The Erasure of Trans Children

transgender children erasure

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

This got me thinking of the erasure of trans children.

All too often trans children are completely erased from discussions.

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

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

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

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

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

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

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

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

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

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

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

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

 Submissions that referred to children more than twice:

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

These can be roughly divided into three categories:

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

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

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

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

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

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

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

 

Conclusion

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

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

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

Stop the erasure of trans children!

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

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

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

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

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

We must do better for trans children.

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

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

Trans children exist and they desperately need support.

Don’t leave them voiceless and invisible.

#SomeChildrenAreTrans #GetOverIt

Follow us on twitter @FierceMum and @DadTrans

 

Further info on the findings

Methodology

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

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

Limitations of the research findings:

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

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

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

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

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

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

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

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

Table: Organisations that refer once or twice to transgender children

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

 

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

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

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

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

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

 

 

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On Gender Stereotypes

Someone recently wrote in to this blog, saying, in essence, that they ‘would like to support trans children’s rights, but can’t get over a nagging fear that children who are simply non-conforming are being pushed into identifying as trans’. The writer remembers being a ‘tomboy’ who hated dresses, and fears that such traits in today’s society would lead to her ‘being pushed into being a trans boy’. She asks whether a ‘butch woman who identifies as a woman can still be a woman’.

This is the way that very many people who are ‘on the fence’ about supporting trans rights feel. It is not dissimilar to the way I myself once thought about trans people, back when I had never knowingly met a trans person, back before I knew my daughter, back when a lifetime of ignorant media portrayals had depicted trans people, almost always trans women, as clichés of femininity.

Anyone who finds themselves thinking this way, please take a minute to consider a few things.

First consider where are you getting your information from? Have you met trans people who you consider to be making their lives harder and facing enormous discrimination simply from ignorance that girls can climb trees and boys can like dolls? Or do you perhaps know very few or zero actual trans people, and you are basing your judgement on media portrayals? If the latter, consider whether such media tropes are written by, directed by and feature trans people, or whether they simply project non trans (cis) people’s interpretation.

Second, can you really scrutinise the first statement – that you would like to support a marginalised group’s rights, but only once you have been persuaded by them that they deserve your support. Only once you have been persuaded that they are not naively/stupidly enthralled to stereotypes.

Can you not hear how that sounds?

It is not dissimilar to someone saying ‘yes I’ll support Muslim rights, as soon as they persuade me they’re not all terrorists’, or ‘yes I’ll support the rights of people on benefits, as soon as they persuade me they’re not lazy’ or ‘yes I’ll support asylum seekers rights, as soon as they persuade me they’re not criminals’.

I’m all too aware that certain people on the far right in our society hold all of these prejudiced views.

There is a mainstream portion of our society who would never dream of stating or even thinking those statements. Who understand that these sentiments and generalisations are grounded in media misrepresentation, ignorance and hate. Who would not buy into media vitriol about other minorities, yet fall into the trap of believing that trans rights, and trans children’s rights, need to be earned, can be withheld, are in some way conditional upon those children (and their parents) proving that their specific trans child is not a stereotype, and is not in fact a non-conforming child ‘forced into a trans identity’.

The insinuation that trans children are just non-conforming children being led astray is pervasive, a scare story proactively spread by those who want to marginalise trans people.

This accusation is thrown at parents like myself daily:

Why couldn’t you just let your boy play with dolls? (…she doesn’t like dolls)

Why couldn’t you just let him do ballet and wear a princess dress (…she likes football and prefers witches)

Those accusing us of stereotypes are the ones seemingly obsessed with outdated notions of gender specific toys and interests.

They worry that parental narrow mindedness or ignorance leads us to presume a ‘tom boy’ must be a trans boy, that a feminine boy must be a trans girl.

Because of course us blinkered parents of trans kids are tied to stereotypes and couldn’t love a non-conforming child.

Because of course, in their mind, all trans girls love pink and dolls and sparkly tiaras, and all trans boys must be ‘tom girls’ who hate dolls and dresses.

Having met many score of trans children, this couldn’t be farther from the truth. Trans children, and trans people in general are those who are tearing down the gender boundaries.

Of course we told my daughter that she could be whatever type of boy she wanted to be. This was totally misunderstanding the point and made our child deeply sad.

It is true that media depictions of trans children often focus on gender stereotypes, with pink = girl.

Every time I see any depiction of trans kids on TV I count the seconds until the trans girl pulls out a doll or the trans boy kicks a football. But guess what. I know scores of trans girls who had zero interest in dolls or dresses. I know trans boys who collect dolls.

Trans children are no more stereotypical than any other children.

The same for trans adults of course. Some trans women are extremely glamorous and feminine (just like I know some cis women who are always in dresses and makeup). Some trans women wear jeans and t-shirts and rarely if ever use makeup – just like me and tons of cis women. Gender expression is not the same as gender identity.

If you are ‘on the fence’ about whether to stand up for trans children, please question where you are getting your assumptions about transgender children from. If it is coming from a transphobic and ignorant media, or if it is coming from anti-trans children political groups, consider if the information you receive is biased, loaded or spun. Would you accept rhetoric about Muslims from Britain First?

On Media Tropes of trans children

I’ve identified three key factors why the vast majority of media does not present a true picture of trans children:

  1. Media stereotyping
  2. Societal expectations
  3. Personal narratives (of children and families)

1. Gender stereotypes are pervasive in media coverage of trans children. There are many reasons for this:

Media stereotyping: TV shows regularly confuse gender identity with behaviour, toys or interests. Some media pieces seem to do this maliciously, to undermine the validity of trans children, to suggest to unaware viewers that non-conforming children are being made trans. In other media pieces the stereotyping may be unconscious. This is particularly the case when transgender people (directors, producers, narrators) are not involved. Many (but not all) trans adults and parents of trans children are acutely aware of the distinction between trans and gender non-conforming – and of the difference between gender expression and gender identity

Simple soundbites: Documentary producers often seek to tell a simple story, and select and edit soundbites to fit their narrative. This usually reinforces a ‘traditional’ and expected depiction wherein gender expression (eg clothing) and toy preferences (boys = trucks, girls = dolls) are highlighted as synonymous with gender identity. The public as a whole is still poorly informed – many people don’t know what the term gender identity means, many have never heard the term cisgender, or assigned gender, and some are unsure whether a trans girl is someone who was assigned male or female at birth. Documentaries need to ‘hold the hands’ of an ill-informed general public, taking small bite size steps into the world of gender identity. In this context, it is hard for a brief media piece to quickly convey complex and nuanced information on identity. It is much easier to revert to old clichés to help tell the story, looking for soundbites like ‘I adored dolls when I was little’ or ‘I was born in the wrong body’. I’m not denying that some trans people do say these things, and for some trans people this is their truth. But this is not the heart of the story for very many trans people, yet these same clichéd and simplified stories are the ones we see in the media time and again. Reporting on adult trans people seems to be moving towards more complex and nuanced stories about identity – not yet so for trans kids.

