transgender

Is this an abusive relationship?

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(or why I won’t be responding to another government consultation on trans healthcare).

Just weeks after having submitted an invited response (invited as an academic expert) to a government consultation on making a legal ban on puberty blockers permanent, ANOTHER government consultation on trans healthcare has today been launched.

This one is on adult trans healthcare services. There are many reasons to approach this consultation with concern. The consultation itself provides a link to the incredibly biased and prejudice-ladden letter from Dr Cass which is a driver of this current review.

I cannot even remember how many government consultations related to trans rights or trans healthcare I have completed over the past 8 years. It is far far far beyond a joke.

And each public consultation takes the same form. The new NHS adults services consultation even provides a link to an analysis and summary of responses to the 2017 consultation. Reading the executive summary of that analysis is very telling and illustrative of the problem. In the 2017 consultation, responses were divided into three groupings:

  • Current, former or prospective user of gender identity services (30.15% of respondents)
  • Individual member of the public (26.8% of respondents)
  • Clinician (16.75% of respondents)

The 2017 consultation responses summarises very succinctly the differences between these responses (worth reading on pages 2-6). In short, the current and former users of gender identity services provided detailed and meaningful suggestions on how services could be reformed and improved. Clinician respondents, who were, mostly GPs, broadly didn’t know what to do with trans people and didn’t want to have responsibility. Members of the public felt being trans was a mental disorder and wanted services to be made significantly worse for trans people. The consultation presented all of these contrasting views, with the views of actual trans people in one grouping (glossing over nuances in actual recommendations re different ways of improving trans health), while views that were ambivalent or fundamentally opposed to trans well-being and healthcare rights were given equal weighting to those of actual service users.

This pattern has then repeated time and time again since 2017.

This pattern will be repeated in this new NHS consultation. Although now the anti-trans lobby is much more organised and assertive, so I expect even more volume of anti-trans submission, including from transphobic clinicians and medical professionals, and including from those purporting to be prospective service users (or concerned family members of service users).

This pattern of public consultation for minoritized healthcare is extremely abusive.

Every consultation response is a huge amount of effort to do well. It is a significant extraction of labour from already exhausted trans people, including from those of us who are called to respond as trans-supportive researchers or on behalf of civil society.

It is abusive to ask us for consultation after consultation after consultation. Every single one we respond defensively, knowing that the purpose of the consultation is not to improve services and respect rights, but to justify an ever further roll back of those rights, and ever more severe degredation of those services.

It is abusive to ask trans folks to engage in yet another consultation where the views of those fundamentally bigoted about trans existence are given equal weight.

It is abusive full stop.

This particular consultation is where I personally draw a line. It is not acceptable.

I expect adults trans healthcare will be made worse in the coming years, building upon Cass. I expect this public consultation, including the thousands of responses from profoundly anti-trans individuals and lobby groups, will be used to justify that degregation of essential healthcare. To justify the inclusion of ever greater rights violations in our healthcare. To justify ever greater encroach into the reasons to deny care to those of us who are the wrong kind of trans.

Esteemed trans healthcare scholar Dr Ruth Pearce wrote all the way back in 2018 (about another consultation on trans health conducted about us yet without us), that “we respond not with hope or optimism, but in fear. This is the power you wield over us”.

Over the past years I have responded to more government consultations on trans topics than I can count. Every single submission I have written, not out of hope, but out of fear. Out of a feeling of responsibility to use my relative privilege to at least try and change the outcomes, to raise my voice to highlight the current injustices and the harms of abusive practice.

But we are clearly not being listened to. Time and time again we are not being listened to.

How long do we keep collaborating in the same pattern. How long do we keep gas-lighting ourselves?

Today I’m saying no.

I refuse to remain in any part of this extremely abusive relationship.

I refuse out of principle to engage in any way with a consultation that is equally interested in the views of non-service users, that does not have really basic ethical commitments to trans depathologisation, dignity and healthcare rights, that does not have trans leadership and trans power at its centre.

I refuse to respond defensively while having zero hope that my words and my time are going to change the outcome. In this case, as before, I fundamentally don’t believe my inputs will in any way change the outcome. Quite the opposite – I believe my words and my submission, alongside those of others submitted and hard-worked-on out of a feeling of responsibility to our communities, will provide the government/NHS with a veneer of respectability, that they asked and listened to all views.

Listening to all views is not good enough. I literally cannot stomach another consultation that will be written up as “here’s what trans people want, however here’s what doctors and members of the public want, so we are therefore going to make trans healthcare worse”. It is not good enough. I am out.

I’m not saying that stepping out of this consultation will be enough to change the outcome. I’m not saying there is a clear path to trans justice.

But I’m at least not going to waste my time on another heartless and fundamentally flawed process.

Today I will choose to do something better with my time.

I hope we can at some point be more coordinated and demanding, standing together in solidarity and power, saying we will not engage with processes that are fundamentally dehumanising and abusive. Most folks I know right now are too worn down by all the loses, by all the pain, by all the energy expended on heartless consultations, to have the energy and reserves to try and take back any power.

Maybe that is one of the ways forward. For now we take time, we rest, we refuse to respond defensively, we let go of the fleeting hope that our submission will be enough to change power structures that continue to inflict harm after harm.

We focus our time and energy on ways to keep ourselves and those who are suffering afloat through these tough times.

We state clearly and in unison that when the government and the NHS decide they believe in our humanity, when they have an ounce of care for justice and equality, when they recognise that anti-trans views are not welcome in consultations on our healthcare, then we have plenty of ideas to share on the meaningful reform of trans healthcare. But until that approach is made in good faith, and with trans people in positions of authority – we have better things to focus on. We focus on surviving the anti-trans hate that continues to grow in the UK, including in senior leadership in the government and NHS.

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WPATH 2024: Part Two

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

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

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

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

From further data analysis they discovered:

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

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

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

Less loneliness

Less gender minority stress

Higher parental acceptance

Higher emotional support

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

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

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

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

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

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

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

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

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

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

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

Overall conclusions were:

Strong satisfaction with decision to receive treatment from youth and parents

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

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

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

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

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

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

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

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

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

Very high levels of satisfaction and very low levels of regret

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1 person regretted the hormones and surgery they received.

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

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

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

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

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

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

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

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

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

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

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

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

WPATH 2024

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

Overall vibe

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

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

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

 Session structure

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

Plenary sessions.

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

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

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

Parallel sessions

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

Symposia

On being a target

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

Trauma-informed approaches to care

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

Evolution of gender expression care

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

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

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

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

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

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

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

Oral abstracts

Engaging Family

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

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

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

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

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

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

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

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

Law, Policy and Ethics

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

Community engagement

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

Other conversations

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

Gender Dysphoria and puberty blockers

/ growinguptransgender / Leave a comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They are criticising puberty blockers for failing to cure transness.

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

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

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

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

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

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

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

We need to reduce gender dysphoria they say.

We need to make children not trans they mean.

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

They just care about making trans kids into cis kids

This is all they ever care about.

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

Trans children’s experiences in primary healthcare in the UK

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This is a pre-publication version of an article on trans children’s experiences with GPs in the UK.

Abstract

Background: Increasing numbers of trans children and parents are engaging with primary healthcare providers. There is limited research on the primary healthcare needs and experiences of this group.

Aim: This research aims to understand the primary healthcare experience of socially transitioned trans children and their families.

Design and Setting: Qualitative research with supportive families with trans children from England, Scotland and Wales.

