The Reality behind the Myths about Trans Children: An Interview with us, Growinguptransgender

Vincent-the-Vixen-2Trans Children Myth Busting

Following recent negative news coverage, we thought it would be good to return to this interview with the LGBT children’s story publisher, Truth and Tails, in which we share our experience of raising a child who happens to be trans. We address many of the myths about Trans children, including advice for other parents, and the reasons for starting this blog.

For the first time we’ve published it here:

Background

We were interviewed by the lovely Truth & Tails, in March 2017, after they had read our blog and sent us a copy of their book ‘Vincent the Vixen’ which explores trans issues from the perspective of a gender questioning fox.

You can read the original interview in full here: Truth & Tails Interview

Interview Th

Truth & Tails: We first discovered the Growing Up Transgender blog back in October, when we read their post 10 reasons why the #dontjudgegender verdict makes families of transgender children concerned in response to a high court judge ruling on gender identity, which resulted in a seven-year-old being removed from their mother. The blog is written anonymously, to protect the family’s identity, by parents of a young transgender child living in the UK.

We spoke to the authors, about their reasons for starting the blog, what support is out there for parents of transgender children, and what the most common misconceptions are that they face day-to-day.

Tell us about the catalyst for starting the ‘Growing Up Transgender’ blog.

A few different things prompted us to start a blog. Firstly, we remembered how alone and confused we felt when we first realised our daughter might be transgender. We appreciated so much the few parents (mostly in America) who had shared their experiences online.

Secondly, we were frustrated by the huge amount of misinformation and distorted claims that are presented as fact on the internet. It took us a long time to be able to distinguish fact from fiction, and to distinguish helpful evidence based information from transphobic bigotry. Having thoroughly researched and understood the different issues, we wanted to share our understanding with others.

And thirdly, we noted a dramatic upsurge in anti-transgender children hysteria in the UK media. Fear-mongering media rhetoric has a direct impact on how adults, and in turn, their children treat our child. We felt compelled to speak out, yet also wanted to maintain our child’s privacy. A blog seemed like the best way to ensure our voices, and our experience of a wonderful trans daughter, could be shared. We hope our blog will in some way help other families dealing with this issue.

When did you realise your daughter was transgender, and how did you know? Is there a specific conversation that you remember?

Our daughter said she was a girl from a very young age. Daily. There was no one specific conversation that opened our eyes, it was more a very persistent stream of assertion over a long period of time. At first we didn’t take it seriously. We tried to dissuade. We tried to tell her she could be whatever type of boy she wanted to be. This was totally missing the point, and made her even sadder. Eventually it got to a point where we realised that we had a very depressed child, who felt rejected by her parents. We realised that we were letting her down.

What would you say to a parent who is beginning to have these sorts of conversations with their child?

Some parents worry about their boy playing with dolls, or preferring being friends with girls, or their girl rejecting dresses and wanting short hair. These behaviours that are related to how a child plays or dresses or expresses themselves are not focused on identity and there is no reason to think such children are likely to be transgender. My view would be not to narrow your child’s horizons, to allow toys to be toys and children to play however they like.

A much smaller number of parents will have the experience we have had, and other parents describe extremely similar experiences. A child who insists that they are a different gender to what you are expecting. A child who doesn’t perhaps care what toys or clothes they have as long as they are acknowledged as the gender they identify with. A child who repeats their identity consistently, persistently, insistently and gets increasingly sad and withdrawn, perhaps accompanied with concern about their body. For parents of those children, I would advise the following:

First, consider how scary and isolating it must be for a child to be repeatedly told that something they feel so deeply is unacceptable to those who love them mostly dearly. Listen to your child. Let them know that you love and accept them whatever. Let them know that you stand by them. Let them know that there are other children in the world who feel the way that they do. Let them know that some children feel like this when young, then grow up and don’t feel like this so strongly. Let them know that other children feel like this when young, then grow up and continue to feel like this and live like the gender they identify with. Let them know that both groups can grow up to have happy and well-adjusted lives. Let them know that either is ok with you. Let them know that they are not alone.

Secondly, find out more about the subject. Read as much as you can. But bear in mind that there is a vast quantity of material on the internet that is immensely transphobic; that is misleading, and even outright lies, and that may make you feel desperately scared for the future. I’d suggest reading some blogs by parents who are supporting their child in their gender identity, to understand that the worst-case scenario that you are fearing for your child really isn’t as bleak as you may be fearing. Our child has gone from a deeply sad to one of the happiest children you could meet since we told her we accepted her as a girl.

Thirdly, get some support for yourself as a parent.

What support is out there in the UK for parents of transgender children, and where have you personally found most support?

For us, the best source of support by a mile is other parents of transgender children. Find a way to reach out to other parents, for us it was through the charity Mermaids. Channels such as Mermaids provide a secure forum for parents to speak directly to each other, to provide a non-judgemental ear, to share experience, to be a shoulder to cry on. Many parents describe coming to terms with a child being transgender as a form of grief. Parents are often completely ignorant of the issue, and often have bleak views on the prospects for their child having a positive future.

In time, in person or virtually, parents come across remarkable trans young people and adults, and learn that with acceptance and support the outcome for trans children today is bright and hopeful. But that doesn’t immediately negate the very strong emotions that parents go through, particularly when they are doubting how to proceed, and particularly when they are facing judgement, criticism and hate from a wider society – including their own friends and family – who may not be willing to understand. Finding a support network, particularly if your own friends and family are not supporting you, is extremely important.

For transgender children approaching puberty, being registered in the UK Gender Identity Service for children at the Tavistock can be critical in case medical intervention (hormone blockers) is required. Waiting lists are extremely long: nine months from GP referral to first appointment and procedures once in the system are prolonged. Don’t wait until things are at a point of desperation to get a referral into the medical system. Better to get a referral a couple of years before puberty and pull out if you don’t later need it than delay referral and enter the waiting list at puberty when a two-year wait might become a major problem. Some GPs are supportive, many GPs are ignorant and unhelpful. Request a referral to Tavistock if you feel your child is transgender, and don’t let an ignorant GP tell you no.

What is the most common misconception about transgender children that you encounter, and what is your response?

There are so many misconceptions about transgender children that we wrote a whole blog on this topic! You can read it here.

The most common ones are:

Myth: Transgender children do not exist.
Reality: Yes, they do.

Myth: This is a modern, Western fad.
Reality: Transgender people have existed in societies throughout the centuries across the world, and there are millions of transgender people across Asia.

Myth: Parents are choosing this for their children to be trendy.
Reality: As a parent who has cried and cried buckets coming to terms with having a transgender child, I can assure you I would never have chosen this – although now I’m finally less ignorant I don’t in any way see it as the terrible path I once feared.

Myth: Kids who are just non-conforming (e.g. a boy who like dolls) are being pushed into being transgender
Reality: My child didn’t care what toys she played with as long as she was acknowledged as a girl. No one is pushing our children. This is just who they are.

Myth: Children are too young to make a life changing decision.
Reality: My child has not made a decision. They have not decided to change gender. They have always known they were a girl, it just took the rest of us a long time to catch up.

Myth: Transgender children can be turned into non-transgender children if you do X, Y, Z
Reality: There is no evidence for that, and a great deal of evidence that reparative therapy causes a great deal of damage.

Myth: Transgender children are likely to grow out of it.
Reality: Perhaps, but there is no clear evidence for this, and statistics quoted on this subject are extremely dodgy – read with care.

Myth: Transgender children/people will have sad and suicidal lives.
Reality: Emotional challenges experienced by transgender people are due to the hate and prejudice they face, not an inherent part of being transgender. Transgender children who are supported and accepted by their families are shown to have the same levels of mental health and well-being as other children.

What advice would you give to parents – not just parents with transgender children, but parents everywhere – around educating their children about gender and acceptance?

The world is a complex and diverse place. The more parents that share this diversity with their children, the more that let children know that it is ok to be different, the better for us all. Teaching love and acceptance will directly benefit your child too – at some point in everyone’s life they feel that they are different or an outsider – and having taught your child that difference is ok will stand your child in good stead whenever they find themselves on the outside.

Which children’s’ books about gender would recommend?

There is definitely a lack of books for younger children about gender. We’ve found many more interesting reads that have the central message that diversity is not only ok, but should be celebrated. We’re still finding our way a bit on books specifically about transgender children and haven’t found many our child identifies with, at least not in their entirety – however well-intentioned, books about boys who like dresses can sometimes perpetuate stereotypes of gender divide.

For young children, we like:
Red, A Crayon’s Story – Michael Hall
Red Rockets and Rainbow Jelly – Nick Sharratt
Vincent the Vixen – Truth and Tails (our daughter has loved this book)

For older children:
Lily and Dunkin – Donna Gephart

is blog has been verified by Rise: R4c1d40dc407da1a0ac3a1e615a7f7e16

About Truth & Tails:

Truth & Tails are a publisher who aim to write stories for young children in a straightforward, sensitive, and easy way. They seek to explain difficult concepts like feminism, racism, gender, and sexuality to children, and believe in the strength of stories to help children  grow up with a sense of understanding, empathy, and acceptance of those who are different to them.

 

 

 

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Endocrine Society consensus on a ‘durable biological underpinning to gender identity’

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A response to Endocrine Society Clinical Practice Guideline for transgender health

In September 2017 the Endocrine Society published a new clinical practice guide titled: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” Journal of Clinical Endocrinology & Metabolism (JCEM), Nov 2011.

Accompanying the guideline is a position statement: https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

This publication, an update to the previous guidance (2009), was produced by leading endocrinologists specialising in support for transgender adults and adolescents from the US, Belgium, and the Netherlands.

The guidelines are endorsed by the world’s leading centres for evidence based practice: the American Association of Clinical Endocrinologists, the American Society of Andrology, the European Society for Pediatric Endocrinology, the European Society of Endocrinology, the Pediatric Endocrine Society, and the World Professional Association for Transgender Health.

In short, the Endocrine Society represents the global medical consensus on the clinical treatment of transgender adults and adolescents.

Here, we will respond in detail to this guidance in the following three sections:

Section A:  A summary of the guidance as it applies to transgender adolescents, including factors underpinning gender identity; diagnosis; prescription; eligibility criteria; consent; age of treatment and risk factors.

Section B: We raise questions which are either unclear within the guidance or were not covered as out of scope.

Section C: Concludes with concerns in seven areas of the guidance and provides suggestions for amendment or further research.


Section A: Summary

i) Gender identity has a “durable biological underpinning”

From the position paper:

“The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder. Such evidence stems from scientific studies suggesting that: 1) attempts to change gender identity in intersex patients to match external genitalia or chromosomes are typically unsuccessful; 2) identical twins (who share the exact same genetic background) are more likely to both experience transgender identity as compared to fraternal (non-identical) twins; 3) among individuals with female chromosomes (XX), rates of male gender identity are higher for those exposed to higher levels of androgens in utero relative to those without such exposure, and male (XY)-chromosome individuals with complete androgen insensitivity syndrome typically have female gender identity 6; and 4) there are associations of certain brain scan or staining patterns with gender identity rather than external genitalia or chromosomes

In summary, although there is much that is still unknown with respect to gender identity and its expression, compelling studies support the concept that biologic factors, in addition to environmental factors, contribute to this fundamental aspect of human development.

Data are strong for a biological underpinning to gender identity”

ii) Treatment is medically necessary

“The Endocrine Society calls on policymakers to consider a biological underpinning to gender identity”

“These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary and should be covered by insurance”

iii) Counselling can support social transition

“During social transitioning, the person’s feelings about the social transformation (including coping with the responses of others) is a major focus of the counseling.”

iv) Recommend puberty blockers

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

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

v) Start puberty before blockers

“We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty.”

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

vi) Diagnosis

“For children and adolescents, an MHP [mental health professional] who has training/experience in child and adolescent gender development (as well as child and adolescent psychopathology) should make the diagnosis, because assessing GD/gender incongruence in children and adolescents is often extremely complex.