Simplified Visuals: Documentary makers like to use imagery to tell their story. A gender identity is not something that can be photographed or visually depicted. Trans kids, like all kids, will have items of clothing of a variety of colours. But it is the photo of a trans girl wearing pink that will make the documentary, that will be selected for the front cover. Trans girls, like most cis girls, will sometimes wear pink. Indeed it is hard to avoid pink in the girls section of most stores. Media images of trans girls almost always show them in pink – this does not mean trans girls wear pink any more often than cis girls. My trans daughter actively dislikes pink.

Participant selection: Some trans girls like football and trousers and climbing trees. Some trans girls like dolls and princesses and pink. Documentaries will give greater emphasis to the latter over the former (I hardly ever see the former shown, despite knowing plenty of trans girls who would rather climb a tree or play a computer game than dress as a princess). Many trans girls will like a wide range of toys, both dolls and cars and will gladly play with both. Which footage will make it into the documentary though? Of course, it will be the clichéd footage of the trans girl with the doll. This is very similar to the clichéd media portrayal of trans women always being introduced showing them putting on make-up. This is part of the truth for some people, but it is manipulative – emphasising stereotypical and clichéd aspects of lives that are rich, nuanced and complex.

2. Gender stereotyped expression may also be more prevalent in trans children, at some stages of their life due to external pressures

Medical gatekeeping: Adult gender identity services, for a very long time, insisted that trans women adhere to restrictive (and often outdated) gender stereotypes as a condition of acceptance for treatment. Trans women who might out of preference dress in a less stereotypically feminine manner were forced to conform to outdated stereotypes in terms of dress and hair style, or be denied support. This type of regressive gatekeeping is still experienced in children’s services, with reports of trans teenagers being told they need to ‘dress in a more stereotypically feminine manner’ or ‘need to sit in a more masculine posture’, or wear certain clothes, or style their hair in certain ways.

Securing support from other children: Trans kids want to gain the support of their peers. Adhering to a very stereotypical gender presentation is a way of signalling their gender identity to other children. When my child was trying to persuade her peers to address her as a girl she took to wearing sparkly hair clips as a visual queue of her identity. One day in the car en route to a party she lost her hair clips. She descended into uncontrollable sobs. When questioned she explained:

‘If I don’t have hair clips in, they will call me a boy’.

Since being accepted as a girl by all her peers, she soon stopped wearing hair clips. It was never about the hair-clip – it was about wanting to be seen by others and respected as a girl.

Asserting identity to parents: Trans kids desperately want to show their parents their identity. Clothing is an obvious route to asserting identity. When we were calling her a boy, my child refused to wear trousers (from a very young age). A very rigid and strident insistence on wearing dresses is for many trans girls a way to communicate their identity to their parents. Gender non-conforming boys like to wear dresses because they like the dress, maybe it sparkles, maybe it has a fun pony on it, maybe it is brighter than the dull colours in the boys section. But for transgender children, clothing is a means to an end, a useful way of trying to communicate and assert their identity. How do you know if it is a gender non-conforming boy or a trans girl? Listen to what the child is saying. Are they focused on liking dresses? Gender non-conforming child. Are they consistently, persistently and insistently saying ‘I am a girl’ and getting deeply upset and depressed when called a boy? That was our daughter. Once our daughter was accepted by us as a girl, her clothing choices gradually shifted to what is now a fairly neutral presentation for a girl – sometimes wearing dresses but most of the time preferring leggings or jeans.

3. Narratives of the child and their parents

Some parents of trans children like stereotypes and some parents like simple narratives that help explain their situation to a sceptical world: Parents of trans kids come from all walks of life. This is not an ideology that only parents with a certain world view sign up to. Trans kids appear in all kinds of families. These families are as varied as wider society, and the families of trans kids will mirror the views and prejudices of wider society.

Some parents of trans kids have very stereotyped and gendered expectations for their children. These parents, when recalling the childhoods of their transgender children, will remember and highlight examples of non-gender conforming behaviour. Such families may well say ‘It made sense that she was a trans girl, as she always liked dolls’. This does not mean that playing with dolls made the parent conclude their child was transgender, rather it meant that once she accepted her child as a girl, she recalled and emphasised examples of non-conforming behaviour that help her understand and accept her child.

Other parents do not have gendered or stereotyped views of children. These parents do not see any clear and simple correlation or causation between the clothes or toys that our children preferred, and their gender identity. Such parents present a more complex and less ‘packageable’ narrative. Such parents do not produce the short media friendly soundbites that documentaries rely on. This more complex parental narrative almost never appears in media depictions of trans children – instead media prefers the parents who say “my child loved dolls so I knew she was a girl”.

Some children need a simple answer: Our daughter has always known she is a girl. Like many children asked to explain her gender identity she cannot do so easily and simply. She quickly got tired of being asked “but why do you think you are a girl?” Gender identity is hard to explain, and adults would struggle to find an answer beyond ‘I just do’. When children assert an identity different to what was expected there is undoubtedly societal pressure to justify how they feel in some way. It would not be surprising to me for children to gravitate to emphasising examples of their own non-conforming behaviour or interests as extra justification for who they are. Especially when this is the depiction of trans children they see in the media. Especially when even the diagnostic criteria used by children’s gender identity services (in the UK and elsewhere) requires stereotypical ‘cross gender interests, behaviour, play preferences’ as credentials for being considered transgender (Gender Identity alone is not sufficient, children are expected to conform to stereotypes of behaviour, clothing or play preferences in order to be deemed gender dysphoric).

There is a popular children’s book written by a transgender girl called “I am Jazz” that seems to equate her liking ‘girls activities’ with being a trans girl. When I first read it with my trans daughter she noticed this and said “that’s silly, of course boys or girls can both like dancing/pink/ballet”. My trans daughter has a more nuanced understanding of the difference between identity and interests. And she shares my dislike of gender stereotyping.

It is possible to criticise some books and programmes about trans children as reinforcing stereotypes without jumping to a rejection of transgender children.

It is possible to dislike gender stereotypes and still want trans children to have happy and safe lives.

It is possible to want the best for gender non-conforming children and still want trans children to be treated with respect, dignity and acceptance.

Those of you on the fence about trans rights can carry on weighing up whether my daughter has proved her ‘not a stereotype’ credentials enough to be shown kindness, respect and acceptance.

I meanwhile will carry on raising a kind, confident, happy child.

I will carry on helping all my children to see beyond the stereotypes, limitations and restrictions society places on girls and boys (and non-binary people).

And I will teach them the importance of tolerance, kindness, and respect, especially for those who we don’t understand, especially for those who are different.

 

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

 

TransGender_Symbol_Color

The perception that trans children are ‘too young’ to know their gender identity is used as a basis for denying them a suite of rights, and has long been a corner stone of arguments against social transition or timely provision of puberty blockers.

Cisgender (not trans) children are generally considered to know if they are a boy or a girl by a young age. But, not so for transgender or gender questioning children, according to the latest paper written by experts from the UK Children’s Gender Service, including the head of service Carmichael.