Method: Interviews were conducted with 30 parents of trans children average age 11 (range 6-16) who socially transitioned at average age 7 (range 3-10. In-depth semi-structured interviews generated data on experiences in healthcare, in families and in education. This article analyses a subset of data on experiences in primary healthcare, applying reflexive thematic analysis within Nvivo.

Results: Findings showed a range of negative experiences with GPs, including dismissal and ignorance about trans children, encounters with prejudice, and approaches grounded in fear and a narrow view of risk, leading to refusal of care. Many families reported losing trust and confidence in health professionals, while others highlighted the positive impacts where GPs listened to families, were willing to learn, and provided empathetic trans-positive care.

Conclusion: Trans children and supportive parents’ negative experiences in primary care indicate a need for greater education, trans awareness and commitment to trans de-pathologisation in UK healthcare. GPs can play a critical role in encouraging and supportive parents to affirm and provide trans-positive care for trans children.

Keywords.

Transgender persons, primary health care, general practice, qualitative research, gender identity, health services, adolescent, child

How this fits in:

Trans children and their families are known to experience challenges within healthcare settings, though there is limited research into experiences specifically within primary healthcare. This study examines these challenges, highlighting experiences of dismissal, prejudice, or refusal of care, with parents losing confidence and trust in primary healthcare providers. The study highlights significant opportunities for progress and positive impact, emphasising how primary healthcare providers can support parents, in turn supporting trans children’s mental health and well-being. The study concludes with recommendations for primary healthcare providers to better meet the needs of trans children and their families.  

Introduction

Lesbian, gay, bisexual and transgender (LGBT) communities are known to be at risk of experiencing poor care, due to a lack of awareness or prejudice within healthcare (1). A national survey of over 14,000 trans and non-binary respondents over the age of 16 by the UK Government Equality Office reported 21% had experienced healthcare professionals ignoring their specific needs in the past year, and 18% stated they avoided seeking healthcare for fear of discrimination or intolerant reactions (2). Trans adults commonly report additional barriers to routine healthcare, experiencing systemic inequality in cisnormative services not designed for trans service users, encountering transphobia and discrimination, as well as experiencing ‘trans broken arm syndrome’ where all medical concerns are ascribed to being linked to trans specific medical care (3). Within primary healthcare, a survey using a convenience sample of 92 trans adults reported 60% experiencing discrimination from a general practitioner (GP), noting that trans patients felt unable to complain “because they did not expect to be taken seriously… and felt powerless” (4).

Poor experiences and negative expectations can be a deterrent to trans people accessing healthcare from providers including in primary care (3,5,6). Healthcare systems have made some efforts to ensure services are welcoming to all, with initiatives like the doctors’ licensing body, the General Medical Council (GMC) producing LGBT patient guidance on rights to equality and dignity in healthcare (7). This guidance explicitly confirms that doctors must not deny trans people access to treatment or services based on personal beliefs, and that doctors must not express personal beliefs in a way that is likely to cause a patient distress.

Trans people face a range of barriers in primary care, including experiences of bias and prejudice, insensitive care, and encounters with professionals who lack knowledge of trans healthcare or broader trans lives (8). The UK’s General Medical Council has authored guidance on supporting trans adults, although his guidance does not cover trans children and families (9). As with adult gender services, trans child and adolescent tertiary care services in the NHS have waiting lists of many years, with many trans people forced to rely on private healthcare services. For pre-pubescent trans children, gender affirmation comprises a social transition, with a child being socially accepted as their gender, commonly including a change in pronoun. At and after puberty, medical transition can include access to puberty blockers and sex hormones, although not all trans adolescents desire to pursue a medical transition.

Current literature on trans-inclusive primary healthcare focuses predominantly on the experiences of trans adults, or on the experiences and perspectives of healthcare professionals (3,10). Research with trans adolescents has emphasised the importance of creating a welcoming primary care environment for trans youth, with respect for affirmed name and pronoun (11). One study with parents of trans children has highlighted specific barriers to primary healthcare providers engaging in shared care for trans adolescent healthcare (12). Existing literature provides limited insight on the primary healthcare experiences of younger trans children or their parents, presenting a critical knowledge gap. Our study aims to explore the challenges and barriers to healthcare faced by trans children and their families, highlighting areas for improvement, alongside recommendations for policy and practice.

Method

In-depth interviews were conducted to explore the experiences of supportive families with trans children in England, Scotland and Wales. 30 parents of trans children, with parents accessed through six closed support groups for parents of trans children in the UK. Interviews were conducted remotely via Microsoft Teams during the period December 2020 to September 2021 (during periods of COVID-19 pandemic related restrictions). Access to hard-to-reach families and children was enabled by the author’s positionality as a non-binary parent of a trans child, helping overcome trust related barriers to hearing from this cohort.

Semi-structured interviews, covering broad topics including healthcare, education and families, lasted 1-3 hours (average 2 hours). This article examines a sub-set of the wider data corpus considering references to primary care. References to primary care came from responses to questions such as “Tell me about your experiences with healthcare professionals”, or following prompts used flexibly to elicit further responses, for example “What happened when you discussed your child with your GP?”.

Interviews were transcribed by the first author and coded in Nvivo, applying reflexive thematic analysis (13), adhering to the 20-point checklist for quality reflexive thematic analysis (14). The analysis combined indictive and deductive coding, with the major themes, experiences in primary care and confidence in primary care, mirroring interview questions on 1) what were your experiences in primary care? and 2) how have your experiences impacted you and your child? The analysis comprised re-reading each transcript to become familiar with the data and generation of initial codes, coding sub-themes diversely without pre-conceived coding categories. The initial sub-themes were then reviewed to ensure they were internally coherent, consistent, distinctive, and accurately captured the dataset. Each sub-theme was analysed, and interpreted, including with reference to existing literature. Indicative quotations from a range of interviewees were selected to accurately illustrate each sub-theme. The research built in ethical best practices for trans-related research (15).

Results

30 parents of trans children were interviewed, discussing experiences with 30 trans children (15 girls, 12 boys and 3 non-binary children) who socially transitioned at average age 7 (range 3-10 years old), and whose average age was 11 at the time of the interview (range 6-16 years old). All parental interviewees were cisgender, 27 were white, 28 were female and 7 were disabled.  

Challenging experiences with GPs

The first section of the results presents findings relating to challenging experiences with GP. Four sub-themes are presented, considering experiences of 1) dismissal 2) negativity 3) disrespect and 4) hostility to trans healthcare.

1. Dismissal of a trans child’s identity

A common theme in parental accounts was dismissal of their child’s identity, with GPs telling parents that their child would ‘grow out of’ being trans, that it was a passing phase. Some parents were told not to take their child’s identity seriously, to ‘give it six months’. For these families who had come to their GP for support and advice, dismissal left them feeling disregarded and not listened to, or as one parent described it ‘a bit fobbed off’.

‘Well, first of all, I went to see the GP who said, don’t worry about it, it’s nothing to worry about, give it six months, it’s no big deal kind of thing. So I felt a bit fobbed off’.

Several parents referenced their GP believing that their child was ‘too young’ to be trans, using age to dismiss their identity or to dismiss their parent’s request for advice.

‘Your GP generally is completely freaked out by this stuff, thinks your child is too young and doesn’t know what to do’.

Several parents were reassured by their GP that being trans would be temporary.

‘When she was about five, we went to the GP. And I had a GP who kind of patted my arm very reassuringly, and was like, “Don’t worry, they grow out of it”’.

Others were told that all children go through such as phase, dismissing their current identity. This parent was thankful that they didn’t listen to their GP and dismiss their child’s identity.

‘So the GP initially told us, don’t worry about it. Everyone goes through this, come back at the age of eight, if there’s a problem. This is, you know, and I went to them at age four. Thankfully, I didn’t listen to them’.