For adolescents, the diagnostic procedure usually includes a complete psychodiagnostic assessment and an assessment of the decision-making capability of the youth. An evaluation to assess the family’s ability to endure stress, give support, and deal with the complexities of the adolescent’s situation should be part of the diagnostic phase”

 

Table 2. DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:

  1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
  2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  3. A strong desire for the primary and/or secondary sex characteristics of the other gender
  4. A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
  5. A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)
  6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

  1. The condition exists with a disorder of sex development.
  2. The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).
Table 3. ICD-10 Criteria for Transsexualism (F64.0) has three criteria:

  1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments.
  2. The transsexual identity has been present persistently for at least 2 y.
  3. The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality

vii) Criteria for blockers

Adolescents are eligible for GnRH agonist treatment if:

1. A qualified MHP has confirmed that:

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

2. And the adolescent:

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

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

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

viii) Criteria for gender affirming hormone treatment

Adolescents are eligible for subsequent sex hormone treatment if:

1. A qualified MHP has confirmed:

  • the persistence of gender dysphoria,
  • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,
  • the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,

2. And the adolescent:

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

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

  • agrees with the indication for sex hormone treatment,
  • has confirmed that there are no medical contraindications to sex hormone treatment

ix) High satisfaction rates for cross-sex hormone treatment

“Follow-up studies in adults meeting these criteria indicate a high satisfaction rate with treatment. However, the quality of evidence is usually low. A few follow-up studies on adolescents who fulfilled these criteria also indicated good treatment results”

x) Cross-sex hormones by informed consent

“Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age.”

xi) Gradually increasing dose of cross-sex hormones

“In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.”

xii) Hormone treatment is safe

“Medical intervention for transgender individuals (including both hormone therapy and medically indicated surgery) is effective, relatively safe (when appropriately monitored), and has been established as the standard of care.

The data are strong for the relative safety of hormone treatment (when appropriately monitored medically)

Federal and private insurers should cover such interventions”

xiii) Fertility counselling prior to blockers

“We recommend that clinicians inform and counsel all individuals seeking gender-affirming medical treatment regarding options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults.”

xiv) Fertility

“Treating early pubertal youth with GnRH analogs will temporarily impair spermatogenesis and oocyte maturation. Given that an increasing number of transgender youth want to preserve fertility potential, delaying or temporarily discontinuing GnRH analogs to promote gamete maturation is an option. This option is often not preferred, because mature sperm production is associated with later stages of puberty and with the significant development of secondary sex characteristics.”

xv) Insufficient evidence to guide on minimum age for chest surgery

“We suggest that clinicians determine the timing of breast surgery for transgender males based upon the physical and mental health status of the individual. There is insufficient evidence to recommend a specific age requirement.”

xvi) Delay genital surgery until adulthood

“We suggest that clinicians delay gender-affirming genital surgery involving gonadectomy and/or hysterectomy until the patient is at least 18 years old”

xvii) Lack of support may interfere with positive surgery outcomes

“Literature on postoperative regret suggests that besides poor quality of surgery, severe psychiatric comorbidity and lack of support may interfere with positive outcomes”

xviii) Significant areas where further research is needed to optimise care, but this research will take a long time

“The gaps in knowledge to optimize care over a lifetime are profound. Comparative effectiveness research in hormone regimens is needed to determine:

  • The best endocrine and surgical protocols, as it is not yet known if certain regimens are safer or more effective than others;
  • Whether there are cardiovascular, malignancy, or other long-term risks from hormone interventions, particularly as the transgender individual ages.
  • The biological processes underlying gender identity
  • Strategies for fertility preservation

To successfully establish and enact these protocols requires long-term, large-scale studies across countries that employ the same care protocols.

Increased funding for national research programs is needed to close the gaps in knowledge regarding transgender medical care and should be made a priority” (Endocrine Society, Position Statement, 2017)


Section B: Questions on guidance

We have seven questions on areas in the guidance which are either unclear or were not covered as out of scope.

1 – Pre-pubertal children

“We recommend against puberty blocking and gender-affirming hormone treatment in prepubertal children with GD/gender incongruence.”

This  recommendation is described as: “a strong recommendation in the face of low-quality evidence”, as “the task force placed a high value on avoiding harm with gender-affirming hormone therapy in pre-pubertal children with GD/gender incongruence”

Question area 1:

Surely no one is advocating for any medical prescription for pre-pubertal children in which case this statement is moot? Is this perhaps instead referring to prescription at the first onset of puberty? Further clarity is required here.

2 – Role of Mental Health Professional (MHP) in social transition

“We advise that decisions regarding the social transition of prepubertal youths with GD/gender incongruence are made with the assistance of an MHP or another experienced professional.”

Question area 2:

Can greater clarity be provided on which “other experienced professional” is suitable to “assist in decision making”? Is a MHP required, what is their role, and why are they necessary for making decisions on social transition? How would a MHP be defined?

We also note there is no evidence provided for such a requirement. Anecdotally many young children socially transition without any support to the child from a mental health professional (though we do see the value of support to the parent and wider family from a MHP or other professional to cope with conflicting emotions and stress of a ‘family in transition’. On this issue, we note the needs of parents, carers and family members are absent from this document).

3 – Monitoring onset of puberty

“Clinicians can use pubertal LH and sex steroid levels to confirm that puberty has progressed sufficiently before starting pubertal suppression. Ultrasensitive sex steroid and gonadotropin assays will help clinicians document early pubertal changes.”

Question area 3:

How frequently should LH and sex steroid levels be monitored? In which countries / locations is this carried out as standard? When does monitoring start?  Can clarity be given on the correspondence between LH/sex steroid levels and tanner stage? At what level of LH/sex steroid do adolescents become eligible for GnRH agonists?

4 – Side effects of blockers

“Individuals may also experience hot flashes, fatigue, and mood alterations as a consequence of pubertal suppression. There is no consensus on treatment of these side effects in this context.

Acne, headache, hot flashes, and fatigue were other frequent side effects.”

Question area 4:

In countries without age based restrictions on cross sex hormone prescription, are blocker related side effects taken into consideration when making decisions on whether and when to proceed to cross sex hormones?

5 – Mental health professional (MHPs) to diagnose prior to gender affirming hormone treatment

“MHPs should diagnose GD/gender incongruence prior to gender affirming hormone treatment “to make a distinction between GD/ gender incongruence and conditions that have similar features. Examples of conditions with similar features are body dysmorphic disorder, body identity integrity disorder (a condition in which individuals have a sense that their anatomical configuration as an able-bodied person is somehow wrong or inappropriate) (66), or certain forms of eunuchism (in which a person is preoccupied with or engages in castration and/or penectomy for reasons that are not gender identity related)”

Question area 5:

It seems that the primary reason for a mental health professional led diagnosis is to distinguish GD/GI from these other conditions. What data is available on the numbers of children presenting for gender affirming hormone treatment who are instead diagnosed with one of these three other conditions?

6 – Blockers always required before cross sex hormone treatment

The criteria for sex hormone treatment refers to “subsequent cross sex hormone treatment”. The implication of this statement is that adolescents will proceed to sex hormone treatment only after having received GnRH agonist treatment.

Question area 6:

How are adolescents already at late stage of puberty treated upon referral? Is prescription of blockers on their own required before prescription of cross sex hormones even for youth already in late puberty?

7 – Medical Risks associated with sex hormone therapy

Table 10. Medical Risks Associated With Sex Hormone Therapy

Transgender female: estrogen

Very high risk of adverse outcomes:

  • Thromboembolic disease

Moderate risk of adverse outcomes:

  • Macroprolactinoma
  • Breast cancer
  • Coronary artery disease
  • Cerebrovascular disease
  • Cholelithiasis
  • Hypertriglyceridemia

Transgender male: testosterone

Very high risk of adverse outcomes:

  • Erythrocytosis (hematocrit . 50%)

Moderate risk of adverse outcomes:

  • Severe liver dysfunction (transaminases . threefold upper limit of normal)
  • Coronary artery disease
  • Cerebrovascular disease
  • Hypertension
  • Breast or uterine cancer

Question area 7:

To a lay reader, table 10 is not informative. It would be useful to know both the actual risk and two comparisons Eg when considering the risk of coronary artery disease for a transgender female it would be useful to understand i) what the level of risk is for a trans female on estrogen (eg 1/10,000) and how this compares both to ii) a trans female not on estrogen (eg 1/9,000) and iii) a cis female (eg 1/9,000). (The numbers in this example are fictitious). Is risk information in this format available?


Section C: Concerns with guidance

There are seven areas of the guidance that we find to be problematic as described below.

1. Reference to gender non-conforming children

The section on areas for further research mentions the need for further research on “The optimal approaches to gender non-conforming children”.

Concern 1:

The vast majority of gender non-conforming children have no need of input from an endocrinologist, so the inclusion of this statement is strange. Why not focus future research on optimal approaches for transgender children?

2. Harm of second social transition

If children have completely socially transitioned, they may have great difficulty in returning to the original gender role upon entering puberty (Source: Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011;16(4):499–516.

Concern 2:

The single source of evidence for this claim is unsound. Steemsa et al (2011) is a small sample, self-selecting, qualitative research study, based substantially on interviews with two children who did not in fact socially transition. This is not an evidence based statement. See: A plea for better transgender research on the perpetual myth of desistance and the harm of social transition.

A more measured assessment of the evidence base, which does not over-reach in its conclusions, is found in the new Australian guidelines, “The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

For further discussion See: Australian Gold standard for care of trans and gender diverse children.

This statement is not supported by robust evidence.

3. Social transition impacting persistence

“However, social transition (in addition to GD/gender incongruence) has been found to contribute to the likelihood of persistence.”

Concern 3:

Where is the evidence for this finding? What is the counter factual? Evidence that socially transitioned children are more likely to be transgender than children who do not socially transition, is not evidence that social transition makes children transgender who would not otherwise have persisted. It is very possible (probable in my opinion and experience) that only the most persistent, insistent, consistent children socially transition, so these children are unlikely to be the same children as those who do not socially transition. This statement is not supported by robust evidence.

4. Inclusion of debunked desistence statistics

“However, the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/ gender incongruent in adolescence (Source: Steensma TD, Kreukels BP, de Vries AL, Cohen-Kettenis PT. Gender identity development in adolescence. Horm Behav. 2013; 64(2):288–297.

Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). In adolescence, a significant number of these desisters identify as homosexual or bisexual. It may be that children who only showed some gender nonconforming characteristics have been included in the follow-up studies, because the DSM-IV text revision criteria for a diagnosis were rather broad. However, the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood (41, 42). With the newer, stricter criteria of the DSM-5 (Table 2), persistence rates may well be different in future studies.”

Concern 4:

Much has been written on these flawed desistance statistics. See: A plea for better transgender research on the perpetual myth of desistance and the harm of social transition.

Within the guidelines the discussion of desistence is inconsistent. In one section the unreliability of the desistance rates evidence base is acknowledged, but in another section the 85% desistance figure is confidently stated without any qualification. Desistence rates have a extremely significant impact on public, media, community, practitioner and parental approaches to a transgender child. Desistance rates have a direct impact on policy (these flawed desistance rates are currently quoted in the consultation documents on whether to allow under 16s rights under the reformed Scottish Gender Recognition Act). Stating as fact desistance rates that are not based on robust evidence is unethical, and if, as many believe, these rates are incorrect, is harmful.

5. Can only assess persistence (and prescribe blockers) after an adolescent has experienced the first stage of natal puberty

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

“Adolescents with GD/gender incongruence should experience the first changes of their endogenous spontaneous puberty, because their emotional reaction to these first physical changes has diagnostic value in establishing the persistence of GD/gender incongruence (85).” (Listed source: Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol. 2006;155:S131–S137.”

Criteria for prescription of blockers includes gender dysphoria worsened with the onset of puberty”.

Concern 5:

The claim that persistence can only be assessed after a youth has experienced the first stages of puberty has one listed reference in the Endocrine guidance –  de Waal and Cohen Kettenis 2006. However, de Waal’s paper does not contain this claim, nor any evidence for this claim. Instead, de Waal and Cohen Kettenis 2006 states that the suppression of puberty using GnRHa is a “very helpful diagnostic aid”, in that it allows time for open exploration. Notably there is no discussion in this paper of the diagnostic value of waiting for the first physical changes of puberty.

The endocrine guidelines contains no reference to any evidence that the early stage of puberty is diagnostic. Why therefore is this unsubstantiated recommendation included?

(We are aware of one deeply flawed and unreliable Steensma publication that over states conclusions on puberty and persistence, which will be the focus of our next research blog – this Steensma paper is not included in the references for the Endocrine guidance)

The belief that GD/GI can only be reliably assessed after a youth has experienced (and been distressed by) the first stage of puberty results in a requirement for transgender children to have to endure the first stage of puberty (and distress at these physical changes) before being deemed eligible for blockers.