Costa, R. Carmichael, P.; Colizzi, M. (2016) To treat or not to treat: puberty suppression in childhood-onset gender dysphoria Nature Reviews Urology 13, 456–462 (2016)

UK Children’s Gender Service experts’ view of Gender Constancy

The Costa (2016) paper has a section on gender identity development. It states that “research has shown that around the age of 3 years, children show a basic sense of self as male or female, owing to their inner experience of belonging to one gender”.

It goes on to note:

“Some research suggests that a developmental lag exists in gender constancy acquisition in children with gender variant behaviour” (reference number 16).

According to the paper “achieving gender constancy represents a cognitive-developmental milestone in gender identity development and is due to the understanding that being male or female is a biological characteristic that cannot be changed by altering superficial attributes, such as hairstyle or clothing”

The belief in trans children having a ‘developmental lag’ in gender constancy leads to this statement “treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults

The belief in trans children having ‘a developmental lag” in gender constancy feeds directly into the Tavistock’s treatment protocols, such as proposing puberty suppression only be prescribed to those aged at least 12 “safely above the gender constancy achievement”.

Only one reference is provided for the claim that transgender children achieve ‘gender constancy’ later than cisgender children, reference 16, which is the source of this key statement:

“Some research suggests that a developmental lag exists in gender constancy acquisition in children with gender variant behaviour (reference 16)

If this single reference underpins the Tavistock’s belief that trans children do not understand their gender at the same age as cisgender children, and if this claim has direct implications on the Tavistock’s approach to treating trans children, then it is vital we review this paper.

The paper in question is:

Zucker, K. J. et al.(1999) Gender constancy judgments in children with gender identity disorder: evidence for a developmental lag. Arch. Sex. Behav. 28, 475–502 (1999).

 

Zucker (1999) 

Gender constancy in the Zucker paper is defined as “the understanding that ‘superficial’ or surface transformations in gender behaviour such as activity preferences or clothing style” do not change a person’s gender. The paper concludes that children referred to a Gender Clinic for ‘problems in identity development‘ have a ‘developmental lag in gender constancy‘. This conclusion merits further scrutiny.

Zucker et al.’s study focuses on a group of children who were referred to the Toronto Gender Clinic between 1978 and 1995.

The majority of the Gender Clinic children in this study were assigned males (207/236 = 88%). There were a small number of assigned females in the sample (12%). In order to simplify this blog post I have decided to focus the examples throughout on assigned males (noting that this editorial simplification perpetuates historical erasure of trans boys / assigned females).

The children registered at the Gender Clinic I will hereafter refer to as the ‘clinical sample’, to contrast with the study’s ‘control sample’ (a sample of children of the same age who were not registered at the gender clinic and were not known to have any gender issues).

It is known (and acknowledged in Zucker’s paper) that some of the clinical sample of assigned males were non-conforming boys rather than trans girls. How many were gender non-conforming (GNC) rather than trans is unknown as historical diagnoses focused on behaviour and interests more than on identity and Zucker did not believe in distinguishing between young gender non-conforming boys and trans girls.

The children in the clinical sample, together with a control group (aged 4-8 – average age 6 and a half) were put through three different types of test, which they either ‘passed’ or ‘failed’.

Zucker 1999, the tests

We will now look at the three tests, and see whether they do provide convincing evidence that transgender children (or children treated in the gender service) have a ‘developmental lag’, and understand their gender identity later than cisgender children.

Zucker 1999: Test 1: Slabey & Frey test

Test 1 Part A focused on Gender Discrimination 

The children were shown dolls and photographs depicting a boy, girl, man, woman and asked to identify them. The children ‘passed’ if they got at least 12 out of 16 ‘correct’. 93% of the clinical sample ‘passed’ this test, compared to 98% of the control group.

Test 1 Part B:  Gender Identity

The children were asked their own gender. The assigned-male-at-birth (amab) children ‘passed’ the test if they answered ‘boy’.

93% of the clinical sample ‘passed’ this test compared to 98% of the control group.

(The very high ‘pass’ rate for the clinical sample at first glance seems high as transgender children like my daughter would certainly ‘fail’ this test.

Perhaps the high ‘pass’ rate may add weight to suggestions that a large proportion of children referred to the Toronto gender clinic in the 1970s, 1980s and early 1990s were there for gender non-conformity (proto-gay cure….) rather than children with a gender identity different to their assigned sex.

The fact that a trans girl was considered to have ‘failed’ in her understanding of gender identity if she said she was a girl is an indication of the bias of the researchers.

Test 1 Part C: Gender Stability

The children were asked if their gender can change over time, for example if they were a different gender when they were born to their current gender. The children ‘passed’ if they said gender can never change over time.

80% of the clinical group ‘passed’ compared to 92% of the control group

Test 1 Part D: Gender Consistency

The amab children were asked questions like ‘if you wear a dress, are you a girl?’ ‘If you played with a doll would you be a girl?’. (the exact script, and the exact phrasing, is not provided so we cannot be sure exactly how the questions were worded)

66% of the clinical sample ‘failed’ this test, by stating that playing with dolls makes you a girl.

46% of the control group also ‘failed’, also thinking that playing with a doll made you a girl.

The fact that nearly half the control also think playing with a doll makes you a girl seems more an indication of the segregated and gendered restrictions on toys of Canadian children in the 70s, 80s and early 90s than any conclusion about gender identity. Given very few of the clinical group identified as trans in this study, it also brought to mind the limited freedom for boys to be feminine or play with perceived girls toys, and made me wonder how many assigned males had been told to ‘stop being a girl’ when playing with dolls or putting on a dress.

Zucker 1999 Test 1 – Conclusion

The data from test 1 parts A-D, and the fact that the clinical sample had a slightly lower ‘pass’ rate than the control sample, was interpreted by Zucker et al. as evidence that children at the gender clinic were more ‘confused’ about gender.

The researchers then take a further leap of faith, into a conclusion that the lower pass rate of the clinical group compared to the control group implied a ‘developmental lag’ in understanding of gender. However, the clinical sample and the control sample were the same age (ages 4-8, average age 6.5), and the clinical sample were not re-tested at a later point in time. How therefore can they claim a developmental lag? It is simply not possible to claim a ‘developmental lag’ based on this data. The assertion of a ‘developmental lag’ (with the implication that the clinical sample reach a similar level of understanding but at a later age than children not referred to a gender clinic) is pure speculation/fabrication.

Test 1 provides zero evidence that transgender children (those with a consistent, insistent, persistent identity different to their assigned sex) have a delayed understanding of gender.

Zucker 1999: Test 2 Boy-Girl Identity Test

The assigned male children were then shown a drawing of a boy. They were asked to give the child in the drawing a name. If they chose a girl’s name for the drawing they were corrected and given a boy’s name, eg ‘this is Tom’.

Zucker 1999 Test 2 Part 1:

The children were asked ‘If Tom really wants to be a girl, can he be a girl?’.