2. Negativity

A common theme in parental accounts was a perception that GPs held negative attitudes or biases towards trans children or towards parents supporting a trans child. Parents noted negativity through GP language or body language. One family noted their GP’s discomfort, interpreting this reaction as a sign of trans negativity or prejudice.

‘The first time we went to the GP to be referred. That’s when we really encountered some bigotry, straight up bigotry… She could not wait to get us out of her room. She was so uncomfortable, like visibly, visibly, uncomfortable, that I brought a child in with this thing…like, viscerally upset, that it was even a thing…she implied that my daughter had got the ideas from outside, not from herself’.

This parent’s GP suggested that something external had caused a child to assert a trans identity, a suggestion that other parents had also encountered. One parent was shocked that their GP insinuated their child being trans was likely a result of child abuse.

‘We had an appointment at the doctors, and [the Dr] basically blamed my husband said that he must have done something to her when she was younger. To make her want to be a girl rather than a boy’.

Several parents reported that they avoided discussing their child’s identity with their GP through fear of GP trans negativity or judgement.

‘I’ve never taken her to the GP about her gender ever. Purely because I felt like talking to a load of old white men about something that historically, they were probably going to judge me on was not going to be helpful. it’s probably a bad judgement to make, but I just didn’t feel comfortable doing it’.

Another parent who had brought their young trans child to an appointment to discuss their identity and ask for GP advice and support, shared her experience of GP trans negativity, and its impact on her child.

‘The doctor turned to me with [Child] in the room and said “If you told [him] to behave [himself], you wouldn’t be doing this”. I literally collapsed internally. I really did…And as we were leaving the doctor’s surgery, he (child) said, “Am I naughty? Am I naughty for being [Child’s affirmed name]?” And I had to say, “Don’t listen to that doctor”. I mean, how messed up is that to say to a 5-year-old? That’s like saying, when the lollipop lady tells you to cross the road? Ignore her. She doesn’t have a fucking clue what she’s talking about’.

The parent felt their child had been let down in this encounter, with potential negative impacts on their child’s self-confidence or trust in GPs. Several parents perceived that their GP’s approach was influenced by bias or negativity towards a child being trans.

3. Disrespect towards trans children

A majority of families referenced examples of feeling they or their child was disrespected during encounters with their GP. One parent described their GP responding to a request for support with derision.

“I did (go) to a doctor’s initially, and the doctor laughed me out of the office…the doctor basically said they couldn’t help me. And then I said about her gender dysphoria and stuff and she, almost – she smirked at me really. It was almost, she was trying to stifle a bit of a laugh. And so, I just, you know, I left and nothing else ever came of that’.

Several parents reported their GP being unwilling to respect their child’s identity, title or pronoun. For one family, their GP continued to use inappropriate pronouns in clinical appointments with their child.

‘The doctors have been very reticent to use the pronouns that we’ve put on the application forms’.

Another family encountered GP unwillingness to update administrative records, leading to their child being misgendered and outed publicly when attending an appointment.

‘So we went to the doctor, and they changed her name, but they still had Mr. At the front of it. And it was on this big TV. We’re surrounded by people’.

For other families, unwillingness to respect a child’s identity influenced their approach to wider identification, with the GP refusing to support an application to update their sex marker on their passport.

‘She had spoken to, like the people who assess risk, the lawyers, whoever they are, for the doctors. And the recommendation was not to write the letter to change the name on the passport. And her language, I found quite disturbing in terms of either ignorance, or anti trans but her response was, “I’m not – we’re not going to do that”’.

Several of these families felt themselves and their children were not treated with respect in primary healthcare.

4. Hostility to trans healthcare.

Parents perceived GP hostility to trans healthcare in a number of ways, through words, actions and refusals to support. One parent’s GP refused to sign a referral to NHS tertiary gender services, even when asked to do so by secondary care professionals.

‘So CAMHS (Child and Adolescent Mental Health Services) then referred back to the doctor and said, yeah, this child should be referred on to GIDS (Specialist Gender Service). The doctor still refused to sign the referral form’.

Another parent was aware of their GP’s hostility to trans healthcare, having been told that supporting a trans child was ‘against God’s will’.

‘(Current GP) refuses point blank to have anything to do with [Child’s] medical needs around (being trans). Who has phoned me up and told me that I’m going against God’s will- I should be ashamed of myself… And as such as a practice, they will not have anything to do with the prescribing of medication for this’.

In both these examples, GP attitude created a barrier to healthcare access. Parents described GPs having discomfort or hostility to families who accessed private healthcare. Several parents described their relationship with their GP deteriorating when they accessed private healthcare whilst on a multi-year wait list for NHS services. One GP initially agreed to support a trans adolescent with taking blood for hormone monitoring, but then withdrew the offer of support.

‘(When) we went with [Provider], you know, the private provider. She was a little bit less supportive. With us choosing to go down the private route. Initially said she’d do bloods and then withdrew it… I think when we went private, she then distanced herself from us a little bit. Cos she didn’t want to be seen to be supporting us going private’.

The parent felt the withdrawal of support was prompted by the GP wanting to avoid any association with private healthcare. A parent who felt private healthcare was critical for their adolescent shared their experience when asking for GP support in administering a private prescription.

‘I spoke to the GP hoping they might support us with a private injection from (Private Provider). My GP said I should think about because it might be seen as a child protection issue. I’ve just was so, so, upset when I came off the phone to her – cried, and I just – I had the day off work, couldn’t work. I was so upset. I just feel – you just feel like there’s all these barriers being put up and you’re kind of pushing them down, and then another one will come up. So it’s just been a nightmare’.

The parent described the significant impact the GP response had on them, feeling their GP was yet another barrier or threat to their child receiving critical healthcare. Parents noted that GPs were uncertain how to support trans adolescents seeking medical transition, with responses grounded in fear.

‘But it just felt like a fight in so many different places. You know, and especially at the doctors – like that surprised me. The lack of understanding, information, and the lack of like clear procedures and practices, you know, they just have no idea and they’re so afraid to do anything’.

Parents perceived that uncertainty or discomfort with trans adolescent healthcare left GPs ‘afraid to do anything’, with trans adolescents and supportive families left without GP support.

Negative impacts on parents and children

The second section of the results presents findings relating to the impacts of experiences with GPs on families. Three sub-themes are presented on 1) a loss of confidence 2) a search for trans-positive GPs and on 3) GP learning.

1. Loss of confidence in GPs

Loss of confidence in GPs was significant theme across many parental accounts. One parent summed up the impact of poor experiences in primary healthcare.

‘I’ve lost faith and I’ve lost trust in the health care system’.

Another parent spoke of exhaustion related to poor experiences with GPs, holding low expectations for future care.

‘I haven’t got the energy to defend myself against services that are not supposed to be there to degrade what you’re trying, when you’re trying to do the best for your child. I have not – I could not. Right now I could not fight’.

The parent chose to avoid any engagements with primary healthcare professionals, rather than risking further judgement or hostility. This distrust between parents seeking the best care for their child, and primary healthcare providers, risks driving children and families towards less safe methods of healthcare, and risks deterring families and children from engaging with routine non-trans healthcare needs. Several parents whose own experiences of hostility had contributed to anxiety and depression, had deterred, or avoided seeking their own mental health care from their GP, due to their apprehension of GPs.

‘I avoid GPs at all costs, if I can’.

Another parent described how negative experiences with a GP had put their child off wanting to see a GP under any circumstance.

‘It was an awful experience with both [Child] and I. And she didn’t want to go see a doctor at all after that’.