It is presumably considered appropriate to cause harm to persistent transgender adolescents (forced to experience the distress of undergoing the early stages of natal puberty before eligibility for blockers) in order to benefit those youth for whom early puberty results in reduced dysphoria and a cisgender outcome (without need for blockers).  We’ll put aside for now the clear prioritisation of the well-being of cisgender youth over the well-being of transgender youth.

For this approach to be at all valid, and for the harm to persistent transgender adolescents to be justified, it must be underpinned by robust evidence that significant numbers of children who are indistinguishable from them pre-puberty, desist during the very early stages (tanner 1-2) of puberty.  Where is this evidence? This evidence is not provided in the Endocrine Guidance.

We would argue that there is a significant difference between an approach that says “for transgender children we will suppress puberty as soon as it begins if a child with a consistent, persistent transgender identity expresses distress at the idea of natal puberty”, and an approach that says “all transgender children will be required to go through at least some of their natal puberty, and only once clinicians notice their increased distress at actual physical changes will we consider them eligible for puberty blockers”. The latter approach surely can only be justified if there is robust evidence for this – otherwise a) it perpetuates the idea that children cannot be considered trans until after puberty b) it imposes stress on children and families as they receive no reassurance that blockers will be offered and c) it imposes distress on trans adolescents who are forced to undergo the early physical changes for no purpose.

6. Cross sex hormones prior to age 16

“We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/ gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years.”

Concern 6:

The phrasing above is curious. It mentions “compelling reasons”, but there is no elaboration or discussion on what those reasons may be. In the same sentence it is stated that published data is minimal prior to 13.5 years. But what about for ages 13.5-15.5? We note that in the referenced study (de Vries et al, 2014) the cohort were given cross sex hormones at mean age 16.7, with the youngest age 13.9 years. This study contained no evidence of harm in the younger catchment (though data numbers are small). The references provided do not provide any evidence for negative impacts of cross sex hormone prior to 16 years old, and do provide evidence of the negatives of waiting so long:

“Currently available data from transgender adolescents support treatment with sex hormones starting at age 16 years. However, some patients may incur potential risks by waiting until age 16 years. These include the potential risk to bone health if puberty is suppressed for 6 to 7 years before initiating sex hormones (e.g., if someone reached Tanner stage 2 at age 9-10 years old). Additionally, there may be concerns about inappropriate height and potential harm to mental health (emotional and social isolation) if initiation of secondary sex characteristics must wait until the person has reached 16 years of age. However, only minimal data supporting earlier use of gender-affirming hormones in transgender adolescents currently exist (63). Clearly, long-term studies are needed to determine the optimal age of sex hormone treatment in GD/gender-incongruent adolescents.”

In the absence of evidence for delaying until age 16, we would advise this statement could be more clearly be written as “there is a paucity of studies on prescribing hormones before 16 years old – the few studies available provide no evidence of harm”. We agree more long term study is needed to establish an optimal age for hormone treatment, and appeal to those working in this field to publish existing data.

We also note the lack of any detailed consideration given here to the benefits of peer-concordance, that is, having the same puberty, at the same time, as the adolescent’s peer group in order to reduce both physical dysphoria and wider social stigma.

Conclusion and recommendations:

We welcome this much needed update to the ‘Endocrine clinical guidelines for the treatment of transgender adolescents and adults’.

The finding that there is a “durable biological underpinning to gender identity” represents an important shift from a historical stigmatising psychiatric approach,  towards the current affirmative model which acknowledges of a biological basis for gender identity, and respects and affirms an individual’s identity.

In section B we have outlined 7 questions, areas where detail is lacking and guidance unclear. In section C we have outlined 6 areas of concern, where the important recommendations are not grounded in robust evidence. We would welcome any clarifications or responses the authors could provide.

Nonetheless, and in spite of some important concerns, the guidelines are a hugely positive shift from the 2009 document, and represent a step forward in transgender health care.

 

References:

De Vries, Annelou LC, et al. “Young adult psychological outcome after puberty suppression and gender reassignment.” Pediatrics134.4 (2014): 696-704. http://dx.doi.org/10.1542/peds.2013-2958

Endocrine Society, Position Statement; 2017. https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

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

Growing up Transgender, Australian gold standard of care for trans children; 2017. https://growinguptransgender.wordpress.com/2017/10/01/australian-gold-standard-of-care-for-trans-children/

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

Steensma, Thomas D., et al. “Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study.” Clinical child psychology and psychiatry 16.4 (2011): 499-516. http://journals.sagepub.com/doi/abs/10.1177/1359104510378303

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

Vitale, A. “Rethinking the gender identity disorder terminology in the Diagnostic and Statistical Manual of mental disorders IV.” HBIGDA Conference, Bologna, Italy, 2005.

 

 

Citation: Growing up Transgender (2017, November 18). Expert consensus of a ‘durable biological underpinning to gender identity’: A response to Endocrine Society Clinical Practice Guideline for transgender health; Growing up Transgender. Retrieved from growinguptransgender.wordpress.com

 

C of E Anti-Bullying Guidance – Send us your reckons!

church6

Today the Church of England released a much needed update to their guidance on tackling homophobic and transphobic bullying in schools:

https://www.churchofengland.org/sites/default/files/2017-11/Valuing%20All%20God%27s%20Children%27s%20Report_0.pdf

Here’s a quote from the introduction:

“All bullying, including homophobic, biphobic and transphobic bullying causes profound damage, leading to higher levels of mental health disorders,self-harm, depression and suicide.

Central to Christian theology is the truth that every single one of us is made in the image of God. Every one of us is loved unconditionally by God.

Church of England schools offer a community where everyone is a person known and loved by God, supported to know their intrinsic value. This guidance helps schools to offer the Christian message of love, joy and the celebration of our humanity without
exception or exclusion.

Church schools must do all they can to ensure that all children, particularly those who may identify as, or are perceived to be, gay, lesbian, bisexual or transgender are kept safe and can flourish.”

A number of Christian commentators have responded with opinion pieces criticising the Church of England for welcoming and caring for transgender children. Sadly many of these opinion pieces are deeply misinformed of the facts.

There is much misinformation on the subject of transgender children and everyone has a view –  I’m reminded of ‘Send us your reckons’ from Mitchell and Webb.

Sadly this misinformation has led to very real consequences for families with transgender children. We know Christian grandparents who have stopped all contact with transgender grandchildren. We know vulnerable families with transgender children who do not feel welcome in their place of worship.

Positive examples of church acceptance, kindness and inclusion (and thankfully in the UK there are many more good stories than bad) are included at the end of this post.

Any Christians commentating in this area, particularly those with a platform and a following, have a moral responsibility to make themselves familiar with the facts, not simply regurgitate  the propaganda of anti-transgender lobby groups, (unless they are part of those groups which seek to restrict the rights of LGBT youth).

I’ve taken as an example a recent article by Ian Paul, expressing deep concern about a move towards “unthinking and unqualified affirmation of those asking for recognition of their transgender status, even if motivated by kindness”. I chose to focus on this article as Ian apparently is open to learning and hearing additional information on this subject. I am happy to share in good faith information with anyone open minded enough to listen. Here therefore is a detailed response to his post (quoted at length in the blue boxes):

“then what of the far more complex question of gender identity?

The famous obstetrician Robert Winston was drawn into the controversy around this question on Radio 4 last week. He pointed out the serious harm that can arise from medical intervention to effect gender ‘transition’.

Speaking on the Today Programme on BBC Radio 4, he said that “results are horrendous in such a big proportion of cases”. He said 40 per cent of people who undergo vaginal reconstruction surgery experience complications as a result, and many need further surgery, and 23 per cent of people who have their breasts removed “feel uncomfortable with what they’ve done”.

He added: “What I’ve been seeing in a fertility clinic are the long-term results of often very unhappy people who now feel quite badly damaged. One has to consider when you’re doing any kind of medicine where you’re trying to do good not harm, and looking at the long-term effects of what you might be doing, and for me that is really a very important warning sign.”

The ‘famous obstetrician’. You are quoting the views of someone who has no experience in treating, much less in performing surgery on, transgender people. The statistics he provides do not accord with the evidence based views of specialists who are clear that transgender surgery has one of the best outcomes of all types of surgery:

This is from those with real expertise treating transgender people, the Endocrine Society:

“Medical intervention for transgender individuals (including both hormone therapy and medically indicated surgery) is effective, relatively safe (when appropriately monitored), and has been established as the standard of care.”

https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

And here’s an overview of the misleading statistics quoted about transition regret:

https://www.huffingtonpost.com/brynn-tannehill/myths-about-transition-regrets_b_6160626.html

Winston refers to two references which do not appear to support his assertions:

  1. Complications of the Neovagina in Male-To-Female Transgender Surgery: A Systematic Review and Meta-Analysis With Discussion of Management PC Dreher et al. Clin Anat. 2017 Oct 23
  2. Postoperative Complications Following Primary Penile Inversion Vaginoplasty Among 330 Male-To-Female Transgender Patients TW Gaither et al. J Urol. 2017 Oct 11

Here are two quotes from the first paper:

“Wagner et al. (2010) describe that gender reassignment surgery (GRS) has proven to be the best solution for patients with discordant gender and contributes significantly to psychosocial stability in these patients”

“An increasing number of patients appear to be seeking this surgery, likely due in part to increasing acceptance by medical and reimbursement communities, high satisfaction rates and improved quality-of-life reports according to Gooren (2011).”

This first paper (Dreher et al) covers surgery worldwide since 1995 and produces an average of 21% of patients requiring additional procedures. It notes that rates of complication are very significantly lower (nearing 0%) in surgeons who have conducted more than 40 surgeries. This suggests improved surgical guidance and training is key to improved outcomes.

The second paper (Wagner et al) looks at the work of an experienced surgeon, and notes 9% required a follow on procedure, almost all of these were conducted as an outpatient and none were severe complications (none graded IV or V). It concludes it is a relatively safe procedure.

It should be recognised that talking about surgery in relation to children is a common tactic used by transphobic groups to misinform and provoke fear. No children in the UK NHS have surgical interventions (the minimum age for surgery is 18).

“For expressing his informed medical opinion, Winston received a torrent of hate mail from transgender activists.”

There is a climate of fear mongering and misinformation in the media about transgender people and transgender children, fuelled by lobbyists such as Christian Concern. I do not condone any hate mail. I do however, understand people expressing their deep frustration at a respected professor using their voice to spout misinformation on a public platform.

Winston’s Daily Mail article follow up is titled “Trolls call me homophobic” which suggests some really basic misunderstanding of the difference between homophobia and transphobia.

You could read this humorous blog post which provided some light relief for those of us who have seen this all before.

https://sexdrugsmh.wordpress.com/2017/11/01/every-trans-media-piece-ever/

You could read this poem to get a sense of how us parents feel every time someone appears on radio or tv and gets their basic facts wrong:

https://growinguptransgender.wordpress.com/2017/11/01/finding-my-fierce/

“But he was expressing from a medical point of view similar reservations expressed by the feminist Camille Paglia:

Although I describe myself as transgender (I was donning flamboyant male costumes from early childhood on),”

Camille here is describing gender expression (what clothing they like) rather than gender identity (who they are). Clothing does not make a person transgender. This is someone who has a history of  appropriating a transgender identity as a rhetorical device with the goal of curtailing the rights of transgender people.

Along with Prof Winston, Camille Paglia also has no known expertise in supporting transgender people

“I am highly sceptical about the current transgender wave, which I think has been produced by far more complicated psychological and sociological factors than current gender discourse allows.”

The phrase ‘transgender wave’ is distorted and dehumanising language. The increase in people seeking support means less people are struggling on their own. Here are the words of experts from the Australian Standards of Care and Treatment:

“with increasing visibility and social acceptance of gender diversity in Australia, more children and adolescents are presenting [….and ] requesting support, advice, and gender affirmative psychological and medical treatment”. They note that with “approximately 1.2% of adolescents identifying as trans […] it is likely that referrals will continue to rise in the future”.

https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/Australian%20Standards%20of%20Care%20and%20Treatment%20Guidelines%20for%20Trans%20and%20Gender%20Diverse%20Children%20and%20Adolescents.pdf

See this thread on twitter which makes a comparison between the current increase in numbers of out transgender people (and referrals to youth gender services) with the rise in prevalence of left handed people last century: https://twitter.com/DadTrans/status/929081990107881472

(In short – in 1900 there was significant social prejudice against left handed people – left handed children were forced to write with their right hand – and only 2% of the population was openly left handed. With increased acceptance of left-handed children, numbers of openly left-handed people rose sharply in the early twentieth century and have remained constant at about 12% of the population since then. Speculators in the 1930s could have expressed concern about the sharp increase in left-handedness. But the phenomenon was clearly related to increasing levels of acceptance leading to left-handed people being more open and not having to pretend to be right-handed. Interestingly, in Japan where there is still stigma and left-handed children are still forced to use their left hand, the prevalence is still 2%).