The children ‘fail’ this test if they say yes Tom can be a girl.

32% of the clinical sample ‘fail’ this task by stating Tom can be a girl vs 21% of the control group

(Interestingly there is not a huge difference between the clinical group and the control group, with 21% of the control group, children with no gender issues, thinking that yes, Tom can be a girl – Canadian 5 year olds from the 1970s, 1980s and early 1990s showing more sophisticated understanding of gender than their specialists…)

The children are asked to give a reason for their answer, and are defined as having reached ‘operational constancy’ if they justify their answer ‘No Tom can’t be a girl’ answer with the justification ‘because he was born a boy’.

This unethical line of questioning Zucker et al put trans children through is a form of coercive persuasion, tantamount to brainwashing, where the ‘wrong answer’ is corrected with the ‘right answer’ – ‘BECAUSE TOM WAS BORN A BOY’ until the child submits and agrees.

Zucker 1999 Test 2 Part 2:

A dress and or long hair is added to the picture of ‘Tom’ and the children are asked ‘If Tom puts on a dress, is he a girl?’ The expected ‘correct’ answer is ‘No’ and the expected justification is ‘because he was born a boy’.

71% of the clinical group ‘fail’ this test, as do 64% of the control group.

Again the control group is pretty similar to the clinical group in their openness to the possibility of Tom being a girl.

Zucker 1999 Test 2 Conclusion

Zucker 1999 Test 2 provides no evidence of a ‘developmental lag’ in understanding gender for trans children.

Zucker 1999 – Test 3 looks at ‘sex-typed behaviour’

Zucker 1999 Test 3 Part 1 asks children to draw a person, and then asks them if the person they have drawn is a boy or a girl.

The assigned male at birth children ‘pass’ if they opt to draw a boy and ‘fail’ if they opt to draw a girl.

66% of the clinical sample ‘fail’ by drawing a girl (in case of the assigned males). 54% of the control sample also ‘fail’ this test by drawing a girl (in case of the presumed cis boys).

Again the results of the control are fairly similar to the clinical group.

Again there is no evidence of trans children having a developmental lag in understanding gender.

Zucker 1999 Task 3 Part 2 has the children watched through a 1-way mirror in a room with ‘gender specific’ toys and or clothes and the researchers assess the amount of time the children spend with ‘appropriately gendered toys or clothes’. They are deemed to have ‘failed’ if they play too much with the ‘wrong’ gender toys or clothes.

This task has no place in today’s society in which children are not constrained by outdated gender stereotypes.

Zucker 1999 Task 3 Part 3 assesses what it calls ‘affected confusion’, assessing a child’s ‘desire’ to be a boy or a girl (rather than their identity). It asks assigned males (who have been referred to a gender clinic for non-conforming behaviour) questions like ‘is it better to be a boy or a girl’ and ‘do you ever wish you were a girl’. Assigned males are deemed ‘deviant’ if they state any wish to be a girl (perhaps because they are a trans girl or perhaps because they are a non-conforming boy who wants to be able to play with his dolls in peace without being taken to Dr Zucker every month/week…). Assigned males are also deemed ‘deviant’ if they acknowledge anything positive about girls or think that there are any ways in which it is better to be a girl than a boy.

64% of the clinical group are labelled ‘deviant’ due to their answers in this part, as are 50% of the control group (reminder the control group are ‘random’ children not being seen by the gender clinic and who are not known to have any gender issues and yet half are deemed by this test to be ‘deviant’).

Zucker 1999 Test 3 Conclusion

What on earth is going on, and how the heck is this research still being quoted in a 2016 journal article by the leading experts at the UK’s Children’s Gender Service!

The high ‘failure’ and ‘deviancy’ rate’ not only in the clinical group but also in the control group is perhaps indication that Canadian 5 years olds in the 70s, 80s and early 90s were did not have such ingrained stereotypes of gender, nor sexism, nor misogyny, as the ‘gender specialists’ who subjected them to such awful tests.

The Zucker 1999 article ends with a ‘blame the parents’ conclusion, proposing that parents of gender non-conforming boys or trans girls must have ‘actively’ encouraged ‘cross-dressing’ or appeared to ‘tolerate’ cross-gender behaviour. It highlights a view that “parental reinforcement of same-sex play was positively related to gender constancy in pre-schoolers”. It is pure ‘drop-the-barbie’ Zucker, more focused on installing out-dated gender conformity in non-conforming boys than any concern for how to help children who may be transgender.

Zucker 1999 in summary

To summarise, the Zucker 1999 research is deeply outdated, transphobic, stereotyped, homophobic, normative and unethical.

The clinical sample is known to contain at least some children who are non-conforming rather than trans and no effort is made to focus specifically on trans children.

The difference in answers between the clinical group and the control group are very small (the paper conducts regression analysis on a wide number of variables until it finds some that are considered statistically significant – this is an unsound approach to valid statistical analysis).

The study looks at a range of things that do not relate to gender identity (including toy preferences).

And most critical of all – the paper looks at the children at one moment in time – comparing the clinical group to a control group of children the same age (age range 4-8). There is no follow up at a later age and no comparison of children of different ages. Any claim to transgender children having a developmental lag (which I interpret to mean achieving a similar understanding of gender at a later age) is pure fabrication.

Given the obvious weaknesses of the the Zucker paper – why is it a core reference in the 2016 Costa paper from leading experts of the UK Children’s Gender Service

UK Children’s Gender Service

There are three major problems with the Tavistock’s view of gender constancy as shown in the Costa 2016 paper.

Problem 1 – Quoting fabricated conclusions as though evidence

The Costa 2016 paper states “Some research suggests that a developmental lag exists in gender constancy acquisition in children with gender variant behaviour”, referencing the Zucker 1999 paper.

As we’ve seen above, the Zucker 1999 research does not provide any evidence for this claim.

Problem 2 – Broadening the relevance of those unsound conclusions and applying them to clinical practice

The Zucker paper mentions a ‘developmental lag’, but does not mention any age at which transgender children reach ‘gender constancy’.

The Costa 2016 paper moves beyond even the conclusions claimed in Zucker 1999, taking a series of assumptions to extrapolate wider conclusions (for which no specific reference is provided). They move from the idea of ‘a developmental lag in gender constancy’ to the claim that “children with gender dysphoria are more likely to express an unstable pattern of gender variance”. They move from that unsupported statement to the claim that “treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults”. And they shift further to arrive at the final statement that puberty suppression is unwise until at least age 12 “safely beyond the age of gender constancy”. It is important to recall that Zucker 1999 provides no information on the age at which trans children ‘achieve gender constancy’ and focuses on children aged 4-8 (where the Costa paper get the age 12 figure from for gender constancy is anyone’s guess).

The Zucker 1999 research bears no relevance to the question of whether trans children understand their gender. Yet Costa et al 2016 use this study as their basis to suggest that transgender children do not know their gender. They use it to support an argument that transgender children have ‘unstable gender variance’ up until puberty, and they extend this to argue against pubertal suppression for those starting puberty under the age of 12.