These accounts highlight significant ongoing impacts on supportive parents and trans children, with a loss of confidence in their GP.

2. A search for a trans-positive GP

Several parents spoke of their search for, or wish for, a trans-positive GP, someone who would support them and their child without displaying trans negativity or hostility. Parents spoke of how hard and stressful it is to search for a trans positive GP for a trans child.

‘You never know what their stance is on this particular topic because it’s quite contentious’.

The parent felt that GP stance or bias directly impacted on their capacity to provide trans positive care. Several spoke of their inability to complain about poor practice. Feeling their concerns would not be taken seriously, or even that complaints could put them in a more precarious position.

‘Because it’s our only GP surgery locally, I didn’t (complain). I was too scared to – to be honest with you. I was too scared to’.

Several spoke of wanting to find a trans positive GP, but not knowing how to locate one.

‘I want to, I really want to find a new doctor. But I don’t even know how to go about doing that…(how do I) find out if they’re trans friendly and trans friendly towards children?’.

3. GP learning to provide respectful care for trans children and families

A final sub-theme relates to GP learning, with parents sharing examples of GPs adapting and growing in their ability to provide respectful care for trans children and their families. For all our interviewees, their child was the first trans child their GP had encountered. Despite inexperience, several GPs demonstrated their ability to provide respectful care. One GP emphasised that they had never supported a young trans child but was able to build upon their experience with trans adults.

‘I was like, I don’t know if you’ve ever come across this before? And he was, no, I definitely have, this is just the youngest person I’ve ever come across this with…And he was very good’.

Another parent shared an example of a GP whose initial reaction was not respectful or well-informed, but who reflected upon their approach, and phoned the parent back to apologise.

‘He rang me back… the same GP and he said, after you left, I went online, I was online for about four and a half minutes, and I realised my approach was really wrong… Because he said, I have children. And because none of them have done this, I didn’t recognise this. I didn’t recognise this. And I pushed that on to you. So this is an apology.

This example demonstrates the importance of GP willingness to reflect and learn, especially when GPs are unfamiliar with trans children and their healthcare needs.

Discussion

Summary

Parents of trans children and trans children themselves have encountered a wide range of poor experiences with their GPs, characterised by scepticism, dismissiveness, and lack of knowledge of how best to care for trans children. In several cases GPs failed to treat trans children and families with respect, dignity, and empathy. In many cases families experienced refusal to provide both medical and non-medical aspects of healthcare. Several families experienced acute prejudice, and many felt unable to challenge poor practice. Negative experiences reduced parent and child confidence and trust in primary care providers, and risk deterring access to healthcare.

Strengths and limitations

This research provides qualitative insights into an under-researched group, examining the primary care experiences of parents who have supported and affirmed their trans children in pre-adolescence and is the first study to focus on this cohort. The research provides indirect insights into the experiences that trans children have with GPs, highlighting an area for further research. Importantly, the research does not illuminate the experiences with GPs of trans children or teenagers with unsupportive parents, nor does it consider the experiences of trans teenagers who come out at adolescence. The parental sample is diverse in several respects, though a large majority were cisgender white women, with scope for future research with individuals facing multiple axes of marginalisation, including children within the care system.

Healthcare bias

Existing literature has examined how healthcare professionals’ attitudes, prejudices, lack of knowledge, lack of training or lack of cultural competency can negatively affect their ability to effectively care for trans people (16–19). Studies have explored trans adults’ experiences in healthcare, with examples of trans adults encountering ignorance, prejudice or refusal of care (3,5,20). Experiences of discrimination or stigma in healthcare can lead to distrust and disengagement from healthcare services, contributing to wider health disparities in trans populations (6). This study contributes to the literature, examining trans children and their families’ encounters with ignorance, prejudice or hostility in primary healthcare, highlighting the negative impacts on their confidence in healthcare providers.

Minority Stress

Research has documented the challenges parents of trans children face when engaging with under-informed or prejudiced professionals (21–24). Parents and carers of trans children can be vulnerable to associative stigma and minority stress caused by interactions with institutions and individuals, including healthcare professionals, who respond to parents of trans children with ignorance or hostility (25,26). This study adds to the literature on parental minority stress, illuminating how negative experiences in primary healthcare contributes to parental stress, worry and distrust of healthcare professionals.

Safeguarding child mental health

Family affirmation is known to be critical to trans children’s mental health (27,28). Many parents of trans children initially struggle to understand and support their trans children, with research highlighting the importance of trans-positive information and affirmative support from professionals (29–31). This study highlights an opportunity for GPs to provide trans-positive reassurance to parents of trans children, playing a critical role in safeguarding trans children’s well-being and mental health.

Implications for research and/or practice
A trans-positive and well-informed GP can make a significant difference to trans children and family experiences in primary care. In the absence of UK guidance on support for trans children and families in primary care, healthcare professionals can look to international guidance, such as guidance for GPs contained in the ‘Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents’ (32). Fear of GP prejudice and ignorance can leave trans children and supportive families isolated and afraid, with distrust in primary healthcare providers risking negative impacts on current wellbeing, on social determinants of health and on future equality of healthcare outcomes. These findings reinforce the critical importance of GPs building knowledge and competence to work with trans children and their families. GPs need the confidence and trans-positivity to affirm, depathologise and de-problematise childhood gender diversity.

Poor primary care practice also misses a critical opportunity to educate unsupportive or uneducated parents of trans children. Trans children who are supported, respected and affirmed, especially by their families, are known to have good levels of mental health, whereas family rejection is strongly correlated with poor mental health, depression, self-harm and suicidal ideation (27,28). With family affirmation a key protective strategy to safeguard trans children’s mental health, GPs may need to reorient their interpretation of ‘risk’, prioritising the protection of trans children’s mental health and well-being.

Trans positive reassurance from primary health care providers like GPs is a critically important preventative mental health intervention that would be expected to deliver double mental health benefits. A supportive GP will reduce the minority stress burden on supportive parents of trans children, helping them to better care for their children. Trans positive advice from GPs to unsupportive or uneducated parents can help provide safe, nurturing family environments for trans children, facilitating trans children’s wellbeing and mental health.

Further research bringing together GPs, supportive families, trans children and trans adolescents can explore the barriers to affirmative primary care for trans children and their families. Such research can explore how to build GP confidence and competence; how to ensure safe and trans-positive access mainstream healthcare. Additional research can also explore how GPs can support access to affirmative trans healthcare for trans adolescents, drawing lessons from countries where trans adolescent healthcare is managed in primary or secondary, rather than tertiary healthcare.

Families reported the enormous difference made by having a GP who understood trans children’s healthcare, understood the failings in the NHS system for trans children, and who would put their child’s wellbeing as their top priority. Parents of trans children highlighted that they wanted to have GPs who are:

Trans-positive, with understanding that childhood gender diversity is not a problem or something to be pathologised (33), that trans children thrive with love and support.

Knowledgeable about research that emphasises the importance of family supportiveness, of respecting a child’s identity at any age, the importance of using a child’s pronoun, or having identification that matches their identity. Evidence shows that supported and socially affirmed trans children have good levels of mental health.

Aware of the prevalence of misinformation on trans children’s healthcare, the prevalence of transphobic attitudes or ignorance including from professionals, and the negative impacts of isolation, transphobia, hostility and minority stress. 

Child-Centred, applying the above knowledge to ensure primary care providers put a trans child’s wellbeing at the heart of their approach.

References

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15.       Vincent B. Studying trans: recommendations for ethical recruitment and collaboration with transgender participants in academic research. Psychol Sex. 2018 Apr 3;9(2):102–16.

