender affirmation processes helped youth to develop a sense of pride and positivity about their gender identity and a feeling of being socially accepted.

    Carmichael et al. (2021) “Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK”. Research of 44 trans youth. Overall patient experience of changes on GnRHa treatment was positive. It identified no changes in psychological function. Bone mass density was as expected.

    Becker-Helby et al. (2020) “Psychosocial health in adolescents and young adults with gender dysphoria before and after gender-affirming medical interventions: a descriptive study from the Hamburg Gender Identity Service”. Followed 75 German trans youth from baseline through to 2 years later. 21 had no medical interventions. 11 had puberty suppression only. 32 had gender affirming hormones only. 11 had gender affirming hormones and surgery, predominantly mastectomy. At baseline all groups had high anxiety and low quality of life scores. For the puberty suppression group, quality of life measures at follow up after 2 years matched German healthy norms. Clinicians’ ratings of global functioning (CGAS) indicated good functioning levels at follow-up. Rates of anxiety and depression were still elevated.

    *Horton (2022) [My article] ““I Didn’t Want Him to Disappear” Parental Decision-Making on Access to Puberty Blockers for Trans Early Adolescents”. This looked at how 30 parents of trans children navigate decisions about puberty blockers, and what factors those parents see as important for their children’s health and well-being. Parents regarded puberty blockers as protective of short and long term mental health. They felt puberty blockers enabled and sustained adolescent well-being and quality of life, enabling trans youth to focus on education, socialising, friendships, enjoying their adolescence. Parents expressed frustration at an excessively onerous process for providing consent, in particular the practice of asking adolescents at the point of accessing puberty blockers to consider the impacts of other medical interventions like HRT and surgery. Parents felt the process of taking consent should acknowledge that taking puberty blockers for a trans adolescent is not a more significant decision than a decision to proceed through endogenous puberty. Parents expressed dismay at the way in which evidence of safety and effectiveness for cis youth was disregarded (the same drugs do not work differently in trans youth). Parents also commented on they fact that they would never engage in a Randomised Control Trial of puberty blockers, highlighting significant practical and ethical flaws.

    Impact on bodies and future surgery

    Van de Grift et al. (2021) “Timing of Puberty Suppression and Surgical Options for Transgender Youth”. Looked at the impact of puberty blocking medication for trans people who later pursue surgical transition. They found that trans masculine adolescents receiving early puberty blockers were less likely to need chest surgery. Trans feminine adolescents receiving early puberty blockers were more likely to require a different type of bottom surgery to trans feminine adolescents who had not received early puberty blockers.

    *Boogers et al. 2023 “Time Course of Body Composition Changes in Transgender Adolescents During Puberty Suppression and Sex Hormone Treatment”. Study compared trans girls on puberty blockers to cis boys and trans boys on puberty blockers to cis girls. Trans girls experienced ongoing lean mass decrease and fat mass increase compared to cis boys during 3 years of PS while in trans boys smaller changes compared to cis girls were observed that stabilized after 1 year.

    On body image and body satisfaction

    ‘Bodily satisfaction’ or ‘appearance congruence’ are recognised as a critical outcome or benefit of access to puberty blockers.

    *Chen et al. (2023) “Psychosocial Functioning in Transgender Youth after 2 Years of Hormones”. It monitored the impact of 2 years of HRT on 315 trans adolescents (mean age 16). During the study period, appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased. Increases in appearance congruence were associated with concurrent increases in positive affect and life satisfaction and decreases in depression and anxiety symptoms. The authors note that two trans youth died by suicide during the study period.

    Kuper et al. (2021) “Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy”. This study was not specifically on puberty blockers. But highlights that bodily satisfaction is a key measure that is changed through gender affirming hormones.