Problem 3 – Omitting reference to critical recent research

The third, and perhaps the biggest error, is one of omission. The Costa 2016 paper, in its section on gender identity development / gender constancy in transgender children, only mentions the Zucker research, omitting mentioning any other research on transgender children’s gender identity.

The Zucker 1999 research paper is now 19 years old. Surely in the last two decades there has been some other research on the gender identity of transgender children, ideally research that makes an effort to focus on transgender (rather than gender non-conforming) children, and research that focuses on the children’s gender identity rather than toy preference? The answer is a clear yes. There are important studies on this topic that the Costa 2016 paper fails to even mention.

So let’s take a brief review of recent research on this topic which are noticeable by their absence:

New research on transgender children’s gender identity

Olson 2015

Olson, K.; Key, A.; Eaton, N. (2015) Gender Cognition in Transgender Children Psychological Science OnlineFirst, published on March 5, 2015

The introduction to the Olson el al 2015 paper describes historical (and current) scepticism to the idea of transgender children knowing their gender:

“This scepticism takes many forms: concerns that these children are “confused” and that they therefore need therapy, that these children are “delay[ed]” in their understanding of gender in part because of the behaviour of their parents (Zucker et al., 1999: Gender constancy judgments in children with gender identity disorder: evidence for a developmental lag), or that these children are merely saying they are the “opposite” gender, much as they might say on any given day that they are a dinosaur or princess.”

Olson et al.’s research aimed:

“to investigate whether 5- to 12-year-old prepubescent transgender children (N = 32), who were presenting themselves according to their gender identity in everyday life, showed patterns of gender cognition more consistent with their expressed gender or their natal sex, or instead appeared to be confused about their gender identity.”

Results:

“When the transgender children’s responses were considered in light of their natal sex, their responses differed significantly from those of the two control groups on all measures. In contrast, when transgender children’s responses were evaluated in terms of their expressed gender, their response patterns did not differ significantly from those of the two control groups on any measure.”

Conclusion:

“Using implicit and explicit measures, we found that transgender children showed a clear pattern: They viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender (nontransgender) control groups. These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.

Our findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.

The data reported here should serve as evidence that transgender children do indeed exist and that their identity is a deeply held one.”

 See here for background and further details

Fast 2017

Fast, A & Olson, K. (2017) Gender Development in Transgender Preschool Children, Child Development

Abstract:

“An increasing number of transgender children—those who express a gender identity that is “opposite” their natal sex—are socially transitioning, or presenting as their gender identity in everyday life. This study asks whether these children differ from gender-typical peers on basic gender development tasks. Three- to 5-year-old socially transitioned transgender children (= 36) did not differ from controls matched on age and expressed gender (= 36), or siblings of transgender and gender nonconforming children (= 24) on gender preference, behavior, and belief measures. However, transgender children were less likely than both control groups to believe that their gender at birth matches their current gender, whereas both transgender children and siblings were less likely than controls to believe that other people’s gender is stable.”

 

Summary

So what do we know about gender constancy/ gender identity in transgender children?

We know that some claims are balderdash (junk science):

  •  The Zucker 1999 study holds no value in informing us about the gender identity development or constancy of transgender children.
  • The statement “a developmental lag exists in gender constancy acquisition in children with gender variant behaviour” is unsubstantiated and shouldn’t be quoted in future articles
  • Conclusions in the Costa (2016) report onchildren with gender dysphoria are more likely to express an unstable pattern of gender variance” and “treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults” are unsubstantiated and should be disregarded
  • Policy recommendations in the Costa (2016) report on withholding pubertal suppression until “at least the age of 12, safely beyond the age of gender constancy” are unsubstantiated and should be disregarded

 

We know that recent research (Olson 2015 and Fast 2017) shows that:

  • “Transgender children do indeed exist and their identity is a deeply held one.”
  • “Three- to 5-year-old socially transitioned transgender children did not differ from controls or siblings on gender preference, behaviour, and belief measures.”
  • “Transgender children aged 5-12 viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender control groups.”
  • “These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.”
  • Research “findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.”

Trans power

Young brunette woman promoting marriage equality.

We were pleased to be recognised on Metro’s trans power list (@DadTrans)

Trans Power List: Top Activists and Influencers

But with the greatest love and respect to all the wonderful advocates on that list (and to the far greater number of amazing advocates who were not on that list) that has got to be the Worst Power list ever!

Where are the trans MPs?

Where are the trans judges?

Trans newspaper editors?

Trans media barons?

Trans billionaires?

The fact that a UK trans power list includes cis parents who blog and tweet anonymously is a great indication of where the power currently lies.

Unless we just haven’t yet been initiated into the ‘all powerful trans lobby’……

(hint hint can we join the secret lobby already?)

Happiness can wait

yellow toy

Since 6-year-old Jazz Jennings appeared in a 2007 US documentary, the social transition of young transgender children has rarely been out of the media. With increasing awareness accompanied by increasing evidence of the mental health benefits of acceptance and affirmation, more parents across the world are supporting their transgender child to socially transition.

A social transition is defined by the American Academy of Pediatrics thus:

“COMMON STEPS IN SOCIAL TRANSITION

For children of any age, gender transition means allowing the child to choose how they express their gender. Children may:

  • Wear clothing that affirms their gender, such as skirts for transgender girls
  • Adopt a hairstyle that affirms their gender, such as a short haircut for transgender boys
  • Choose a name that affirms their gender
  • Ask others to call them by pronouns (such as “he” or “she” or “they”) that affirm their gender
  • Use bathrooms and other facilities that match their gender identity”

Social transition is completely reversible if the child determines it’s not right for them.”

Some ‘experts’ in Europe, in opposition to experts in North America and Australia, caution against social transition. A example of a European ‘expert’ cautioning against social transition is a 2017 Swedish publication on transgender children by Louise Frisen et al:

The Frisen article has some positive sections, but it does also include some outdated statements that I am weary of reading in journal articles:

“Follow-up studies show that no more than about 20 percent of pre-puberty children who meet diagnosis criteria for sex dysphoria will have a residual desire for gender confirmation [6-8].”

And I was shocked to see this recommendation:

“Restraint for the younger with early social transition

Since no more than about 20 percent of prepubertal children who meet gender diagnosis criteria will have a residual desire for gender confirmation [6-8], the recommendation for the younger children is restraint regarding early social transition (living as the perceived gender). It is important to discuss the social consequences and to be aware that the majority of the younger children will not have a remaining desire for gender confirmation.”

The recommendation against social transition, and the two statements quoted above rely on just three sources:

  1. Drummond KD, Bradley SJ, Peterson-Badali M, et al. A follow-up study of girls with gender identity disorder.Dev Psychol. 2008: 44 (1): 34-45
  2. Steensma TD, Biemond R, de Boer F, et al. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011: 16 (4): 499-516
  3. Wallien MSC, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008: 47 (12): 1413-23.