16.       Brown S, Kucharska J, Marczak M. Mental health practitioners’ attitudes towards transgender people: A systematic review of the literature. Int J Transgenderism. 2018;19(1):4–24.

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18.       Stroumsa D, Shires DA, Richardson CR, Jaffee KD, Woodford MR. Transphobia rather than education predicts provider knowledge of transgender health care. Med Educ. 2019;53(4):398–407.

19.       Turban JL, Winer J, Boulware S, VanDeusen T, Encandela J. Knowledge and attitudes toward transgender health. Clin Teach. 2018;15(3):203–7.

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21.       Carlile A. The experiences of transgender and non-binary children and young people and their parents in healthcare settings in England, UK: Interviews with members of a family support group. Int J Transgender Health. 2020 Jan 2;21(1):16–32.

22.       Galman SC. Parenting Far from the Tree: Supportive Parents of Young Transgender and Gender Nonconforming Children in the United States. In: Ashdown BK, Faherty AN, editors. Parents and Caregivers Across Cultures: Positive Development from Infancy Through Adulthood [Internet]. Cham: Springer International Publishing; 2020 [cited 2020 Apr 12]. p. 141–53. Available from: https://doi.org/10.1007/978-3-030-35590-6_10

23.       Katz-Wise SL, Galman SC, Friedman LE, Kidd KM. Parent/Caregiver Narratives of Challenges Related to Raising Transgender and/or Nonbinary Youth. J Fam Issues. 2021 Sep 20;0192513X211044484.

24.       Kuvalanka KA, Munroe C. Parenting of Trans Children. In: Goldberg A, Beemyn G, editors. The SAGE Encyclopedia of Trans Studies [Internet]. Thousand Oaks: SAGE Publications, Inc.; 2021. p. 597–601. Available from: http://sk.sagepub.com/reference/the-sage-encyclopedia-of-trans-studies

25.       Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Prof Psychol Res Pract. 2012;43(5):460–7.

26.       Hidalgo MA, Chen D. Experiences of Gender Minority Stress in Cisgender Parents of Transgender/Gender-Expansive Prepubertal Children: A Qualitative Study. 2019 [cited 2020 Jul 12]; Available from: https://journals.sagepub.com/doi/abs/10.1177/0192513X19829502

27.       Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics. 2016 Mar;137(3):e20153223.

28.       Russell ST, Pollitt AM, Li G, Grossman AH. Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. J Adolesc Health Off Publ Soc Adolesc Med. 2018;63(4):503–5.

29.       Kuvalanka KA, Weiner JL, Mahan D. Child, Family, and Community Transformations: Findings from Interviews with Mothers of Transgender Girls. J GLBT Fam Stud. 2014 Aug 8;10(4):354–79.

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31.       Pullen Sansfaçon A, Robichaud MJ, Dumais-Michaud AA. The Experience of Parents Who Support Their Children’s Gender Variance. J LGBT Youth. 2015 Jan 9;12:39–63.

32.       Telfer MM, Tollit MA, Pace CC, Pang KC. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. Melbourne: The Royal Children’s Hospital; 2018.

33.       Horton C. Depathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Child Soc. 2022;37(753–770). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/chso.12625

Ban on social transition is cruel and anti-science

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In December 2023, the UK government released school’s guidance, proposing restrictions on social transition, including a complete ban on social transition at primary school.

The guidance is non-statutory, meaning schools do not need to follow it. Indeed, leaked civil service legal advice revealed that even government lawyers recognise the guidance as likely to be illegal, and likely to fail when it will be challenged in court. Any school considering following this guidance needs to know that their actions will likely be found unlawful when challenged in court.

Here I want to outline the reasons the guidance is not just cruel, but also anti-science. I will focus on one aspect of the guidance, the proposed restrictions on social transition, and the proposed ban on social transition at primary school. I am well-qualified to write on this topic, having focused my entire PhD on researching the experiences of trans children and families who socially transitioned at primary school in the UK, and being myself a parent of a trans child who similarly socially transitioned at primary school.

The guidance claims to be an effort to address ideology, but it is very clear that the guidance is entirely driven by anti-trans ideology, rather than by evidence, science, or indeed by listening to the experiences of those with lived experience of being or supporting a trans child.

Last week I published my 14th peer reviewed article on the topic of trans children. Within science and evidence based policy-making, peer review in credible journals is a vital part of assessing evidence, ensuring our decisions are based on the best available evidence. My latest peer reviewed article analyses and synthesises all existing studies on the topic of social transition. It examines them in detail, clarifying what evidence underpins their conclusion. Within all modern (post 2013) literature, evidence concludes that social transition is either beneficial, or neutral. The vast majority of studies conclude that social transition is beneficial for trans children. Just two studies conclude that social transition is neutral, neither beneficial nor harmful. My latest article examines one of those two studies, highlighting a wide range of limitations that undermine its stated conclusions.

The latest government guidance states that social transition is not neutral, raising the suggestion that it is either beneficial or harmful. If they looked to the evidence they can see that there is zero modern (post 2013) evidence that social transition is harmful, and multiple studies, of multiple types (qualitative, quantitative, retrospective), from multiple countries (UK, USA, Spain) demonstrating that social transition is beneficial, indeed critical for trans children’s well-being, self-esteem and happiness.

Claims that social transition is harmful are supported by the most pathetically flimsy of evidence, comprised of two main strands.

One flimsy strand of evidence used by opponents of social transition, looks to a 2011 published study of 2 Dutch girls, who changed their gender expression (wore trousers or cut their hair short) and then regretted changing their clothing and haircut due to the bullying that ensued. Neither child asked to be seen as a boy, neither child changed pronoun. There was no social transition in this study, nor is it clear that the children in question were even trans. I wrote about this back in 2017. The 2011 study on two girls who never socially transitioned was used by WPATH in their standards of care version 7 (published in 2013) to caution against social transition, guidance that has caused uncalculated harm across the world. (This poor science from 2011 also made it to version 8 of the standards of care).

You cannot tell me that 2023 social policy on social transition should be governed by a 13+ year old study of two children, neither of whom socially transitioned, or even asked to socially transition. The fact this same study is influencing gov guidance in 2023, ignoring all the continually growing body of modern evidence that social transition is vital and life-saving, is beyond belief.

The second flimsy strand of evidence used by opponents of social transition, argues that it is social transition itself that makes children remain trans. It argues that support for social transition somehow changes a child’s future trajectory, keeping children trans who would otherwise escape into a life of cis normality. The evidence for this claim of social transition ‘concretising’ identity is entirely speculative. Anti-trans voices look to the high degree of consistency in trans children in 2023, where a majority (but not all) of socially transitioned trans children continue to identify as trans into adolescence and adulthood. They compare this with studies from the 1950s-2000s, where children in gender clinics did not commonly identify as trans in adolescence. There is one humungous problem with this pet theory. Gender clinics in the 1950s-2000s did not focus on trans children at all. Instead they focused on boys who were deemed excessively and problematically feminine, boys who were referred to by research study leaders as ‘sissy’ or ‘proto-gay’. Clinics were not focused on trans children at all, instead they were focused on making feminine boys ‘man-up’, lest they become either gay or trans in the future. A scholar who experienced such gender clinics as a boy, who has written about the deep harm the experience had on him, is now a gay man. He wrote how conversion therapy at gender clinics left him feeling that there was something deeply wrong with him, that he was unacceptable for being gender non-conforming. These older abusive studies should in no way guide modern practice for two reasons. One, they did not focus on trans children. Indeed, one analysis from this cohort claimed, without no self-awareness, that they had deducted that a good way of distinguishing the children who would grow up to be a trans woman from those who would grow up to be a gay man was to actually ask them, whether they were a girl, with the majority i) not identifying as a girl and ii) not growing up to be a trans woman. Almost like researchers need to actually listen to those whose lives they seek to understand! The second reason to discount the findings from these earlier studies conducted from the 1950s onwards, is that there were deeply abusive and coercive sites of conversion therapy, a practice now recognised as abusive and harmful.