    Grannis et al. (2021) “Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys”. This study was not specifically on puberty blockers. It examined the well-being and bodily satisfaction of trans boys who had not received puberty blockers, comparing those who accessed Testosterone to those who had not yet accessed Testosterone. Those who had been through puberty without puberty blockers had high bodily dissatisfaction, anxiety and depression. Those on testosterone had reduced bodily dissatisfaction, with lower depression and suicidality. Group differences on depression and suicidality were directly associated with body image dissatisfaction

    Articles on the rates of satisfaction with treatment and rates of continuation of gender affirming healthcare after puberty blockers

    *Van der Loos et al. (2022) “Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands”. 720 people were included, of whom 220 (31%) were assigned male at birth and 500 (69%) were assigned female at birth. At the start of GnRHa treatment, the median age was 14·1 (IQR 13·0–16·3) years for people assigned male at birth and 16·0 (14·1–16·9) years for people assigned female at birth. Median age at end of data collection was 20·2 (17·9–24·8) years for people assigned male at birth and 19·2 (17·8–22·0) years for those assigned female at birth. 704 (98%) people who had started gender-affirming medical treatment in adolescence continued to use gender-affirming hormones at follow-up. Age at first visit, year of first visit, age and puberty stage at start of GnRHa treatment, age at start of gender-affirming hormone treatment, year of start of gender-affirming hormone treatment, and gonadectomy were not associated with discontinuing gender-affirming hormones. Most participants who started gender-affirming hormones in adolescence continued this treatment into adulthood. The continuation of treatment is reassuring considering the worries that people who started treatment in adolescence might discontinue gender-affirming treatment.

    *Cavve et al. (2024) “Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort”. From those seen at this Australian clinic between 2014 and 2020, 1% of trans adolescents accessing medical treatment including puberty blockers later reidentified with their assigned sex when followed up in 2022.

    *Van der Loos et al. (2023) “Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol”. This Study looked at the pathways of children who received puberty blockers over a 20 year period. Of all 266 AMAB who started GnRHa at our center, 9 (3.4%) discontinued treatment. Six (2.3%) ceased treatment because of abating GD. In 2 AMAB (0.8%), GnRHa treatment ended due to psychological or social issues hindering transition. In 1 individual (0.4%), GnRHa was discontinued due to compliance issues. Of all 616 AFAB, 5 (0.8%) broke off GnRHa. In 3 (0.5%), remission of GD led to discontinuation. In 2 (0.3%), GnRHa was suspended due to compliance issues. Of 707 eligible VUmc participants using GnRHa, 93% subsequently started GAH. The majority of people who had not yet started GAH did so for protocol reasons respectively. They were either too young or had not used GnRHa for the required amount of time.

    *Masic et al. (2022) “Trajectories of transgender adolescents referred for endocrine intervention in England”. Not very informative.

    *Butler et al. (2022) “Discharge outcome analysis of 1089 transgender young people referred to paediatric endocrine clinics in England 2008–2021”. Looked at pathways of those who had accessed endocrine services. 999/1089 (91.7%) continued identifying as gender variant. 90/1089 ceased identifying as gender variant. 58/1089 (5.3%) stopped treatment either with the gonadotropin releasing hormone analogue (GnRHa) or gender-affirming hormones (GAH) and reverted to their birth gender: <16 years (20/217; 9.2%); ≥16 years (38/872; 4.4%). Subdividing further, 16/217 (7.4%) <16 years ceased GnRHa and 4/217 (1.8%) after GAH. Of those ≥16 years, 33/872 (3.8%) ceased GnRHa and 5/872 (0.6%) GAH. At discharge, 91.7% continued as transgender or gender variant, 86.8% sought ongoing care through NHS GICs. 2.9% ceased identifying as transgender after an initial consultation prior to any endocrine intervention and 5.3% stopped treatment either with GnRHa or GAH, a higher proportion in the <16 year compared with the ≥16 year groups. 

    On impact of puberty blockers on future sexual functioning

    Van der Meulen et al. (2024) “Timing of puberty suppression in transgender adolescents and sexual functioning after vaginoplasty“. Looked at 37 transfeminine individuals treated with a gonadotropin-releasing hormone agonist (puberty suppression), estrogen, and vaginoplasty (penile inversion technique or intestinal vaginoplasty) in the Netherlands, between 2000 and 2016. Experiences regarding sexual functioning and difficulties were assessed with a self-developed questionnaire ~1.5 years after genital gender-affirming surgery and compared between early (Tanner stage G2-3) and late (Tanner stage G4-5) treatment with puberty suppression. Following surgery, 91% of transfeminine individuals was able to experience sexual desire, 86% experienced arousal, and 78% could attain an orgasm. Seventy-five percent of transfeminine individuals who had not experienced an orgasm pre-surgery were able to experience one post-surgery. Of all participants, 62% reported having tried penile-vaginal intercourse post-surgery. The majority reported the presence of one or multiple sexual challenges. There were no significant differences in postoperative sexual function or sexual difficulties between groups treated with early versus late puberty suppression. This study found that post-vaginoplasty transfeminine individuals after both early and late suppression of puberty have the ability to experience sexual desire and arousal, and to achieve orgasms. Outcomes are comparable to previous findings in those who started treatment in adulthood.