The above reference 6 (Drummond) and reference 8 (Wallien) are two discredited studies on desistance that have been widely criticised see here

Reference 7 (Steensma) is a study with totally unreliable conclusions, as discussed here:

The Swedish paper contains no acknowledgement that the data it quotes on the number of transgender children continuing to be transgender as adults are highly contested and could be completely wrong as discussed here

I am so tired of seeing these same unreliable (unscientific, unethical, unsound, shambolic) studies trotted out time and again in journal articles.

Parents of transgender children do not normally have the time, the access to the referenced literature (in inaccessible / expensive academic journals) or the capacity to fact check the advice they are given. And they should not have to. This is literally the job of the supposed experts writing papers like this latest Swedish one. The reliance on discredited studies and conclusions is deeply worrying.

And the advice against social transition can cause serious harm.

he Swedish study advising against social transition is worrying, not only due to the inclusion of unreliable/discredited research in their paper as discussed above, but also due to the exclusion of critical information that Swedish parents (and those caring for Swedish transgender children) have a right to know such as research demonstrating the benefits of social transition, and the positions of world leading experts from the American Academy of Pediatrics and ANZPATH, both of whom endorse social transition.

The Swedish paper does not mention the latest research study from Olson in the United States showing that socially transitioned and supported children have higher levels of mental well being than children who are living as their natal sex:

“Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.”

The Swedish paper fails to mention the guidance from the American Academy of Pediatrics that social transition is positive:

“In many cases, the remedy for dysphoria is gender transition: taking steps to affirm the gender that feels comfortable and authentic to the child. It is important to understand that, for children who have not reached puberty, gender transition involves no medical interventions at all: it consists of social changes like name, pronoun and gender expression.

While acceptance and affirmation at home can help a great deal, children do not grow up in a vacuum, so even children with supportive families may experience dysphoria. Nonetheless, families and doctors of transgender children often report that the gender transition process is transformative — even life-saving. Often, parents and clinicians describe remarkable improvements in the child’s psychological well-being.

The American Academy of Pediatrics describes social transition as “transformative – even life saving”. They continue:

A child’s gender transition is almost always a positive event. Often, the child’s debilitating gender dysphoria symptoms lift, diminishing difficult behavior that came with them. Dr. Ehrensaft calls this the ex post facto (“after the fact”) test: a dramatic reduction in stress, and blossoming happiness for the child and family, indicate that social transition has been the right choice. Along with joy at this renewed well-being, families are often thrilled to find that gender transition removes the emphasis on gender in a child’s life. With their gender identity no longer in conflict, the child can focus on the important work of learning and growing alongside their peers. Many children feel relief, even euphoria, that the adults in their life have listened and understood them.

This describes exactly our experience. Over night our daughter went from incredibly sad and distressed to a happy, carefree child. She went from wanting to talk about gender every single night to completely losing interest in the topic once the world was set to rights as we had accepted her as a girl.

The American Academy of Pediatrics are also very clear why those who, like the Swedish experts, advocate for delayed transition for all children, are wrong:

 Delayed Transition: Prolonging Dysphoria

“delayed transition prohibits gender transition until a child reaches adolescence or even older, regardless of their gender dysphoria symptoms.

There is evidence that both reparative therapy and delayed transition can have serious negative consequences for children”

Many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition.”

Delayed-transition advocates treat unnecessary or mistaken gender transition as the worst-case scenario, rather than balancing this risk with the consequences of the delay.

Untreated gender dysphoria can drive depression, anxiety, social problems, school failure, self-harm and even suicide.

There is no evidence that another transition later on, either back to the original gender or to another gender altogether, would be harmful for a socially transitioned child — especially if the child had support in continuing to explore their gender identity.

While delaying a child’s gender exploration can cause serious harm, a deliberate approach is wise. Some children need more time to figure out their gender identity, and some do best by trying out changes more slowly. For these children, rushing into transition could be as harmful as putting it off. The problem with “delayed transition” is that it limits transition based on a child’s age rather than considering important signs of readiness, particularly the child’s wishes and experiences. A gender-affirmative approach uses this broader range of factors, with particular attention to avoiding stigma and shame.”

For children with mild gender dysphoria, the family and therapist’s affirmation of their gender expansive traits often relieves their distress. For this group, it appears that gender dysphoria — and even a moderate desire to change gender — can result from trouble reconciling their masculinity or femininity with being a girl or boy. Adolescents affirmed in their gender-expansive traits are happier and healthier, whether or not they grow up to identify as transgender.

Other children have an insistent, consistent and persistent transgender identity; they thrive only when living fully in a different gender than the one matching the sex assigned at birth. In differentiating these children from the gender-expansive children described above, clinicians use two general rules: They focus on a child’s statements about their sex and gender identity, not their gender expression (masculinity or femininity), and they look for “insistent, consistent and persistent” assertions about that identity. Clinicians help these children and their families socially affirm the child’s gender identity.

The latest ANZPATH (Australian Professional Association for Transgender Health) provides similar clear, evidence based guidance for those supporting transgender children:

“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.

Social transition should be led by the child and does not have to take an all or nothing approach.

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”.

Acceptance = love. Rejection = shame

Remember, social transition is a fully reversible change involving a change of pronoun, perhaps accompanied by a change of hair style, clothing, name. Nothing medical at all.

At its heart, a social transition is a clear message to a child that they are OK, that they are accepted, that they are not wrong or broken, that they are loved.

The Swedish study takes the view that there is a paucity of evidence, therefore children should not be supported to socially transition.

I agree that there is a paucity of rigorous long-term scientific studies on the outcomes for children who from an early age are supported and accepted.

What does exist is a whole heap of anecdotal evidence of the huge benefit of social transition. I personally know of over a hundred families for whom social transition has been transformational for their child’s happiness. Experts in Australia and America have found the same.

I have met scores of families whose only regret is that they did not embrace and support their child earlier. This includes our child. She was miserable every day – in acute distress. Since social transition she is one of the happiest children you can find. Loving school. Loving her friends. Having a wonderful childhood. Time and again from parents all over the world I hear the exact same story. A story that I hadn’t even heard before I lived it with my child.

From these very many happy socially transitioned children, I know of 2 cases where after a few years of social transition, the child has said to their parent, I want to try living as my assigned gender. In these small number of cases, a second social transition occurred that was no more difficult than the first social transition. At all stages a child needs to feel loved and accepted, that their family are listening to and respecting them. I know of a few more children who have grown into embracing a more nuanced or complex non-binary identity as they have got older (perhaps as they grow more aware of the existence of space between two binaries). Again – no known harm to those children whose understanding of their identity expands over time – as long as they are loved, cared for and accepted.

What is very well evidenced is the great harm that is caused when children are rejected, forced to live a lie, told that who they are is wrong or disturbed or shameful or unacceptable. The message trans girls learn quickly when their parents refuse to call them a girl.