Literature conducted in the modern era in fact reveals the opposite conclusion to that speculated by anti-trans actors. A study by Olson et al concluded that social transition did not concretise identity, but was in fact a consequence of the children who felt most strongly and consistently being most likely to be supported to social transition.

All modern (post 2011) studies on social transition shows either neutral or positive impacts. The vast majority of studies show overwhelmingly positive impacts of social transition. The only two studies that show neutral impacts, were situated in gender clinics and have significant study limitations, including not bothering to actually ask the children in question for their views.

Positive benefits concluded by a majority of studies on the topic include reduced anxiety, reduced depression, increased self-worth, reduced suicidal ideation, reduced suicidal behaviour, improved mood, increased confidence, increased happiness.

Trans children have a right to their identity. They have a right to health, happiness, equality. They have a right to social transition. Denying a child’s social transition is oppressive, abusive and harmful.

For more detail, please do click on this article here:

The importance of child voice in trans health research: a critical review of research on social transition and well-being in trans children

Please see these articles on experiences of social transition:

“Euphoria”: Trans children and experiences of prepubertal social transition

“I never wanted her to feel shame”: parent reflections on supporting a transgender child

Read this research on the harms of denying social transition

“I Was Losing That Sense of Her Being Happy”—Trans Children and Delaying Social Transition

And these articles on trans children’s experiences at school:

Gender minority stress in education: Protecting trans children’s mental health in UK schools

Institutional cisnormativity and educational injustice: Trans children’s experiences in primary and early secondary education in the UK

Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools

Trans children have a right to a safe and happy childhood. Trans children have a right to social transition.

You can respond to the government’s abusive proposal here

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Trans kids in 2023: Optimism and defiance

/ growinguptransgender / 1 Comment
Image from She-Ra and the Princess of Power (2018) by ND Stevenson

Caring about trans kids in 2023 continues to be heart-breaking. Worry and far too many tears.

Over the past 4 years, most ‘spare’ hours in my day (or more usually in the night) have been focused on my PhD: “Cis-supremacy: Experiences of trans children and families in the UK”. I chose to embark on a PhD in frustration at the bad science that informed policy and practice across the UK, frustration borne from failed attempts to advocate for trans children’s rights since 2015.

I have now submitted my PhD (phew), having already published 12 peer reviewed articles on the experiences of trans children and supportive families (research that has to date been ignored by UK media, NHS and policy makers…).

At this point of transition from PhD to what comes next, I’ve been taking stock on the last 7+ years of trying to advocate for trans children in the UK.

At first, my reflection was rather subdued. Since 2015, year upon year, across a host of different indicators of progress, the situation in the UK has got worse. Healthcare for trans kids has gone from abysmal to worse than abysmal. Media coverage has got worse. Discrimination appears harder to combat. Guidance for schools has got worse.

Having tried for so many years to help build a better world for trans kids than the one I saw in 2015, it has been beyond dispiriting to see everything year upon year seem worse. Year upon year it has been harder to make room for hope.

But

That is not the end of the story.

I was actively searching for the signs of optimism that I need to keep up the fight.

The thing I ended up on, our greatest strength, (and the reason why we will win) lies in supported and self-confident trans kids.

Since 2015, year upon year, more and more trans kids are being supported by their families. Amidst private forums, the numbers of affirming families continue to rise. Families whose kids know that they are respected, valued and cherished for who they are.

Year upon year I have seen families supporting trans kids at a younger age, families waiting shorter and shorter periods before affirming and embracing their trans kids, requiring trans kids to fight less hard for parental love. Year on year I have seen more families react with instant positivity, affirmation and love to a child sharing their identity. A noticeable shift from even 5 years ago when that was a rarity.

Year upon year I have seen majority discourse within family support groups shift from a focus on ‘loss’ or worry about a child’s identity to love and pride.

Year upon year I have seen more families stand up alongside their child at any age and argue for their equal rights.

Year upon year I see more trans kids who can speak up and claim their rights even in primary school (not that I think trans kids should carry this burden…)

Year upon year I see more families and kids demand genuine equality and respect from their wider families, schools and communities, not settling for tolerance or segregated accommodations.

I see within communities of trans kids the difference that this trans positivity makes. I meet trans kids who have been supported, who have grown up expecting to be treated as genuine equals to their cis peers. Trans kids surrounded by love and support can grow up without the heavy blanket of shame that so many older folks carry through our lives (see toxic shame).

When I look back over the past years of advocacy, the issue that gives me most pride is every family who I have in some small way supported to gain the knowledge and confidence to support and advocate for their trans kid. Every single supported trans kid makes a difference.

Those supported trans kids go out into the world a bit stronger, a bit less kicked down by this trans-hostile world. Many such trans kids and trans positive families end up providing a safe space for trans kids without affirming families. Many trans kids (whether supported at home or not) end up supporting a whole network of trans youth, providing peer advice, validation and mutual aid.

Every trans kid makes the world a better place.

This is why transphobes are so afraid of social transition.

Because trans kids who are supported young are less likely to grow up overwhelmed by shame or self-hatred.

Trans kids with self-respect will fiercely demand their rights. And they will fight even harder for the rights of their friends.

Trans kids are no longer isolated and alone.

Some trans kids stand on many strong pillars of support and trans-positivity. Some trans kids wobble on only a few. Every bit of support and trans-positivity matters.

Transphobes, including in the NHS, are trying to formally discourage social transition. To deny trans kids support. To deny them connection. To instil in them shame.

But, in the internet age, that boat has already sailed. Trans kids can’t be kept in the dark any longer. Their route to self-knowledge and self-actualisation cannot be controlled by the NHS, the media, transphobic parents or transphobic politicians.

Families of trans kids are now able to connect to each other. Amongst private parent support groups the case for social transition is recognised fact. Family after family after family report what is glaringly obvious to any trans person. Trans kids need love and support, and with love and support they can thrive.

So yes, the UK context is dire. It is dire in a way that continues to cause immense harm to trans people, especially trans children.

But, the fight does not primarily lie in legislation or in policy or in the NHS. Those fights are vitally important and will continue.

But even while those fights are slow, demoralising, unjust and depressing as hell, the real victory is coming from every single trans kid who grows up without being overwhelmed by shame. From every trans kid who grows up expecting equality. From every trans kid who believes there is space for them in this world.

That is where the real battle lies. And that is where we will win.

Because trans kids are easy to love. They are easy to respect.

Trans kids who have love and respect will claim their place. Trans kids can and do have childhoods filled with excitement and joy.

Trans kids change the world, family by family, school by school, community by community.

Happy trans kids change the world. Pissed off and angry at all the bullshit trans kids change the world.

Every single time you show love and support for a trans kid (or for a family struggling to stick up for a trans kid) you are shifting our world towards a better place. Towards a kinder place.

So, for everyone beaten down by cis-supremacy and transphobia – think how many individual lives you have touched in some way with trans-positivity. That matters.

For every family who is struggling to keep their trans kid happy and safe – know that being affirmed and celebrated in childhood is setting your kid up for the future, and that is a huge part of this fight.

It is so easy to be overwhelmed by fear and stress.