“Furthermore, I condemn the escalating prescription of puberty blockers (whose long-term effects are unknown) for children. I regard this practice as a criminal violation of human rights.”

This is the ideologically based opinion of someone with no qualifications in this topic. Puberty blockers are safe and reversible.  They have been prescribed for precocious puberty since the 1970’s and continue to be prescribed for this purpose (delaying the puberty of children who begin puberty too young).

For a thorough review of the ethics of hormone blockers see the following article: Gender Atypical Organisation in Children and Adolescents: Ethico-legal Issues and a Proposal for New Guidelines, Simona Giordano http://booksandjournals.brillonline.com/content/journals/10.1163/092755607×262793

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

The safety and reversibility of puberty blockers are looked at in the recent Australian national medical guidance (published September 2017) which states:

“Puberty suppression is most effective in preventing the development of secondary sexual characteristics when commenced at Tanner stage 2”. ”reduction in the duration of use of puberty suppression by earlier commencement of stage 2 treatment must be considered in adolescents with reduced bone density to minimise negative effects.”

Further, this month the Endocrine Society (published new guidance: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” (published online and  in the November 2017 print issue of the Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of the Endocrine Society).

Recommend puberty blockers

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

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

Start puberty before blockers

“We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty.

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

Here’s the criteria for blockers, which are not handed out on a whim:

Criteria for blockers

“Adolescents are eligible for GnRH agonist treatment if:

  1. A qualified MHP has confirmed that:
  • the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),
  • gender dysphoria worsened with the onset of puberty,
  • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,
  • the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,
  1. And the adolescent:
  • has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,
  • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,
  1. And a paediatric endocrinologist or other clinician experienced in pubertal assessment
  • agrees with the indication for GnRH agonist treatment,
  • has confirmed that puberty has started in the adolescent (Tanner stage $G2/B2),
  • has confirmed that there are no medical contraindications to GnRH agonist treatment.”

“The cold biological truth is that sex changes are impossible. Every single cell of the human body remains coded with one’s birth gender for life. Intersex ambiguities can occur, but they are developmental anomalies that represent a tiny proportion of all human births.”

Does this author actually believe that transgender people do not exist? This is a deeply transphobic perspective and the fact that the author describes herself as transgender does not undo the clear transphobia here. Camille also clearly does not understand the difference between sex and gender.

Intersex ambiguities are estimated by WHO to be 1% of births which is hardly a tiny proportion.

Futhermore, the findings of the Endocrine Society note conclusive evidence of ‘a biological underpinning for gender identity’ and list the many scientific studies noting a biological underpinning. Below I’ve provided the cold biological truth about transgender people as written by the global experts in endocrinology

In September 2017 the Endocrine Society published a guideline, entitled “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” (published online and will appear in the November 2017 print issue of the Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of the Endocrine Society). This updated guidance was produced by leading endocrinologists specialising in support to transgender adults and adolescents from the US, Belgium, and the Netherlands. The guidelines are endorsed by the American Association of Clinical Endocrinologists, the American Society of Andrology, the European Society for Pediatric Endocrinology, the European Society of Endocrinology, the Pediatric Endocrine Society, and the World Professional Association for Transgender Health.

Accompanying the guideline is a position statement: https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

Here’s a longer quote

The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder. Such evidence stems from scientific studies suggesting that: 1) attempts to change gender identity in intersex patients to match external genitalia or chromosomes are typically unsuccessful; 2) identical twins (who share the exact same genetic background) are more likely to both experience transgender identity as compared to fraternal (non-identical) twins; 3) among individuals with female chromosomes (XX), rates of male gender identity are higher for those exposed to higher levels of androgens in utero relative to those without such exposure, and male (XY)-chromosome individuals with complete androgen insensitivity syndrome typically have female gender identity6; and 4) there are associations of certain brain scan or staining patterns with gender identity rather than external genitalia or chromosomes

In summary, although there is much that is still unknown with respect to gender identity and its expression, compelling studies support the concept that biologic factors, in addition to environmental factors, contribute to this fundamental aspect of human development.”

“Data are strong for a biological underpinning to gender identity”

“All this makes Synod’s passing of a motion on this issue last July look at best naive, at worst very foolish.”

“All of this”. All of what? You have quoted two people with no expertise or experience.

A clearer interpretation is that the General Synod has moved towards being compassionate to transgender people, in line with recent scientific research and expert endorsed best practice.

“Winston is pointing out the (unintended) consequences of hasty and naive action in this area, just as Jon Kuhrt is pointing out the results of hasty and naive action in response to the homeless. There are the consequences of giving an unthinking and unqualified affirmation of those asking for recognition of their transgender status, even if motived by kindness. It is, in any complex situation, quite possible to harm even when intending to do good, if care and love are not shaped by awareness and wisdom. What is true of those asking for money is true of those asking for recognition. These are the facts that the Church needs to take account of; in fact, these are the things any of us needs to take account of if we are to be wise and compassionate pastors.”

To be wise and compassionate pastors you should follow the guidance provided by those who are best qualified in this topic. The actual experts. Transgender people exist. Transgender people have always existed. There is a “durable biological underpinning to gender identity” (Endocrine society).

Here’s several quotes from Australia’s Standards of Care:

“being trans or gender diverse is now largely viewed as being part of the natural spectrum of human diversity”.

“increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved”.

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

“for children, family support is associated with more optimal mental health outcomes”

“trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”.

Australia’s Royal Children’s Hospital Gender Service new “Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents”. These guidelines are compiled by the leading Australian experts, based on the best and most current evidence from around the world. These guidelines are endorsed by ANZPATH (the Australian and New Zealand Professional Association for Transgender Health) and were launched at the recent ANZPATH conference. They are now the official guidelines for all health professionals working with transgender children in Australia.

Transgender trend” are a non-religious group representing parents of children with gender dysphoria who do not agree with the current transgender ideology. They made a presentation to the Government, opposing the planned demedicalisation of the legal process around ‘transition’. I reproduce below some of the facts they set out—facts that the Church of England will need to take into account in anything that it proposes in this area as part of its wider debate on sexuality.”

“Transgender trend” are considered by parents of transgender children like myself as an anti-transgender hate group. Their posts, publications and tweets are deliberately incendiary, malicious and frequently based on an extremely biased review of evidence. They pose as ‘concerned parents’ but constantly attack the rights of transgender people in general and transgender children in particular. Their website is neither neutral, nor concerned for the well-being of transgender children. The key individuals on the site do not have transgender children. The group name “transgender trend” should give you a clue. These are not experts but a small group with the sole agenda of undermining the well being of transgender children. Why not quote from the highly respected charity Mermaids, who has over 1,000 parent members, all parents of transgender children in the UK. Mermaids co-hosted with the NHS the 2017 conference on trans children that you quote in one of your sources. “Transgender trend” meanwhile is a fringe anti-trans lobby group without credibility.

“I also speak to urge caution on behalf of the children of this generation who are caught up in the teaching of a new rigid, anti-science belief system presented to them as fact.”

The Endocrine Society are scientists. Supporting transgender children is evidence based science. Please provide a source that supporting transgender children is anti-science

“If Gender Identity is established in law as a Protected Characteristic, it will apply to children of any age. But a child’s identity is not fixed: it changes over time, and it is shaped by factors like parental approval and societal influences. If all trusted adults are reinforcing daily a little boy’s belief that he is really a girl, this will have an obvious self-fulfilling effect. Puberty blockers supply the ‘answer’ to the created fear of a puberty he now believes to be the ‘wrong’ one.”

You are quoting a transphobic view here that is completely inaccurate. Let me explain:

A) You are suggesting that parents are imposing or reinforcing a child’s gender identity. The Lancet report is clear:

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

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00683-8/fulltext

B) You are suggesting that parental denial of a child’s identity will make them less likely to be trans

Here’s the Endocrine Society:

“The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity.1,2 Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.”

https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

3) You are claiming that a trans girl is a boy who is deluded and wrong.

The Endocrine Society concludes:

“a durable biological underpinning to gender identity”

The World Professional Association of Transgender Health and ICD are removing the classification as a mental health disorder, acknowledging that it is natural human variation. Note these bodies are slow moving – ICD only de-classified homosexuality as a mental disorder in 1992

https://www.psychologytoday.com/blog/hide-and-seek/201509/when-homosexuality-stopped-being-mental-disorder

See this from the American Academy of Pediatrics:

“While researchers have much to learn about gender-expansive and transgender children, there is evidence that both reparative therapy and delayed transition can have serious negative consequences for children. While some groups promote these strategies in good faith, many use misleading descriptions of research or even outright misinformation.”

https://www.aap.org/en-us/Documents/solgbt_resource_transgenderchildren.pdf

“Almost all children on blockers progress to cross-sex hormones at age 16. [2] Very few come off this path of increasingly invasive medical treatments once they are on it and so-called ‘social transition’ is the first step. This approach clearly works to prevent normal resolution of childhood gender dysphoria and foster persistence of opposite-sex identity.”

The protocols for receiving blockers in the NHS are exceedingly conservative. Families first need to get a referral from a GP, which many GPs are unwilling to provide. Many are sent on a time-consuming detour via the child mental health service CAHMS (until CAHMS confirm gender identity is not a mental health issue and refer on to the Gender Identity service). Once referred to the Gender Identity Service there is a 12 month wait for first appointment. Then a 6 month assessment process. Then prolonged monthly sessions with psychologists talking about identity. Even then blockers are very far from guaranteed – a young person can only get blockers if referred from the NHS Gender Service, and they are extremely conservative. Only the most persistent children, the ones with the most clear cut and long held identity, the ones who insist session after session and show no doubt, who are supported by their parents, who are usually socially transitioned and accepted as their identified gender in their lives – these are the very small number of children who are referred for blockers. It is not surprising to me that the small number of children who jump through all the medicalised hoops for years and years to get blockers, are likely to continue in their identity.

This quote also refers to two myths that are incorrect. One the myth that the majority of prepubescent children will ‘desist’ from a transgender identity at puberty. Please see: https://growinguptransgender.wordpress.com/2017/03/04/a-plea-for-better-transgender-research-on-the-perpetual-myth-of-desistance-and-the-harm-of-social-transitioning/

This analysis concludes thus:

“Certainly the studies listed in the 2016 paper provide no conclusive evidence that consistent, persistent, insistent transgender children are likely to desist. In fact the best of these bad studies does not support desistance at all, but instead clearly showed a 58% persistence rate”.

To talk about it as a ‘path’ is also extremely misleading. Whilst many transgender adolescents (none before the age of 15 years 10 months on the NHS) end up eventually taking hormones, not all will have further interventions such as surgery (and surgery is never available in the NHS before age 18).

“While trans activists call for the de-medicalisation of ‘transgender,’ in the case of children they campaign aggressively for social transition, blockers and cross-sex hormones at ever earlier ages”

Again, this is couched in unnecessarily incendiary language such as “at ever earlier ages”. Advocates for the rights of transgender children understand that puberty blockers should be prescribed at the start of puberty (otherwise they have no purpose – there really is a clue in the name). Concerned parents are conflicted about the advice on the ideal age for cross-sex hormones, with some experts arguing for this to start at around age 16 (as is the current NHS protocol even though for many children it is late in their pubertal developmental) whereas some experts are arguing for the prescription at a younger age. This debate on appropriate age for cross-sex hormones is ongoing and is outlined in the Endocrine Society’s guidance and it is right that this .This debate is not one between transgender activists and concerned parents, it is a debate between competent medical professionals who are currently divided and who take different value judgements when deriving their approach. Your blog post could have presented this in an informed and sensitive way – instead of repeating the material espoused by the group called “transgender trend” who do not believe in the existence of transgender children.