    Articles examining how puberty blockers impact on other aspects of health

    Strang et al. (2021) “Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status”. The study looked at executive functioning in 124 trans youth. 21 % of non-autistic and 69 % of autistic transgender youth had clinically elevated EF problems. Autism, anxiety and depression were all associated with lower executive function. Those on just puberty blockers for a year or less saw no impact on executive function. Being on puberty blockers without HRT for more than a year was slightly associated with low executive function. Being on gender-affirming hormones was associated with better executive function. It noted that experiences of stress, rejection and gender minority stress are likely to negatively impact on executive function.

    *Valentine et al. (2022) “Multicenter Analysis of Cardiometabolic-related Diagnoses in Transgender and Gender-Diverse Youth: A PEDSnet Study” The study found that GnRHa were not associated with greater odds of cardiometabolic-related diagnoses.

    Perl et al. (2021) “Blood pressure dynamics after pubertal suppression with gonadotropin-releasing hormone analogs followed by estradiol treatment in transgender female adolescents: a pilot study”. This research found that being on puberty blockers for trans feminine adolescents did not impact on blood pressure.

    Perl et al. (2021) “Blood Pressure Dynamics After Pubertal Suppression with Gonadotropin-Releasing Hormone Analogs Followed by Testosterone Treatment in Transgender Male Adolescents: A Pilot Study”. This research found that being on puberty blockers for trans masculine adolescents had some impact on blood pressure, with this effect disappearing when on testosterone.

    Russel et al. (2020) “A Longitudinal Study of Features Associated with Autism Spectrum in Clinic Referred, Gender Diverse Adolescents Accessing Puberty Suppression Treatment”. The research found that for autistic trans youth, being on puberty blockers did not affect their social responsiveness. (?)

    Articles related to bone health

    *Van der Loos et al. (2023) “Bone Mineral Density in Transgender Adolescents Treated With Puberty Suppression and Subsequent Gender-Affirming Hormones”. This looked at people average age 28, who had been on affirming hormones for an average of 11-12 years, having started affirming hormones at 16, after previously being on puberty blockers from tanner 2-3. Trans girls had lower bone mass than cis boys before the start of puberty blocker treatment. The study provided evidence that bone mineral accrual is temporarily suspended by the use of puberty suppression but, due to an increase during GAH treatment, BMD catches up with pretreatment levels at long-term follow-up, except for the lumbar spine in individuals assigned male at birth. The study concluded that treatment with a GnRH agonist followed by long-term gender-affirming hormones is safe regarding bone health in transgender persons receiving testosterone, but bone health in transgender persons receiving estrogen requires extra attention and further study.  Estrogen treatment should be optimized and lifestyle counseling provided to maximize bone development in individuals assigned male at birth. [Note this is yet another study inappropriately using Z scores compared to assigned sex which other lit (see earlier blog) has found are not the most useful way of studying bone density for this population]. Whilst this article predominantly compares trans people to the bone density of their assigned sex, when comparing trans people to their affirmed sex it notes “At follow-up, when participants were in their late 20s (around 28 years), the majority had z scores within the normal range when using reference data of the affirmed gender”.

    Navabi et al. (2021) “Pubertal Suppression, Bone Mass, and Body Composition in Youth With Gender Dysphoria”. Found that reduced bone density of trans adolescents on puberty blockers was related to insufficient Vitamin D. Found that trans adolescents on puberty blockers need to take vitamin D. (This is standard healthcare). 

    *Bachrach et al. (2023) “Bone Health Among Transgender Youth: What Is a Clinician to Do?” provides advice for clinicians on how to advise trans youth and families on managing bone health relating to puberty blockers.  

    Articles related to research ethics on puberty blockers

    *Ashley et al. (2023) “Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare”. Outlines why RCTs are inappropriate, unpractical and unethical for puberty blockers.

    *Moscati et al. (2023) “Trans* identity does not limit children’s capacity: Gillick competence applies to decisions concerning access to puberty blockers too!”. Outlines why being trans does not override important medical ethical principles of decision making.  