It is so easy to see no light at the end of the tunnel.

Focus on the trans kids in our world. They probably don’t even want to go through that tunnel anyway. Follow their lead (with swords at the ready).

Keep up the fight.

Ten Easy Tips for Trans Inclusive Education on Puberty and Bodies

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Schools have a duty of care to trans pupils, with a requirement to provide LGBTQI+ inclusive PSHE. However, many schools still struggle to provide trans inclusive primary and early secondary school education on puberty and bodies, with schools often drawing upon outdated and exclusionary curricula.

Research has shown that trans children can experience exclusionary curricula, especially on bodies and puberty, as upsetting, delegitimising and harmful. Schools providing trans exclusionary education are associated with high levels of minority stress for trans pupils, with minority stress leading to poor levels of mental health and increased chances of trans pupils dropping out from education.

The good news is that trans inclusive education should not be difficult, once educators become confident in a slightly different and more inclusive way of approaching the subject.

In this blog I will share 10 recommendations for trans-inclusive puberty education, with quotes from educational resources that are trans inclusive. Importantly, this blog and the content highlighted herein focuses on how to ensure mainstream education on puberty and bodies is trans inclusive (it is aimed at ensuring the education every child receives is trans-inclusive, rather than aiming to specifically cater to trans children’s unique needs). (I’d also be interested in any additional advice on ensuring trans inclusive materials like these are intersex inclusive as well as disability inclusive).

This blog will primarily focus on a new educational resource called You-ology. It is produced by the American Academy of Pediatrics (the world’s biggest organisation of paediatricians), and aims to provide puberty education tailored for EVERY body. It is available in e-book form for £8.

You-ology: A puberty guide for EVERY body

This book does a couple of important things well:

1. It acknowledges, and frames puberty according to, the important role played by hormones.

On hormones:

“During puberty there are hormones that tell your body to grow faster, hormones that tell your breasts or testes (also known as testicles or balls) to start growing, hormones that tell your hair to sprout in new places, and hormones that cause new smells to creep out of your armpits”.

Growing bigger:

“Growing is one of the first signs of puberty. A hormone called growth hormone increases a ton during puberty to make you grow fast. Your hands and feet start to grow! So when you find yourself outgrowing your trainers faster than normal, you can smile to yourself and know puberty is starting!”

Testosterone and oestrogen:

“There are hormones called oestrogen and testosterone that cause most of the changes. A tiny, pea-sized gland in the brain, called the pituitary gland, sends a chemical messenger (yep, another hormones) to the testes or ovaries to tell them to start making hormones. Testes make a lot of testosterone. Ovaries make a lot of oestrogen and a little testosterone. Throughout this book, we will tell you more about what each of these hormones does.”

2. It considers the changes that happen to a majority of bodies. It emphasises shared experiences in puberty, rather than suggesting humans have two completely distinct and separate puberties. Rather than presenting ‘girl puberty’ in one lesson and ‘boy puberty’ in another, it instead divides up pubertal changes into the different types of changes. It provides one chapter on hair changes, one chapter on body odour changes, one on emotions. The similarities are emphasised as well as the differences, emphasising within the section on hair that in puberty most bodies develop increased hair on the legs and under the arms, while some bodies, especially bodies with a lot of testosterone, also develop hair in other places. Below is a quote from the You-ology chapter on hair.

On hair:

“where you sprout hair depends on – you guessed it – hormones. EVERY body begins to make the hormone testosterone early in puberty. Testicles make a lot. Ovaries make a little. Even a little testosterone will cause EVERY body to grow darker, thicker hair on their legs, in their armpits, around their private parts; around their nipples or on their face. The amount of testosterone you have determines how much and where the hair shows up. If you have a lot of testosterone, you will grow more hair on your face. You might also (later in puberty) grow hair on your chest, abdomen (belly) and back”.

3. Where changes are significantly gendered, with most girls having a different experience to most boys, it divides the content according to the specific type of change, rather than dividing into girls vs boys. It provides one chapter on breasts and chests, one chapter on periods, one on testosterone driven changes. It manages to talk about these changes without excluding, shaming or delegitimising trans children.

On vaginas:

“If you have a vagina. So let’s get back to body parts and start with outside private parts that most girls, and some nonbinary and trans kids have. If you have these parts, you know some of the names for them. If you don’t have these parts, it’s a great time to learn more about them!

On penises:

“Let’s shift to talking about the genitals that most boys and some trans and non-binary kids have. If you were born with a penis, you’ve been looking at and touching it since you were a baby, right? And at some point (hopefully a long time ago!), you learned to hold your penis to aim it into the toilet when you pee. So if you’re like most kids with a penis, you have been pretty familiar with your genitals for a long time, and you know the names too, but let’s go through them just to be sure. If you don’t have a penis, it’s still important to learn about these parts to understand how EVERY body works!”

On uterus and ovaries:

“Most girls and some trans/non-binary kids have some pretty cool inside parts that work together. First, remember how we talked about the opening of the vagina? The vagina is actually a soft tunnel that starts at the vulva and goes inside the body to connect the inside parts to the outside world…”

On sperm & testes:

“Most boys and some trans/non-binary kids have bodies that can make sperm, and the penis is involved. Do you wonder how? We already mentioned that urine travels in the urethra as it passes through the penis and out of the body. But guess what also comes out through the uretha? Sperm. The cool thing is that urine and sperm comes from very different places inside the body. Urine is made by the kidneys and then sent into the bladder to be stored. Sperm …etc ”

On breasts:

“If you are like most girls, or some nonbinary or transgender kids, you have ovaries, which also help puberty start by making oestrogen. The very first thing oestrogen usually does is telling the breasts that it’s time to start growing”.

Where diagrams are used to show specific body parts, there is no reductive label provided of ‘boy’ or ‘girl’ bodies. This kind of title is not needed and alienates and invalidates trans pupils in front of their peers. Below is an example of a diagram of body part that does not need to have a ‘girl’ or ‘boy’ heading.

4. It recognises and is not afraid of acknowledging diversity, explicitly recognising the existence of trans people, intersex people, and the reality that not every person experiences puberty in the same way. Key to this inclusive approach is bringing in the word ‘Most’. When talking about gendered changes, this resource talks about, for example, periods being something that happens during puberty for ‘most girls, and some trans and non-binary kids’. Addition of the word ‘most’ is really important for trans, non-binary and intersex kids, making space for the reality that all bodies are different. Addition of the word ‘most’ is also important for cis girls who may not have periods for a variety of reasons.

5. I also like the way that this resource talks about puberty as inherently about moving from a child’s body towards having an adult’s body, in comparison to other puberty resources that describe puberty as building bodies ready for reproduction. De-centring fertility and reproduction during education on puberty is helpful, especially for individuals who are likely to have a non-traditional route to building (chosen) families, a category that is likely to include a significant proportion of LGBT youth.

6. Hormone driven changes. The resource is clear that the changes of puberty are driven by hormones. It finds a way to talk about hormones explicitly, talking about the changes that are caused by oestrogen, and the changes caused by testosterone. It talks about breast development being a pubertal changes that occurs in bodies with a large amount of oestrogen. It acknowledges that a majority of all bodies have some testosterone. It talks about the types of changes that are typical for bodies that have a large amount of testosterone.

7. Clear and upfront on body parts. Where body parts are integral to a particular pubertal change, this resource again is clear and upfront. When talking about periods, it talks about the changes that happen to people with a uterus, which includes most girls. Most girls, and anyone else with a uterus, when they have a large amount of oestrogen during puberty, are likely to start having periods.