Parents of transgender children know all too well that there is not enough useful research out there. We know that we have been deeply let down by past decades of research on transgender children that is not useful. Let down through the transphobia, homophobia, cis-het-normativity and or sheer incompetence of past researchers who failed to distinguish between trans and gender non-conforming children, and failed to explore which options would lead to the best outcomes for transgender children – including of course the option to affirm, love and accept them.

Much transphobic research continues in this vein. A few researchers, like Kristina Olson from the Trans Youth Project at the University of Washington, are now tracking the outcomes of socially transitioned, affirmed, supported children.

The initial results are very promising, with a number of recent research studies documenting evidence that trans children do know who they are, even young children, and that the outcomes for trans children who are loved and accepted as their identified gender are positive.

 

But proper science takes time.

These longitudinal studies will be of enormous help to the next generation of transgender children – those children who are not yet born. But my child cannot wait.

In the meantime, loving parents of transgender children have to make the best possible decisions based on the limited evidence that we have now.

As stated in the American Academy of Pediatrics Guide: Supporting Transgender Children (that I recommend reading in full):

“Not treating people is not a neutral act. It will do harm”

And in the guidance from ANZPATH Treatment Guidelines for Trans and Gender Diverse Children (summarised here):

“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”

The suggestion that ‘do nothing’ is even an option for parents of insistent, consistent, persistent transgender children is a mis-characterisation of life with a distressed child. As I describe in an earlier blog post

People say: “The best course of action would be for parents not to make any decisions at all”

This shows little understanding of what it is like to parent a transgender child.

Life is full of decisions.

Before making the extremely difficult and heart-breaking decision to support my child, for months I made the decision to say ‘I love you, but no, you are not a girl you are a boy’ and watched their sad face.

For months later, when they said ‘I am a girl’ I decided to change the subject or look away.

For months further I avoided directly calling them a boy but decided to sit in silence as others called them a boy and I watched their shoulders hunch in and the sad look of rejection on their face.

For months further I sat with them at bedtime as they cried and listened to them say ‘but I am a girl’ and I decided not to say ‘that is OK, we love you whatever’.

Life with a very insistent transgender child is full of difficult and painful and troubling decisions for a parent who cares deeply for their child.

Making a decision finally to say ‘that’s OK, we love you whatever’ was the latest in a very long line of decisions.

Which eventually moved on to ‘OK, we’ll call you a girl’, and ‘OK, we’ll help others to call you a girl’ and ‘OK, we’ll help others to understand you are a girl’.

We do not wake up one morning and think, wouldn’t it be fun to choose this incredibly hard and traumatic path for our children.

The above are my words from a couple of years ago. My perspective and understanding has shifted a great deal over the past few years and I no longer see being transgender as a negative or scary thing (though I dearly wish my child would not have to face a transphobic world or deal with prejudice and hate). But at the time I was ignorant and very afraid.

Parents do not consider supporting their child to socially transition on a whim. Take a look at the first 5 mins of this video in this link and see the experience of one American family.

Parents working up the courage to support their transgender child already have to overcome their own transphobia and ignorance (the vast majority of the cis parents I know knew nothing at all about trans children before our own child).

Parents working up the courage to support their transgender child already face extreme hostility from wider society. We already face social isolation and losing friends and family. It is not easy, even when a parent knows in their heart it is what their child needs.

Parents in this situation need ‘experts’ who understand what is at stake, who present all the facts and all recent research including the evidence in favour of social transition. We need experts who are willing to offer support and guidance to  families and children for whom extended delay, extended rejection, extended denial of identity is cruelty to our transgender child.

To force children to live as their assigned gender, when doing so is causing them deep distress; to tell them to ‘wait until we have long term data’, when we know anecdotally how many children benefit from social transition, when we know zero evidence of harm, is gross negligence.

The ‘experts’ telling families to ‘wait until we have long term data on the outcomes for those socially transitioned children who we know are currently happy and thriving’ are telling parents to keep their child in a state of deep distress for no good reason. These ‘experts’ like this Swedish author have presumably not spent night after night holding a deeply distressed miserable child. They presumably have not watched their child shrink and lose all enjoyment of life. They also can’t have spent much time around children like mine who absolutely shine with happiness now that they have socially transitioned.

On one level, supporting a child to socially transition seems like the biggest, scariest, most inconceivable step in the world. And, at the time, for a family surrounded by a sceptical and transphobic community, it is.

But, on another level, it is just a change of pronoun. It is the smallest change in the world, and the biggest bargain out there. For this small change I got my happy child back. For this small change my child found love and acceptance instead of rejection and shame. For this small change my child got a carefree childhood full of games and play and friends and fun.

Yet “Just wait” they say.

Reminds me of this tweet from @charllandsberg:

It also brings to mind this quote from the inspirational Sarah McBride:

“When we ask people to wait patiently for their rights, we ask them watch their one life pass by without the dignity they deserve”

These children, children like my daughter, only get one childhood.

They can spend it happy, supported, loved and accepted –

or miserable, rejected, shamed.

We need to stop letting transgender children down.

Childhood is now.

Happiness cannot wait

 

 

Gender Recognition for Under 16s – Consultation on the Scottish Gender Recognition Act

scot flag

Scotland is currently holding a consultation on reforming their Gender Recognition Act. This proposes options to simplify the process for transgender people in Scotland to obtain full legal gender recognition (acquiring a Gender Recognition Certificate and amending their birth certificate).

This consultation seeks views on reforming the 2004 Act. The Scottish Government proposes to streamline the process for obtaining legal recognition and also to allow people aged 16 and over to apply. We are also seeking views about the options for people under 16 and for recognition of non-binary people.

We are inviting responses to this consultation by 5pm on 1 March 2018. 1.07. Please respond to this consultation using the Scottish Government’s consultation platform, Citizen Space. You can view and respond to this consultation online at: https://consult.scotland.gov.uk/family-law/reviewof-the-gender-recognition-act-2004.

Key information:

The consultation provides key information on the Gender Recognition Act. It is critical to note however that even without a Gender Recognition Certificate, transgender people are legally protected under the 2010 Equality Act and have rights to change identity markers in systems including schools, the NHS and their passports, and have the right to use facilities matching gender identity. The Gender Recognition Act is however the only route to updating a birth certificate.

“GRC” – a gender recognition certificate. Under the 2004 Act, a full GRC provides legal recognition of an applicant’s acquired gender. When a GRC is issued under the 2004 Act, the applicant’s legal sex also changes to male or female. ”

“The 2004 Act allows transgender people aged 18 and over to apply for legal recognition of their acquired gender and to change their legal sex accordingly”

The consultation considers two main models for gender recognition, the current system of an assessment model (where a doctor, psychologist and or court ‘evidences’ a person’s gender identity) or a self-declaration model (as already applied in Norway, Denmark, Malta, Colombia, Argentina, and the Republic of Ireland).

For an example of how this is working in practice, this article provides a useful overview of how a self-declaration based process is already in action in the Republic of Ireland.