“The surge in sex hormones at puberty triggers the enormous changes in the teenage brain which don’t complete their job until the mid-twenties. [4] The brain /personality is not fully-formed until then. The effects of blockers on adolescent brain development are unknown [5] although studies on adults, including men taking the drug for prostate cancer, indicate risk of memory loss, depression and cognitive impairment. [6] Recent reports from the US indicate long-term serious health effects for women who were administered blockers for precocious puberty, such as excruciating muscle and bone pain, depression, weakness and fatigue.”

The potential dangers of puberty blockers need to be weighed up against the very real and known impacts of a transgender person going through the wrong puberty. People who recognise the existence of transgender people are very aware of this balance. “Transgender trend” does not acknowledge (or care) about transgender people so only presents potential negatives.

Here’s the take from the Australian specialists in their guidance published this year:

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

“Preventing a child’s sexual development in early puberty, followed at 16 by cross-sex hormones, results in sterility as viable eggs or sperm have not developed”

It is accepted that cross-sex hormones can be a barrier to fertility in many youth, though this is not a reason to withhold necessary treatment. This is a discussion to be had, but it needs to be held much more sensitively based on an understanding of the needs of transgender adolescents and adults. For any individual and any family, difficult discussions around fertility are core to any decision about cross-sex hormones – this is not rushed in to on a whim, and counselling about potential impact on fertility is a requirement before eligibility.

“These children are prevented from ever experiencing puberty: hormones can only superficially feminise or masculinise secondary sex characteristics, they cannot create the puberty of the opposite sex”

This is a non-scientific statement that shows very limited knowledge of endocrinology.

“Risks of cross-sex hormones include cardiac disease, high blood pressure, blood clots, strokes, diabetes and cancers. [9] Some significant effects are irreversible, such as male-pattern baldness and body and facial hair, masculinised voice and compromised fertility.”

All medical treatments have potential side-effects. If I listed the potential side effects of paracetamol without context it would look similarly alarming. This is intentionally inflammatory.

“There have been no clinical research trials into the long-term effects of this treatment on children”

We have over 20 years of data with no ill effects observed in that period. We’d of course like more data and this will come in time. We do conversely have plenty of long term evidence of the poor outcomes (particularly in terms of mental health, depression, wellbeing) for transgender adults who have not been supported and accepted in childhood. Concerned parents are hoping for a better outcome for their own children, and the latest evidence, including from the Netherlands, is very positive.

“this is a non evidence-based practice [10] to treat a non evidence-based diagnosis of being ‘a girl trapped in a boy’s body’ and vice versa [11] and this generation of children are the guinea pigs.”

This is a ‘Straw man argument’. There is no diagnosis of ‘being a girl trapped in a boy’s body’. This is a phrase that some transgender people in the past have used to try to explain in simple terms how they feel. This is not a scientific diagnosis and no one claims this is the situation. What is known is that some children have a clear and consistent gender identity that differs from the sex they were assigned at birth. Experts have found “conclusive evidence that there is a durable biological underpinning for gender identity” – speculated to be due to hormone fluctuations in utero.

As a concerned parent I would much rather be living 40 years in the future when there is better long term data. However, this is not in itself reason for with holding treatment. We have to make the best evidence based decisions we can based on what is currently known. Again here’s a quote from the Australian national health guidelines:

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

“‘Transgender’ is an ideological label distinct from the clinical diagnosis ‘gender dysphoria.’ To call a child ‘transgender’ is to make both a claim that the child’s feelings represent material reality and a prediction about that child’s future: they will not change.”

Unlike the apparent anti transgender ideology of the author quoted, transgender is not an ideology. Transgender is an adjective to describe people whose gender identity is different to the sex they were assigned at birth from a cursory inspection of their genitals.

“An analysis of all published research studies of children with ‘gender dysphoria’ shows that 80% will naturally come to be happy as the sex they were born and this is true of even some of the most severe cases, we can’t know which children will persist and which will desist.

Opposite-sex identity in childhood is overwhelmingly predictive of gay or lesbian sexual orientation in adulthood, not transsexualism.”

This statement is demonstrably false and shows the people at “Transgender Trend” are intentionally conflating the distinction between children who are gender non-conforming (eg boys who like dolls) and children who are transgender (eg children assigned male at birth who have a consistent, insistent and persistent identity that they are a girl). The research that gave rise to the myth of 80% ‘desistance’ has been comprehensively discredited as deeply flawed and unreliable as it lumped together gender non-conforming and transgender children – In fact:

“Certainly the studies listed in the 2016 paper provide no conclusive evidence that consistent, persistent, insistent transgender children are likely to desist. In fact the best of these bad studies does not support desistance at all, but instead clearly showed a 58% persistence rate).

https://growinguptransgender.wordpress.com/2017/03/04/a-plea-for-better-transgender-research-on-the-perpetual-myth-of-desistance-and-the-harm-of-social-transitioning/

“Affirming a child’s ‘gender identity’ can therefore be seen as gay conversion therapy by another name.”

Gender identity and sexual orientation are two separate things. Some transgender people are homosexual, some are heterosexual, some are bisexual, some are pansexual (attracted to people regardless of gender including non-binary people). The same therapists who attempted ineffectual and harmful conversions of gay people later applied the same techniques to attempt conversion of transgender children.

“There has been an almost 1000% increase in children referred to the Tavistock clinic in London over the past 6 years. [14] These figures are inflated by the unprecedented rise in the number of girls – nearly 70% of the figure overall and over 70% of adolescent referrals last year. [15] By comparison, in the late Sixties 90% of adult transsexuals were male. [16] We are aware that teenagers and young adults are susceptible to indoctrination, brainwashing and social contagion which is why we block online anorexia and self-harm sites. The internet, however, is chock-full of Tumblr bloggers and Youtube vloggers with hundreds of thousands of followers, who are selling vulnerable young people the myth of transformation through cosmetic alteration of their bodies, including amputation of healthy body parts, and a lifetime’s dependency on powerful off label hormones.”

I’ve mentioned prevalence earlier in this response (see above). This increase in numbers referred to the UK Gender Identity Service (GIDS) was not unexpected or unusual but predicted, as was the increase in assigned female referrals (specialists had predicted years ago an increase in assigned female referrals). Yes, it is a fact that there are a few openly trans people on the internet – individuals who are followed by individuals who before the availability of the internet would have been completely on their own. Isn’t it wonderful that now a few trans people are sharing their experiences, offering support to isolated transgender people. The remainder of the quoted section is pure conjecture and hyperbole.

“Recent reports of girls’ mental health indicate that girls and young women in the UK are in crisis. [17] Recently published evidence of the rate of sexual abuse and harassment in schools across the UK is a matter of national shame. [18]

Reports such as the recent Stonewall Schools Report [19] which indicate high suicidal ideation in ‘trans’ youth serve to cover up the fact that the vast majority of these youngsters will be teenage girls, now hidden in the category ‘trans boys.’”

The Stonewall report indeed outlines what a tough time transgender children are having at school. Media hysteria, continual criticism, and trans boys being described as girls is exactly what makes life hard for a trans child or adolescent. The C of E guidance supports acceptance of all people, even those who are different. It encourages schools to be welcoming safe places where transgender children can get an education without harassment or bullying. Who would want more bullying of transgender children? The C of E guidance is extremely sensible and should be welcomed by all who care about children. In the past schools were not welcoming places for children who were different. This did not mean these children didn’t exist– it just left them bullied, depressed, ashamed and needing to hide.

“A PSHE teacher and Head of Year at a large comprehensive told me that in her school the kids who identify as ‘trans’ are, without exception, either lesbian, autism spectrum, have mental health problems or have suffered sexual abuse.”

This kind of rhetorical anecdote is a well worn device familiar to anyone who has watched a political debate. For an easy to digest discussion on this phenomenon see http://www.bbc.co.uk/news/uk-politics-20956126

About 8% of trans children have autism (https://www.theatlantic.com/health/archive/2016/11/the-link-between-autism-and-trans-identity/507509/) but this is seen as co-occurring rather than either autism making them transgender or vice versa.

Sexuality and gender identity are different concepts, something this teacher seems confused about.

Many trans children suffer mental health problems such as depression – this is recognised as ‘minority stress’. Depression, stress and anxiety not because of who they are but because of how they are treated.

This important US study evidences that trans children who are accepted and supported at home and at school have normal levels of mental health. http://pediatrics.aappublications.org/content/pediatrics/early/2016/02/24/peds.2015-3223.full.pdf

Supporting trans children is the best option for those who genuinely care about their wellbeing. I’m glad the Church of England has been informed by experts and those who know trans children.

“Parents are also concerned about the relentless gender identity propaganda their children are subject to today – across the media, [20] the internet and in schools, through organisations such as GIRES, Gendered Intelligence, Mermaids and Educate and Celebrate. The belief that gender is an innate identity is taught to children as truth, with no alternative views offered, in contravention of the UN Rights of the Child.”

Trans children exist. They have always existed. And the few quiet voices speaking up for them are dwarfed by the powerful anti-trans voices that are platformed daily across tv, newspapers and radio. As  I write this, in the last week, The Times alone has published 7 articles attacking trans children. The reality is that anti transgender rhetoric is prominent and inescapable, much to the distress of transgender children, adults and their friends and families.

“The ‘transition or suicide’ trope is repeated endlessly, against all Samaritans guidelines. There is no evidence that children will commit suicide if their parents fail to support them in taking a medical pathway, but of course the threat terrifies parents into feeling they have to.”

I agree that writing about suicide needs to be handled sensitively and in accordance with the Samaritans guidance. Seeing as you raised this, (as anecdote, and without irony, in the same sentence as saying it shouldn’t be mentioned), here’s a statement of evidence from the Endocrine Society:

Transgender individuals who have been denied care show an increased likelihood of committing suicide and self-harm”

https://www.endocrine.org/advocacy/priorities-and-positions/transgender-health

“There are over 260 trans youth support groups across the UK [21], which provide the ‘tribe’ where our most vulnerable young people will be accepted, maybe for the first time, as long as they identify as trans. All transgender organisations advertise their support for ‘gender non-conforming’ youth, sweeping up all children who are ‘different’ and don’t fit in.

These organisations claim to support ‘diversity’ but of course they do the opposite: a girl who rejects feminine stereotypes is transformed into a ‘boy’ who conforms to masculine stereotypes. Gender non-conformity is erased. Regressive and reactionary sex-stereotyping is being sold to young people as a progressive social justice movement.”

This shows very little knowledge of these organisations and their scope. A girl who rejects feminine stereotypes would not be ‘transformed’ by a youth group into a boy who conforms. My transgender daughter is not a cliché or a stereotype of femininity. She likes football and art, wears jeans more than dresses, and is a normal well rounded child with a variety of interests and likes. The majority of transgender children and adults I know are defiantly breaking down gender stereotypes. It is “Transgender Trend”, who seem set on reducing trans children to the regressive stereotypes they claim to be against. At this point I doubt very much whether they have even met any transgender children.

“To teach children that their ‘authentic self’ is something in their heads, split off from and in opposition to, the body, is to create gender dysphoria. Mind-body disassociation is recognised as a state of mental ill-health: in this case uniquely, it is presented as a normal variation and something to be celebrated. Mental health is based on being equipped to accept reality.

Since children have been taught that it is their ‘gender identity’ which makes them a boy or a girl and not their biological sex, calls to Childline from young people confused about their gender have doubled in a year – eight calls are now received every day from children as young as eleven. [22] The concept of ‘gender identity’ is clearly – and inevitably – causing mental health problems for young people.”

Again the author deliberately and falsely presents transgender people as mentally ill, deluded or confused. Throughout the 20th century, methods were applied to trans people to stop them being trans including electroshock and attempted conversion therapies. These techniques, historically used also on gay people, disabled people, and other marginalised groups, did not work. Instead trans people were harmed with resulting depression and shame. All forms of conversion therapy are now seen as both unethical and ineffective.

http://www.rcgp.org.uk/news/2017/january/uk-organisations-unite-against-conversion-therapy.aspx

“Any child who suffers genuine gender dysphoria must of course be sensitively supported in schools and youth organisations. But teachers, professionals and other children cannot be asked to collude in the reinforcement of a child’s belief which contradicts reality. Recognition of biological facts is not bigotry.

When girls are told that a male classmate is now a girl, their sense of their own reality is shattered. If a biological male is a girl, then it is not female biology which makes you a girl, it is something else. Girls must look to a male classmate to find out the invisible magic quality they need, and the boy is given the power to define what a girl is. We cannot predict the long-term practical or psychological effects on girls taught to deny their own biology, without the right to even define themselves correctly as the female sex.”