8. It avoiding ruse of the reductive term ‘biological sex’. Within any trans inclusive puberty education it is important to avoid simplistic and reductive definitions of sex or ‘biological sex’. Where biological characteristics are relevant, it is important to refer to them in the plural, as ‘biological sex characteristics’. The Endocrine Society (global experts on hormones or endocrinology) advises against using the term biological sex noting that “the terms ‘biological sex’ and ‘biological male’ or ‘biological female’ are imprecise and should be avoided”. There are multiple sex characteristics (chromosomes, gonads, hormone levels etc), and humans do not fall into only two binary divisions in terms of sex characteristics. This recognition is critical to including trans and intersex people, as well as to including people who may not have a specific sex characteristic for a variety of reasons (eg cis women who have had a hysterectomy).

9. Likewise, it is important to avoid using gendered language like ‘male’ or ‘female’ to define body parts. Within this specific You-ology resource, there are a couple of references to ‘male bodies’. This type of reductive language goes against the ethos of the wider book and is rather frustrating. Let’s be clear here – using the word male to describe bodily features is just as exclusionary and harmful as talking about a ‘boy’s body’. There is no way to respectfully (or even accurately) describe a trans girl as having a ‘male body’. This type of language is delegitimising, inaccurate and disrespectful. If we care for the well-being of trans pupils, non-binary pupils or intersex pupils, we need to evolve away from inaccurate and binary language that excludes, delegitimises and stigmatises. (the image below comes from work by Sophie Labelle)

10. Being up front about the diversity amongst humans is easy to do, it simply requires educators who are themselves educated, and unafraid of talking about diversity. In the UK however, we have a generation of teachers who have themselves grown up under section 28, who have not have the opportunity to themselves receive diversity informed education. This is why inclusive educational resources like this one are so very important.

Further resources

I’ll include here a few other recommended resource, but please send me other ideas to add in.

What makes a Baby by Cory Silverberg and Fiona Smyth provides visually appealing information on babies, reproduction, fertility and families, suitable for any age. It is designed to be trans inclusive, and inclusive of all ways of building a family, including IVF, adoption, chosen families.

A guide for adults to help children engage with the book is also available here

A new resource (You know, sex) by the same team aims at a slightly older audience, covering bodies, puberty, and sex ed. with the same visually engaging and inclusive style.

The above resources are all paid-for US resources, not included in the curricula of major UK providers of PHSE education. The limited UK PHSE materials that I have seen have had woeful trans inclusivity, and would require adaptation by individual teachers to avoid harming trans pupils. This is obviously poor, and more is needed to pull up the standard of generic and off-the shelf PSHE materials, especially from PSHE specialist providers.

A downside of these resources shared above is that they do not include practical class materials or worksheets. (Mainstream UK puberty worksheets can often be trans-exclusionary and harmful, requiring individual adaptation by any teachers who care for their trans pupils). If any educators have produced free to access class worksheets or other materials that are trans inclusive, please email me (c.horton@gold.ac.uk) with links to any trans inclusive educational materials or worksheets.

Trans inclusive education is not difficult to do. It is time to make sure education is fit for every pupil.

Update: Someone has also recommended this book (that I’ve not yet read) The Every Body Book: The LGBTQ+ Inclusive Guide for Kids about Sex, Gender, Bodies, and Families by Rachel Simon and Noah Grigni

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Supporting Trans Children in Schools: Findings and Recommendations

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This blog summarises Key Findings & Recommendations for supporting trans children in schools. This summary is based upon newly published research which reviews the literature & policies for supporting trans pupils & provides recommendations for schools & allies:

Findings and recommendations from a 2020 Frontiers of Sociology article on LGBT inclusive education (open access). Thriving or surviving? Raising our ambition for trans children in primary and secondary schools Cal Horton, Goldsmiths, University of London

Finding: Trans pupils face stigma and invalidation at school, often alongside discrimination and harassment.

Recommendation: Affirmative language, respect and trans-positivity are critical.

Finding: Trans pupils experience persistent stress, navigating systems that delegitimise and exclude them. An anti-bullying approach may underestimate the emotional and psychological impact on trans pupils of cisnormativity*.

Recommendation: Schools need to address the cisnormative practices that negatively impact on the wellbeing and mental health of trans pupils.

Finding: Schools respond to individual requests reactively, with trans pupils shouldering the burden of negotiating their own inclusion.

Recommendation: Schools need to move from individualized accommodation to proactive and sustained adaptation.

Finding: A culture of silence surrounds trans lives at school – minimal trans representation can be perceived as excessive. Trans pupils denied representation in school experience shame and low self-esteem, and are forced to educate their own peers.

Recommendation: Trans representation and visibility needs to become common and unremarkable, enabling trans pupils to grow up with a sense of belonging and self-worth.

Finding: Trans pupils may experience ignorance and hostility from school staff, causing significant harm. Even one supportive and trusted teacher can make a profound positive impact on a trans pupil’s experience of school. Teacher trans-positivity is significantly correlated with pupil well-being.

Recommendation: Schools need to recognize and address the pressures and barriers to teacher action. Clear leadership is essential, and can be driven by governors, head teachers and individual members of staff.

Finding: Schools lack ambition for trans pupils, aiming for the low bar of protection from harassment and abuse. Trans pupils need equality of opportunity, in schools where they can excel and thrive.

Recommendation: Trans pupils should be affirmed and welcomed, in schools where they are represented, validated and respected as equals.

Finding: Teacher education and training needs to move beyond basic education on transphobic bullying, to helping staff understand the ways in which cisnormativity privileges cisgender individuals and makes life harder for trans pupils.

Recommendation: Trans pupils need at least one adult who can advocate for them, help them understand their rights, and help them navigate cisnormative cultures. Teacher allies need to understand and challenge the systems and approaches that delegitimise and marginalise trans pupils.

Finding: Trans children have a right to an educational experience that is safe, inclusive and affirming.

Recommendation: Schools should listen to trans pupils and centre child rights. Schools also need to consider their institutional responsibilities, ensuring schools are fulfilling their duty of care to trans pupils. 

Cisnormativity*: When systems, policies and people assume that everyone is (or should be) cis (not trans). Cisnormative schools place trans pupils at a disadvantage, requiring them to navigate systems designed to exclude them.
Trans: The term trans is used here to include people who are transgender, non-binary and/or gender diverse.
This text is from the Infographic, ‘Supporting Trans Children in Schools’ available to download here for FREE in various web ready and Print formats
Supporting Trans Children in Schools, Infographic summarising research paper: ‘Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools’ https://doi.org/10.3389/fsoc.2020.00067
Download

 

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Supporting Trans Children in Schools – Peer Reviewed Education Resource

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image blog

I’m pleased to share the publication of my new peer reviewed journal article. The article synthesises the literature on how to best support trans children in primary and secondary schools, together with analysis and recommendations on school guidance.

Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools

article

Thriving or Surviving? Raising Our Ambition for Trans Children in Primary and Secondary Schools

The article is free to read and or download here

1 Page Infographic Resource and Poster

For teachers and schools there is a short infographic with some key recommendations (available to download or share in A3 or A4 versions linked below):

Infographic summarising article findings and recommendations. Yellow background with images of children and text in boxes.

A Free to Use Infographic providing findings and recommendations on how trans children can be enabled to thrive in schools.

 

Please view and download the Supporting Trans Children in Schools infographic here in your preferred version:

Web Version

Infographic PDF A3 Web Version

Infographic PDF A4 Web Version

Print Version

Infographic PDF A3 Print Version

Infographic PDF A4 Print Version

This infographic is free to use and share.