    Articles related to height

    Schulmeister et al. (2021) “Growth in transgender/gender-diverse youth in the first year of treatment with gonadotropin-releasing hormone agonists”. It looked at impact on rates of growth in height. It followed 55 trans adolescents who started blockers at average age 11, 62% at tanner 2 and 29% at tanner 3.  Pre-pubertal cis children grow at average 6.1 cm a year (range 4.3 – 6.5). Trans children who started puberty blockers at tanner II grew at a median of 5.3cm a year (range 4.1 – 5.6cm). Trans children who started puberty blockers at tanner III grew a median of 4.4cm a year (range 3.3 – 6.0cm). These rates are slightly lower rates of height growth than pre-pubertal youth. Trans children who started puberty blockers at tanner IV grew a median of 1.6cm a year (range 1.5 – 2.9cm), at a lower rate of height growth than pre-pubertal youth. In summary, trans adolescents on puberty blockers at tanner 2 and 3 continue to grow in height at similar rates to pre-pubertal children. Trans adolescents on puberty blockers at tanner 4 grow in height at slower rates. More information on the timing of affirmative healthcare and impacts on height will be valuable for those who desire a height in ranges typical for cis men and women.

    *Boogers et al. (2023) “Transgender Girls Grow Tall: Adult Height Is Unaffected by GnRH Analogue and Estradiol Treatment”. This study looked at how gender affirming healthcare affects the height of trans girls. In the Dutch population, cis men reach a mean adult height of 183.8 cm, which is more than 13 cm taller than cis women (170.7 cm)  This study looked at 161 trans girls who started puberty blockers before age 16 and started oestrogen at an average age of 15 or 16 years old. The cohort were at different tanner stages when starting blockers (Tanner 2 – 5). The mean duration of puberty suppression 2.4 years. Individuals had an average growth velocity of 5.3 cm/year in the first year of treatment. This decreased to 3.5 cm/year in the second year.  When starting oestrogen at 15 or 16 they were either treated with estradiol at a regular dose (2 mg), with high growth-reductive doses of estradiol (6 mg) or with ethinyl estradiol (EE, 100-200 µg).

    Growth velocity and bone maturation decreased during GnRHa, but increased during GAHT. Adult height after regular-dose treatment was 180.4 ± 5.6 cm.  Growth velocity in the first year of GAHT was 2.8 cm/year, which decreased to 1.4 cm/year in the second year. From the start of GAHT, height increased by 5.9 cm to an adult height of 180.4cm.

    The high dose estradiol group mostly had 1.5 years on regular dose before moving to high dose. Compared to regular-dose treatment, this group reduced adult height by 0.9 cm (179.5cm).

    The EE group reduced adult height by 3 cm (177.4cm). High-dose EE resulted in greater reduction of adult height than high-dose estradiol, but this needs to be weighed against possible adverse effects.

    Individuals who started affirming hormones at a lower bone age reached an adult height that was 1.6 cm/year lower than those who started hormones at a higher bone age.

    Potentially earlier initiation of estradiol in transgender girls (before age 15-16) might result in shorter adult height.

    Willemsen et al. (2023) “Just as Tall on Testosterone; a Neutral to Positive Effect on Adult Height of GnRHa and Testosterone in Trans Boys”. This study looked at 146 transgender boys treated with GnRH analogues and testosterone who reached adult height. Adult height was on average 172.0cm. Trans boys who started pubertal suppression at a young bone age were significantly taller. PS and GAHT do not have a negative impact on adult height in transgender boys and might even lead to a slightly taller adult height, especially in those who start at a younger age.

    *Ciancia et al. (2023) “Early puberty suppression and gender-affirming hormones do not alter final height in transgender adolescents”. This study found that trans boys and trans girls height aligned with cis peers of their assigned gender rather than affirmed gender, with puberty suppression and gender affirming hormones not impacting on height. This study was for trans boys starting puberty suppression at average age 12, and trans girls starting puberty suppression at average age 13 (I couldn’t see the age of starting affirming hormones as I can’t access the full article).

    Science does not stand still. We need to ensure we are up to date with the latest research in this field. Charities and those supporting trans children and young people need to keep informed about the latest evidence, and ensure the most accurate, up to date, and comprehensive evidence is made widely available, for informed decision making.