This is denial that trans people exist. This is extremely disturbing and appears to be advocating for teachers not to work in accordance with the 2010 Equality Act. This damaging bigotry harms children like mine who just want to live their life without prejudice. This also shows no understanding of the complexities of biology.

“If teenage girls must consent to a male classmate using their toilets and changing-rooms they learn that their boundaries may be violated and their consent is unimportant. Girls learn that they are not always allowed to say ‘no.’ This is grooming; lessons on the importance of consent become meaningless.

Girls who are coached at school into ignoring their own discomfort and intuition may go on to put themselves in risky situations with any man who claims to be a woman, out of fear of being seen as transphobic.

In the case of public swimming pool changing rooms a young girl cannot name a male with a penis as a man: voyeurism and indecent exposure cease to exist as crimes if a man claims to be a woman. Normal child protection protocols effectively become unlawful.”

This rhetoric is now moving beyond bigotry towards hate. It reveals what was clear from the start, there is no care for transgender children, but simply hate rooted in fear. These exact same arguments were put forward against gay people in the 1980s and gave rise to Section 28.

I am deeply concerned that we are not learning from the lessons of the past, and that history may repeat itself, with transgender people the latest in a long history of marginalised groups being attacked, stigmatised and othered.

Trans women are women. Trans girls like my daughter are girls. They are not a threat.

For anyone wanting to sensitively address the stance of organised religion to trans issues then the following must be the foundation for any discussion: Trans people exist; Trans people have always existed; Trans children exist.

If you choose to comment on these issues, you can do as this writer has done whether maliciously or through ignorance, and seek to marginalise trans people, present them as mentally deluded or potentially dangerous, encourage others to fear and reject them.

Or, instead, you can choose to embrace them, tell them you love and accept them as they are. My own grandparents were deeply committed Christians and I know they would have loved and supported my daughter. Please open your eyes and your hearts. Tell transgender children and their families that they are welcome in your schools and even in your churches (temples, mosques etc). Commit to protecting vulnerable transgender children from bullies including uniformed writers who spread misinformation, hate and fear.

To the Church of England. I am grateful that The Church of England have bravely ignored media hysteria and stood up for one of the most misunderstood, marginalised and attacked groups of children.

I commend them for caring for my transgender child.

To conclude here (with permission) are positive stories of Church and Christian community acceptance, inclusion and love:

“Our C of E/Methodist church has been very supportive. We often have talks on inclusivity and the love of God. My daughter also goes to a C of E school and the message we’ve had there is one of acceptance and kindness. In fact the head teacher said that as a Christian school they should be the first to show kindness and acceptance, and zero tolerance to any kind of unkindness.”

“We’re so lucky, our C of E church have been wonderful”

“We were at our previous church when our child socially transitioned. My husband was suddenly asked to stop doing sermons in church. We ended up going to another church. Our new church however have been incredible, from day one they used our child’s pronouns, and when he chose a new name a month after we joined the church absolutely everyone began using it immediately. They’ve been nothing but supportive and accepting.”

“The vicar at our c of e place was just calmly accepting and kind when I told her about my child. It’s a Church that does loads of social justice stuff and has a welcoming, un-judgemental attitude in general.”

“A Sunday School teacher was the first one to tell me that my child was using a different name. We attend the Church of Scotland. If you look at who Jesus was actually hanging out with it’s fairly clear to me that Christians are called to support people who are perhaps a little bit different and not accepted by wider society.”

“So far I have been surprised by our religious relatives (Jehova’s Witnesses and Christians), I was expecting some discomfort from them but they have all been supportive and accepting.”

“The poignant words of my eldest daughter’s blog detailing our family’s sad estrangement from the local CofE church. https://bethmackin.wordpress.com/…/may-2017-faithfully…/ We left said church and now attend a inclusive church that is a URC/Methodist church. I feel much safer, loved and cared for but mourn the loss.”

“Many positive examples to be found at Diverse Church – a UK wide organisation with groups for 18-30 LGBTA+, they also have a parents forum that has a specific hub for Christian Parents of Transgender children http://diversechurch.website/

See also OneBodyOneFaith – Great for engagement with current issues as well as networking to find safe and accepting churches. http://www.onebodyonefaith.org.uk/ and OpenTable which is a collection of LGBT inclusive eucharist services. This Sunday Open Table London will hold a special service for Transgender Day of Remembrance https://www.facebook.com/opentablelondon/”

“Here’s an article on inclusive approaches to baptism http://www.independent.co.uk/…/new-chapel-unitarian…

“@JamesMartinSJ is a very vocal supportive priest on twitter”

 

Finding my fierce

lion

 

My heart is racing

My mouth is dry,

I bite my lip, I try not to cry

The pressure is sinking me,

My head will soon pop,

The criticism, the hate,

When will it stop

 

A headline, opinion, radio debate,

Another scare story, platform of hate

Day after day another attack

The mindless celebrity, the scientist quack

All spouting distortion, spitting out lies

They don’t know the facts, yet pretend to be wise

About surgery, hormones, desistance, trends

They couldn’t care less about my child and their friends

 

“There is a durable biological underpinning to gender identity”

This isn’t a choice

 

But I feel so alone

I can’t find my voice

 

I see how you stare on the playground each day

Eyeing the dress, judging the way

That I raise my family

It couldn’t happen to you

With your conforming children

You’d know what to do

If your child cried about gender in bed every night

If your child was depressed, saw no hope in sight

If you held them as they sobbed in your arms

Asking you to love them just as they are

 

The hate almost breaks me, it makes me despair

So many lies, so much distortion, it is all so unfair

I’m so close to crumbling, my head is a spin

I can’t let myself sink under, can’t let them win

I feel so hopeless, so alone, fragile and weak

If no one will stand up, I need to speak

I need to find courage

It must be somewhere deep

If I don’t come up fighting

I’ll lie here and weep

 

But the thing is

Now

they are happy

I wish you could see

They know who they are

They just want to be

Left alone to live their life

without fears

Without pointing fingers,

and whispers and jeers

 

You want me to squash them,

make them feel small

Tell them there’s no space for them

in this world at all

But the world is bigger than you can know

There’s room for trans children to grow

Up into adults who will succeed and thrive

Who will be happy

Thankful to be alive

 

I see their spirit, their courage, their heart

They need vocal allies, me for a start

They need sturdy defenders,

stood by their side

Telling the world they are perfect,

they don’t need to hide.

So I will stick up for them,

fight the battles to come

I will find my fierce,

my strength,

be a mum

 

NHS Failing Transgender Children

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

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

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

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

Where are our allies standing up for transgender children?

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

“Some Children Are Trans: Get Over it”.

somechildrenaretrans

Where is the challenge from the experts in the NHS?

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

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

In response to today’s Times piece they should:

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

I’ll even write it for them:

 

Press release:

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

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

Here’s a Tweet to go with it:

tavistep up

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

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

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

Australia Presents a Gold Standard of Care for Trans and Gender Diverse Children

Part 1. The Guidelines for Trans and Gender Diverse Children and Adolescents

Introduction

This week Australia’s Royal Children’s Hospital Gender Service has launched the “Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents”. These guidelines are compiled by the leading Australian experts, based on the best and most current evidence from around the world. These guidelines are endorsed by ANZPATH (the Australian and New Zealand Professional Association for Transgender Health) and were launched at the recent ANZPATH conference. They are now the official guidelines for all health professionals working with transgender children in Australia.

The standard is clearly written and concise and it is definitely worth reading in full. Here,  for convenience, please find below a brief synopsis of selected key extracts from the document. In Part 2 we will look at Why this standard matters, and why it should be adopted in the UK NHS.

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents (pdf)

 aus standard care

Key extracts from the document:

Evidence Based:

“Recommendations are made based on available empirical evidence and clinician consensus”, “developed in consultation with professionals….from multiple disciplines, trans and gender diverse support organisations, as well as trans children and adolescents and their families”.

Numbers expected to increase:

“with increasing visibility and social acceptance of gender diversity in Australia, more children and adolescents are presenting ….requesting support, advice, and gender affirmative psychological and medical treatment”. with “approximately 1.2% of adolescents identifying as trans” “it is likely that referrals. ….will continue to rise in the future”.

Natural:

“being trans or gender diverse is now largely viewed as being part of the natural spectrum of human diversity”.

(This Australian guidance was completed before the latest Endocrinology guidelines, stating that “there is a durable biological underpinning to gender identity”.

Affirmative care:

“increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved”.

General principles for supporting trans and gender diverse children and adolescents

  • Individualise care”. Emphasises the “importance of tailoring interventions”, recognising each individual’s “unique clinical presentation” and “individual needs”.

  • Decision making should be driven by the child or adolescent wherever possible, this applies to options regarding not only medical interventions but also social transition”.

  • “Use respectful and affirming language”.

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

  • “consider legal requirements” outlines legal requirements that are barriers to “obtaining identity documents that accurately reflects their gender”. Considers “implications for young people’s right to privacy and confidentiality when enrolling in school or applying for work”.

Children vs adolescents:

“the clinical needs (of children vs adolescents) are inherently different, and consequently we provide separate guidelines for trans and gender diverse children and adolescents”

Psychological Support for a younger child:

  • “Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach”.

  • “for children, family support is associated with more optimal mental health outcomes”

  • “trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”.

  • “others may benefit from a skilled clinician working together with family members to help develop a common understanding of the child’s experience”.

  • “when a child’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, learning or behavioural difficulties …. a more intensive approach with input from a mental health professional will be required”.

Social Transition for a younger child:

  • “social transition should be led by the child and does not have to take an all or nothing approach”.

  • “provision of education about social transition to the child’s kindergarten or school is often necessary to support a child who is socially transitioning to help facilitate the transition and minimise …bullying or discrimination”.

  • “social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers”.

  • “The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

Key roles for a clinician of younger child:

  • Supportive exploration of gender identity over time

  • Work with family to ensure a supportive home environment

  • Advocacy to ensure gender affirming support at school

  • Education (to child and family) on gender identity and signposting to support organisations for child and for parents

  • If child is expressing desire to live in a role consistent with their gender identity, provision of psycho-social support and practical assistance to the child and family to facilitate social transition

  • Referral to endocrinologist ideally prior to onset of puberty

Supporting Adolescents:

[For] “adolescents with insistent, persistent and consistent gender diverse expression, a supportive family, affirming educational environment and an absence of co-existing mental health difficulties, the adolescent and parents may benefit from an initial assessment followed by intermittent consultations with a mental health clinician”

Supporting Parents of Adolescents:

“adolescents often encounter resistance from their parents when their trans or gender diverse identity is first disclosed during adolescence”. “For the clinician, investing time for parent support… will assist in creating a shared understanding….and enable optimisation of clinical outcomes and family functioning”

Fertility Counselling for Adolescents:

“Although puberty suppression medication is reversible and should not in itself affect long term fertility, it is very rare for an adolescent to want to cease this treatment to conduct fertility preserving interventions prior to commencing gender affirming hormones. It is therefore necessary for counselling to be conducted prior to commencement of puberty suppression or gender affirming hormones”

Commencement of puberty suppression

“Puberty suppression is most effective in preventing the development of secondary sexual characteristics when commenced at Tanner stage 2”. ”reduction in the duration of use of puberty suppression by earlier commencement of stage 2 treatment must be considered in adolescents with reduced bone density to minimise negative effects.”

Commencement of gender affirming hormone treatment

  • “The ideal time for commencement of stage 2 treatment in trans adolescents will depend on the individual seeking treatment and their unique circumstances” “adolescents vary in the age at which they become competent to make decisions that have complex risk-benefit ratios”. “The timing…will also depend on the nature of the history and presentation of the person’s gender dysphoria, duration of time on puberty suppression for those undertaking stage 1 treatment, co-existing mental health and medical issues and existing family support”

  • “While later commencement of hormone treatment during adolescence provides time for further emotional maturation and potentially lessens the risk that the adolescent will regret their decision, this should be carefully balanced by the biological, psychological and social costs to the adolescent of delaying treatment”.  “Biological implications of delaying hormones include ….relative osteopenia, and (for) trans females …linear growth…” “Psychological costs may include the negative contribution treatment delay may have on an adolescent’s sense of autonomy and agency, and may contribute to, or exacerbate, distress, anxiety or depression with subsequent increase in self-harm or suicide risk”. “Social costs of delayed treatment include peer group and relationship difficulties with pubertal development occurring significantly behind expected norms”

Surgical interventions

  • “Chest reconstructive surgery may be appropriate in the care of trans males during adolescence”.

  •  “delaying genital surgery until adulthood is advised”

Transition of care to adult care providers

“the young person’s GP is vital in facilitating a smooth process and many GPS continue as the primary doctor involved in hormone prescribing and monitoring of mental health after engaging in a shared care agreement during paediatric treatment”.

 

In Australian Standard of Care Part 2. (Below) we discuss:

  • Why this standard matters, 
  • Why it should be adopted in the UK NHS
  • A comparison between the Australian Standard and UK Service Specification
  • A comparative analysis of the evidence base underpinning the Australian and UK approaches 

 

Australian Standards of Care Part 2

Why the Australian Guidance Matters

(and why we need it in the UK)

  • Why this standard matters, 
  • Why it should be adopted in the UK NHS
  • A comparison between the Australian Standard and UK Service Specification
  • A comparative analysis of the evidence base underpinning the Australian and UK approaches 

The “Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents” provide clear, confident and unequivocal guidance on how to support transgender children. This is something we desperately need in the UK.

In order to understand the significance of this guidance for transgender children and families, we need to talk about fear, confusion and isolation.

At this time in the UK, fear is a constant companion to parents supporting transgender children. Fear of misinformed people reporting us to social services. Fear of ignorant social services grilling us on our parenting. Fear of transphobic judges withdrawing parental access in custody cases. Fear of being accused of child abuse. Fear of being judged. Fear of losing family and friends. Fear of being front page news. Fear of having the tabloids at our door. Fear of our lives being criticised and debated on day time television.

Confusion is common for parents trying to work out how to best support their children. The media is awash with transphobia and misinformation. Transphobic hate groups, often posing as concerned parents, ignore all medical consensus, peddle distorted arguments, debunked research and discredited statistics. UK parents of trans and gender diverse children are forced to themselves become lay experts – reading and analysing the research, appraising the validity of contested data and polarised arguments, trying to come to their own conclusion on what current evidence shows is the best way to support their child.

Isolation is a key feeling for vulnerable parents in the UK. Parents themselves are left to explain the existence of trans children and how best to support them to schools, GPs, hospitals, social services, family courts. Parents are left to try to educate (and defend themselves to) the media, their local community, and to the wider public.

In this swirling storm of fear, confusion and isolation, the UK Children’s Gender Identity Service is at best passive, at worst actively unhelpful. UK parents do not receive clear and coherent public backing, leaving them feeling fearful of their position. UK parents do not receive clear up to date evidence based guidance on how to best support transgender children, leaving families to muddle through the confusion by themselves (leaving some parents vulnerable to manipulation by anti-trans lobby groups). The UK Children’s Gender Identity Service does not consistently provide written guidance for schools or GPs on transgender children, leaving parents to advocate by themselves. The Service does not effectively advocate for transgender children with the media, failing to challenge media distortions, and failing to correct false and harmful misinformation.

The Australian Standards of Care provides a vital framework for reducing the fear, confusion and isolation felt by parents of transgender children and transgender young people themselves. They provide a confident, consistent and clear message on the existence of transgender children. They provide clear and assertive evidence based recommendations on how best to support transgender children (see Part 1 for further details). This confident, credible guidance makes a huge difference to fearful, confused, and isolated parents trying to decide how they should best support their child. Clear credible written guidance not only assists a family to support their child but also makes it more likely that the family will in turn receive the support of their GP, their school, their family, their community.

Having a supportive family has been shown to be absolutely critical to the well-being of transgender children. Reducing fear, confusion and isolation is essential to enable parents to be the supportive family that transgender children desperately need. The Australian Gender Service guidance is a significant step forward for transgender children and families and should be used as a template of best practice internationally.

The UK Children’s Gender Identity Service needs to step up and do better. Our children deserve better. The Australian Service are willing to share their guidance and share their experience with the UK. Are those supporting transgender children in the UK willing to listen?

Contrasting the Australian Guidance with the UK’s approach

Introduction

 

Australia

UK

Transgender children Focuses on “trans and gender diverse children and adolescents” UK does not use the clear term “trans children” (or gender diverse) preferring the convoluted phrase “young people presenting with difficulties with their gender identity”

 

Evidence based “recommendations are made based on available empirical evidence and clinician consensus” UK approach just emphasises uncertainty and lack of knowledge evidence or consensus avoiding making clear recommendations at all (even though “Go Slow” “Watchful Waiting” is obviously a vague not evidenced based recommendation).
Working with families guidance being developed “developed in consultation with professionals….from multiple disciplines, trans and gender diverse support organisations, as well as trans children and adolescents and their families”. UK service does not collaborate with key support organisations – does not consult or engage with trans children and families on their approach.
Prevalence Outlines that with “with increasing visibility and social acceptance of gender diversity in Australia, more children and adolescents are presenting ….requesting support, advice, and gender affirmative psychological and medical treatment”. UK outlines the total lack of any clarity why the rise in referrals, considers the suggestion that girl body image confidence could be a key cause, does not challenge harmful media rhetoric on trends or contagion
Rise in referrals Outlines that with “approximately 1.2% of adolescents identifying as trans” “it is likely that referrals. ….will continue to rise in the future”. UK emphasises the shocking, unexpected inexplicable rise.

 

‘Causes’ Says “being trans or gender diverse is now viewed as being part of the natural spectrum of human diversity”. UK website mentions autism, bereavement, trauma in discussion on reasons for gender identity ‘issues’. As a service they “look at all theories”. UK website reassures that gender diverse expression or interests are normal (no such reassurance that being transgender is normal)
‘Causes’ This Australian guidance was completed before the latest endocrine society official guidelines were released. These include the evidence based conclusion that “there is a durable biological underpinning to gender”. UK website on the other hand says “Current research hasn’t found much difference between ‘boys brains and girls brains – and many of the differences they have found may come from the experiences boys and girls have rather than their DNA or hormonal development”
Gender affirmative care “increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and wellbeing outcomes can be significantly improved”. UK does not endorse or even offer gender affirmative care, preferring the alternative ‘watchful waiting, also known as ‘delayed transition’ despite lack of evidence in favour of this, despite clear evidence in favour of affirmative care, despite affirmative care having been endorsed for children and adolescents in both the USA and now in Australia

General principles for supporting trans and gender diverse children and adolescents

 

Australia

UK

Decision making “Decision making should be driven by the child or adolescent wherever possible, this applies to options regarding not only medical interventions but also social transition”. UK not child driven. Regular UK service discussions questioning competence/ability to consent even of older adolescents.

 

Language “Use respectful and affirming language”. Too many examples of repeat misgendering in the UK system.
Avoiding harm “Avoid causing harm”. “withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications”

 

UK’s emphasis on ‘caution’ prioritises inaction over action, totally missing the significant evidence of potential harm of inaction.
Legal requirements “consider legal requirements” outlines legal requirements that are barriers to “obtaining identity documents (eg passport) that accurately reflects their gender”. Considers “implications for young people’s right to privacy and confidentiality when enrolling in school or applying for work”. UK system refuses to support passport gender marker change until adolescence as gender not clear until then. UK system does not advocate for the rights of trans children to privacy or confidentiality.

 

 

Supporting trans and gender diverse children

 

Australia

UK

Gender affirmative approach “Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach”. UK does not endorse a gender affirming approach, especially not for younger children
Transgender children Australia guidance take as given, the fact that transgender children do exist, and endorses a child-led approach. UK website shows a sceptical and undermining view: “children can go through various stages of ‘magical thinking’ during which they can get confused between reality versus fantasy, at least until middle childhood and sometimes this can make it hard to know how much a younger child fully grasps what they are saying or understands about their own gender.”.
Family support “for children, family support is associated with more optimal mental health outcomes”

 

UK does not provide families with any clear or consistent guidance on supporting their children, quite the opposite
Support for younger children “trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”. The UK does not provide this useful advice that happy settled transitioned children do not need extensive gender focused therapy. UK does not advocate for GPs or school to have a role in basic emotional support
Support for younger children with more complex situations “when a child’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, learning or behavioural difficulties …. a more intensive approach with input from a mental health professional will be required”. This entails an “exploration of the child’s developmental history, gender identity, emotional functioning, intellectual and educational functioning….”. UK does not clearly distinguish between simple cases and those complex cases where more engagement from specialists is needed, pathologising healthy children and wasting time and resources on appointments that are neither wanted nor needed.

 

 

Social Transition for younger children:

 

Australia

UK

Social transition “social transition should be led by the child and does not have to take an all or nothing approach”. UK emphasis that “young children are not usually considered able to make decisions on their own”. Families deterred from supporting social transition for younger children, families already having transitioned prior to entering the service face questioning, judgement.

 

Supporting school and nursery “provision of education about social transition to the child’s kindergarten or school is often necessary to support a child who is socially transitioning to help facilitate the transition and minimise …bullying or discrimination”. UK advises a period of ‘watchful waiting’ (ie delaying transition) according to leading specialist “until at least around 8 or 9”.  Support to nursery or infant school rare.

 

Social transition “social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers”. No such clear evidence based reassurance from UK
Risk of social transition “the number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”. UK regularly tells parents of socially transitioned children that their specific children will almost certainly end up identifying in their gender assigned at birth (quoting totally debunked desistance rates) and tell families that their children’s social transition will harm their child when they retransition (quoting as unreliable/debunked research (that only considered two children who hadn’t socially transitioned) as evidence).

Website says “However, quantitative and qualitative follow-up studies by Steensma et al (2011; 2013) present evidence to strongly suggest that early social transition does not necessarily equate to an adult transgender identity.  The qualitative study reports on two girls who had transitioned when they were in elementary school and struggled with the desire to return to their original gender role.  Fear of teasing and feeling ashamed resulted in a prolonged period of stress. One girl even struggled to go back to her previous gender role for two years. As such, in our approach, we would encourage exploration of gender roles in this younger cohort, with a view to keeping options open and not having any pre-conceived ideas as the longer term outcome. This could be summarised as a ‘watch, wait and see’ approach.

(NB the two girls in the Steensma paper had not changed pronoun and were not being called boys – therefore had not socially transitioned) so these two old cases or inconsequential in terms of advising on social transition.

Role for clinician with younger child Key roles for a clinician include:

i) Supportive exploration of gender identity over time

 

Lack of an affirmative approach leaves families and children feeling questioned and judged and feeling a need to defend their (or their child’s) gender identity. This non-supportive atmosphere does not enable exploration for those children who need to explore gender. Continual questioning is also deeply undermining, stigmatising and pathologising for children who are extremely clear on their identity, with potential consequences for their self-esteem. Parts of the service still show a regressive, stereotyped and binary approach.
Role for clinician with younger child ii) Work with family to ensure a supportive home environment No clear evidence based guidance to parents on how to support their child
Role for clinician with younger child iii) advocacy to ensure gender affirming support at school Extremely patchy. Some support to some schools, but as demand has risen the service has been unable to keep up leaving very many children and schools without 1-1 support. In absence of 1-1 support clear written guidance on best practices for schools would be useful. Some educational charities and schools have developed guidance, but UK service has not endorsed these and does not offer schools access to written guidance.
Role for clinician with younger child v) Education (to child and family) on gender identity and signposting to support organisations for child and for parents Education to families is extremely weak and outdated. Service continues to state outdated and somewhat transphobic views, and to quote outdated research on desistance. The UK service itself could benefit from more up to date training on gender identity in partnership with a wider range of transgender and gender diverse individuals. The service does not signpost to UK support organisations. It does not even mention Mermaids to parents (the main support organisation for UK parents with over 1000 members).
Role for clinician with younger child vi) If child is expressing desire to live in a role consistent with their gender identity, provision of psychosocial support and practical assistance to the child and family to facilitate social transition UK service do not actively facilitate early social transition, preferring to delay until the family have been in the system for several years. Majority of UK families are therefore not approaching UK system for support – managing their way through social transition on their own and approaching the UK system after social transition. The majority of younger children are now arriving at the system already socially transitioned. There is also a long (8 months+) wait to get into the system – during this waiting period (and during the initial 4 month assessment) the UK service will not engage with or advise the family on aspects of social transition
Role for clinician with younger child vii) referral to endocrinologist ideally prior to onset of puberty UK service extremely reluctant to refer promptly. See no need for prompt referral and do not take into account the harm and stress of dealing with a system that sees no reason for prompt referral. This puts pressure on families to advocate for their children to be referred promptly. The lack of prompt referrals puts extra pressure and stress onto families and creates a barrier between clinician and client. Families feel they have to fight to get a prompt referral. Children without supportive or proactive parents will not receive a referral to an endocrinologist prior to onset of puberty

 

Supporting trans and gender diverse adolescents

 

Australia

UK

Supporting adolescents “adolescents with insistent, persistent and consistent gender diverse expression, a supportive family, affirming educational environment and an absence of co-existing mental health difficulties, the adolescent and parents may benefit from an initial assessment followed by intermittent consultations with a mental health clinician” No acknowledgement that simpler cases do not require extensive mental health engagement.
Supporting parents “adolescents often encounter resistance from their parents when their trans or gender diverse identity is first disclosed during adolescence”. “For the clinician, investing time for parent support… will assist in creating a shared understanding….and enable optimisation of clinical outcomes and family functioning” Lack of clear guidance for parents of adolescents
Fertility counselling “Although puberty suppression medication is reversible and should not in itself affect long term fertility, it is very rare for an adolescent to want to cease this treatment to conduct fertility preserving interventions prior to commencing gender affirming hormones. It is therefore necessary for counselling to be conducted prior to commencement of puberty suppression or gender affirming hormones” Guidance unclear.
Cross-sex hormones “reduction in the duration of use of puberty suppression by earlier commencement of stage 2 treatment must be considered in adolescents with reduced bone density to minimise negative effects.” This is not considered. Arbitrary age based minimum of 15 years 10 months regardless.
Cross-sex hormones “The ideal time for commencement of stage 2 treatment in trans adolescents will depend on the individual seeking treatment and their unique circumstances” “adolescents vary in the age at which they become competent to make decisions that have complex risk-benefit ratios”. “The timing…will also depend on the nature of the history and presentation of the person’s gender dysphoria, duration of time on puberty suppression for those undertaking stage 1 treatment, co-existing mental health and medical issues and existing family support” Arbitrary age based minimum of 15 years 10 months, no consideration of individual circumstance. Also mandatory year on stage 1 treatment prior to stage 2, even for adolescents who have already gone through puberty.
Cross sex hormones “While later commencement of hormone treatment during adolescence provides time for further emotional maturation and potentially lessens the risk that the adolescent will regret their decision, this should be carefully balanced by the biological, psychological and social costs to the adolescent of delaying treatment”. No such consideration in the UK. Arbitrary 15 year 10 month age.
GP support “Role of the General Practitioner in the assessment and ongoing care of adolescents with gender dysphoria”. Page 21 of the guidance lists a number of areas where GP support is expected In the UK all support is channelled through the Children’s Gender Identity Service. This creates bottle-necks, long delays and the time, expense and missed schooling of adolescents (and children) regularly travelling London and a few other locations where specialist support is available. GPs regularly refuse to support trans children and adolescents, claiming simple and straightforward tasks are too complex to be handled at GP level.
Chest surgery “Chest reconstructive surgery may be appropriate in the care of trans males during adolescence”.
Transfer to adult services Transition of care to adult care providers:

“the young person’s GP is vital in facilitating a smooth process and many GPS continue as the primary doctor involved in hormone prescribing and monitoring of mental health after engaging in a shared care agreement during paediatric treatment”

 

GPs routinely refuse shared care. Adolescents are forced to engage with specialists services (in a very limited number of locations) for almost all support. Transfer to adult services is not smooth, with adolescents forced to join a waiting list between children’s and adults’ services.

 

Number range and relevancy of referenced evidence

It is interesting to contrast the reference section of the Australian Guidelines to the references (‘Summary of Evidence’) provided on the UK GIDS website.

No of references (%) 1960-2000 2001-2005 2005-2010 2011-2012 2013-2014 2015 2016 2017
Australia guidance 4 (3%) 0 (0%) 11 (7%) 8 (6%) 16 (12%) 7 (5%) 17 (12%) 11 (9%)
UK website summary of evidence 1 (5%) 0 (0%) 4 (20%) 3 (15%) 6 (30%) 5 (25%) 1 (5%) 0 (0%)
Findings The UK evidence base presented on the website focuses on a very small number of older studies, by a limited number of authors. The 6 most cited by UK GIDs are by two authors (Steensma and DeVries). In a field where, by the UK GID’s own acknowledgement, evidence is lacking and constantly developing, keeping up to date with recent evidence is absolutely critical. As new evidence emerges, it needs to be made available to parents and wider stakeholders.

 

The UK’s GIDS current protocols and policies are driven by the summary of the ‘evidence base’ reviewed in 2017 for the updated service specification.

It is important to note that the evidence base for the updated service specification was extensively and widely criticised as deeply flawed. See GIRES Response Part 1: service specification including evidence review , and GIRES Response Part 2: prescription of hormones. The method and process by which the evidence review was completed was also widely criticised and feedback from stakeholders was completely ignored. 

The NOTE TO Sir Nick Partridge OBE Chair of the Clinical Priorities Advisory Group (CPAG) NHS England Specialised Commissioning stated

The evidence review:

(a) was based on biased terms of reference,

(b) was undertaken by Deloitte, which apparently has no relevant scientific or clinical competence and

(c) disregarded or misquoted a substantial proportion of the available evidence”

When comparing the reference section of the Australian Guidelines to the referenced literature (‘Evidence Base’) that was reviewed in support of the 2017 update of the UK service specification it is interesting to see:

No of references (% of references) 1960-1980 1980-1999 2000-2004 2005-2010 2011-2012 2013-2014 2015 2016 2017
Australia guidance 1 (1%) 3 (4%) 0 (0%) 11 (15%) 8 (11%) 16 (22%) 7 (9%) 17 (23%) 11 (15%)
UK evidence base 4 (8%) 5 (10%) 3 (6%) 15 (30%) 8 (16%) 6 (12%) 7 (14%) 1 (2%) 0 (0%)
Findings   The Australian evidence base is predominantly material published since 2011 (59 out of 74 =80%). 38% is published since 2016.

The UK evidence base focuses on older studies. Only 44% of the studies included in the UK evidence review (and a smaller number, 22 instead of 51) are published since 2011. Only 1 study (2%) is published since 2016.

In a field where, by the UK GID’s own acknowledgement, evidence is lacking, keeping up to date with recent evidence is absolutely critical. As new evidence emerges, policies and protocols need to be updated to keep apace, as Australia has demonstrated with these new guidelines.

The UK references are also taken from a very small number of authors (who work very closely together and are joint authors on many of them. The following shows the portion of the evidence base part produced by just 4 authors (de Vries, Steensma, Cohen-Kettenis, Zucker).

No of references (%) 1960-1980 1980-1999 2000-2004 2005-2010 2011-2012 2013-2014 2015 2016 2017
Total in UK evidence base 4 5 3 15 8 6 7 1 0
No in UK evidence base from 4 authors 4 3 8 4 1 3 0 0
No in UK evidence base from other authors 4 1 0 7 4 5 4 1 0
Findings The UK evidence base also relies on a very small number of authors for evidence. Out of 45 sources listed since 1980, 23 (over 50%) were produced in part by just 4 authors. Of the remainder a number of sources are non-academic, meaning those 4 authors have an extremely significant influence over the UK recommendations.

The Australian evidence base considers a much wider range of authors, only 9 out of 74 references (12%) come from those 4 authors.

Over reliance on data and analysis from a very small number of authors, is excluding the evidence and research of a wider group of authors. In a field where, by the UK GID’s own acknowledgement, evidence is lacking, keeping up to date with recent evidence from a range of quality sources is critical. UK policies and protocols need to be updated to include all quality, peer reviewed, research findings.

 

An Open letter to MPs on the UK Gender Recognition Act

Dear MP,

As a parent of a transgender child I wanted to write to you ahead of the upcoming review of the Gender Recognition Act, to emphasise the importance of care and respect in any debate on this topic.

As you will be aware, the 2010 Equality Act already provides legal protection for girls like my daughter. My transgender daughter already uses girls’ changing rooms, girls’ bathrooms, attends school as a girl, attends the girls only Girl Guides, plays for her girls’ football team. She is accepted and seen by everyone in her life as a girl. She faces the same discrimination and sexism as other girls, in addition to the discrimination and hate she encounters for being transgender.

As a concerned parent of a transgender daughter, I want safety and protection for all women and girls (including for my daughter). Yet I am aware that there are a small group of people in the UK arguing that rights and respect for my daughter come at the expense of rights and respect for other women and girls. This is simply not true. This ‘protect women and girls’ argument has in the past been used to dismiss the rights of other minorities and is now being rolled out to argue against transgender rights.

Many of the arguments being put forward about the proposed changes to the Gender Recognition Act are not relevant to that Act, but are attacking rights already guaranteed by the 2010 Equality Act. Arguments bring up ‘monster’ scare stories about the new Act letting men invade women’s spaces, arguing that it is a threat to women’s and children’s safety. This ignores the reality that transgender women have always used women’s changing rooms in the UK (with no harm to anyone), and the 2010 Equality Act already guarantees their right to do so.

The current Gender Recognition Act already allows legal gender recognition without surgery or without imposing a stereotype of what a woman or a man should dress like.  A reformed Act would simply make it easier and more dignified for transgender adults to change their birth certificate – a change that has no bearing on ability to change passport, or change gender marker in systems including education, sport, or the NHS, areas where a Gender Recognition Certificate is not in any case needed. The proposed reform to the Gender Recognition Action would enable legal self-identification rather than the current humiliating, time-consuming, bureaucratic and expensive process.

Self-identification has already been adopted for 2 years in Ireland, with take up by only 240 individuals, with zero significant impact on non-transgender people. While my daughter is a minor the upcoming review of the act is relevant for her right now in two important ways.

Firstly, a streamlined and less pathologised approach to Gender Recognition sends out an important message to her that she lives in a country where the government respects her as a valued human being. Reform of this Act sends out an important message to an ill-informed public that my lovely daughter is not someone to be feared, is not a threat, is not mentally ill, is simply a girl who is a member of a very victimised and vulnerable minority who needs love, respect and acceptance.

Secondly, the upcoming debate about the Gender Recognition Act is of current relevance to my daughter because she notices and is affected by any discussion on transgender rights. Debates such as the reform of the GRA provide a platform for transphobic individuals in the UK to raise their powerful voices. For me as a mother, at this point in time, the outcome of the reform of the Gender Recognition Act is less important than the way in which the debate is conducted.

Transphobic groups are trying to set the tone for this debate. They are trying to feed an ill-informed general public and media with ignorant lies about transwomen and girls being a threat to other women and girls. They argue that improving rights for transgender girls like my daughter risks damaging the well-being of other women and girls. These messages are insidious and cause tremendous damage to my daughter’s safety, happiness and well-being. Please bear in mind that the girls who are most vulnerable in this whole debate are transgender children like my daughter, who just want to find space in this society to quietly live their lives.

Please do not give credence to arguments that suggest a gain in rights and respect for a tiny and very marginalised minority reduce rights for other women and girls.  I am a mother who cares deeply about the well-being of women and girls, and rights are not zero sum.  We all benefit from an inclusive and respectful society, a society in which my daughter, all women and girls and all transgender people can thrive.

As you are likely aware, there are no transgender members of parliament. I cannot imagine any other minority having their right to exist debated in parliament without representation.

If you would like to know more about transgender children like my daughter, you can also reach out to Mermaids, the UK’s leading support organisation for transgender children and their families. CEO@mermaidsuk.org.uk

Please also see the following useful resources:

On self-identification and a reformed GRA
https://nutlgbtexec.blogspot.co.uk/2017/08/statement-on-gender-recognition-act.html?m=1&fref=gc&dti=627122064058158

http://www.pinknews.co.uk/2017/07/26/what-will-actually-happen-if-the-uk-adopts-a-self-declaration-gender-recognition-law/?fref=gc&dti=627122064058158

On transgender children
http://assets.hrc.org/files/documents/SupportingCaringforTransChildren.pdf?fref=gc&dti=627122064058158

http://pediatrics.aappublications.org/content/early/2016/02/24/peds.2015-3223?fref=gc&dti=627122064058158

Warm regards,

Loving parent of a wonderful girl (who happens to be transgender)