I won’t focus here on the proposed options for how the gender recognition system will operate, but will instead give attention to eligibility based on age – namely whether trans youth and trans children are permitted to get a Gender Recognition Certificate and change their birth certificate.

Under 18s.

At present in Scotland, as elsewhere in the UK, trans youth and trans children under 18 are not eligible for a Gender Recognition Certificate, meaning under 18s cannot update their birth certificate. Trans children and youth are however given legal protections under the 2010 Equality Act, and already have the right to change their gender marker in almost all other documentation, without the need for a Gender Recognition Certificate (including a right to change their gender marker in their passport, and in systems including schools and the NHS) (*as with adults options for identity recognition for trans youth/children with non-binary identities are extremely limited).

The consultation questions:

 The survey starts with 4 questions for how GRC should work for adults including:

Question 1 The Scottish Government proposes to bring forward legislation to introduce a self-declaratory system for legal gender recognition instead. Do you agree or disagree with this proposal?

16-17 year olds.

The consultation proceeds to focus on 16-17 year olds:

“The Scottish Government considers that people aged 16 or older should be able to apply for legal recognition of their acquired gender using the proposed self-declaration process.

4.05. There is clear evidence that people aged 16 do live full time in their acquired gender and want this to be legally recognised. For example, the Women and Equalities Select Committee heard evidence from LGBT Youth Scotland to this effect. In the Republic of Ireland, 8 people aged 16 and 17 have received a GRC31 after obtaining a court order permitting them to apply under their self-declaration system. The court in the Republic of Ireland is required to consider evidence about the young person’s transition to their acquired gender. ”

Question 5 The Scottish Government proposes that people aged 16 and 17 should be able to apply for and obtain legal recognition of their acquired gender. Do you agree or disagree?

It is curious that the report notes the “clear evidence that people aged 16 do live full time in their acquired gender and want this to be legally recognised” and yet in subsequent sections does not similarly note the existence of transgender children under the age of 16. Parents of transgender children, and other groups supporting transgender young people were perhaps overlooked in the preparatory consultations? This oversight makes it especially important that parents and supporters of transgender children and young people provide feedback during this consultation that transgender children do indeed exist, and those under the age of 16 both want and need full legal recognition. Inputs from any under transgender young people themselves might also be an important addition to this consultation.

Under 16s

The consultation moves on to consider under 16s:

“4.08. The Scottish Government’s view is that there is a careful balance to be struck in relation to people under 16. On the one hand, we should treat children with dignity and respect, giving weight to their views and wishes in line with their individual capacity. On the other hand, we should ensure that children have the right protection and care. 4.09. People who are under 16 years of age can act on their own behalf in relation to a range of matters. Annex E contains further information about this. The CRWIA at Annex M refers to research evidence about children who identify as transgender. 4.10. The Scottish Government considers that there are five broad options in relation to people under 16 being able to apply for legal gender recognition.”

The consultation proceeds to outline 5 potential options for transgender children under the age of 16. I’ve quoted these here in full, following which I’ve outlined my thoughts on each option:

Under 16s – option 1 – nothing for those under 16 

4.11. Under this option, applicants would have to be at least 16 to apply for legal recognition of their acquired gender. This would be straightforward, but would stop those under 16 with a clear view of their gender identity from obtaining legal gender recognition.

Under 16s – option 2 – court process 

4.12. Option 2 would be for Scotland to adopt a court based process.

4.14. Any court based process, whether instigated by a child’s parents or by the child themself, would focus on the assessment of the child’s welfare. We would also consider specifying the matters the court would have to have regard to in determining what was in the child’s best interests. 4.15. Under this option, a court action could be raised by the child if they had sufficient capacity to do so, or if they did not, by a person or persons who had PRRs (parental responsibilities and rights) for them acting on their behalf.

4.19. Malta has a court based process of legal gender recognition for those under 18. Those with parental authority for a child may file an application in the court. The court must consider the best interests of the child and give due weight to the views of the child depending on their age and maturity

4.20. In the Republic of Ireland, applications cannot be made by those aged under 16. However, applications by 16 and 17 year olds require to be accompanied by a court order permitting the application to be made. The court may only grant the order if the child’s parents, surviving parent or guardian consents. Two medical certificates must also be produced to the court. The medical certificates must confirm that: · the child has a sufficient degree of maturity to decide to apply for gender recognition; · the child is aware of, has considered and fully understands, the consequences of that decision; · the child’s decision is freely and independently made; and · the child has transitioned, or is transitioning to, their preferred gender.

4.21. Under option 2, a child who may not have reached puberty might apply to the court or a person with PRRs for such a child might apply.

Under 16s – option 3 – parental application

4.22. Option 3 would be to permit an application to be made on behalf of a person under 16 by someone with PRRs (parental responsibilities and rights) for them. Typically, this would be the child’s parents. Further information about PRRs, when parents get them and who else may have PRRs is in Annex F. 4.23. Usually, where more than one person has parental rights in relation to a child, each can exercise their rights without the consent of the other or any of the others.36 4.24. Where a person with PRRs is reaching a major decision regarding the fulfilling or exercise of PRRs, the person is under a duty to have regard to any views the child expresses, taking account of the child’s age and maturity. The person making the decision must also have regard to any views expressed by any other person with PRRs for the child concerned.37 The Scottish Government considers that seeking legal recognition in an acquired gender is an example of a major decision. 4.25. One possibility under this option would be to require the application to be made by all parents with PRRs for a child. This would mean that a person who had PRRs for the child but was not their parent would not require to be involved. However, we would still expect the person(s) applying on the child’s behalf to have regard to the views of such a person. 4.26. Another possibility under this option would be to require all people with PRRs to apply, not just a parent or parents with PRRs. This may mean that a local authority that had PRRs for a child would need to be involved in the application process. 4.27. If all the people who required to be involved in the application did not agree38, then a court order could be sought under existing arrangements. Section 11(1) of the Children (Scotland) Act 1995 allows the Sheriff Court or the Court of Session to make an order in relation to PRRs. The court could then make a decision based on the child’s welfare. 4.28. There are some children for whom no one has PRRs. One option might be for a person who has an interest to obtain PRRs from the court and then apply for legal gender recognition on behalf of the child.

4.30. In summary, therefore, under this option all parents with PRRs (or, perhaps, everybody with PRRs) would have to apply, having had regard to the child’s views. If there is a dispute amongst those with PRRs, an application could be made to the court to resolve the matter. There may be restrictions on the role of a person with limited PRRs. 4.31. Under this option, applications could be made on behalf of very young children, including both those who lack legal capacity and who have not reached puberty.

Under 16s – option 4 – minimum age of 12

4.32. Option 4 would permit children aged 12 and above to apply in the same way as those aged 16 or above

4.34. However, this option would take no account of a child’s capacity to take decisions nor their physical maturity.

4.36. The Scottish Government does not favour this option as it would allow a child to apply irrespective of their capacity to understand the nature and consequences of their decision.

Under 16s – option 5 – application by capable child

4.37. Option 5 would permit a person under 16 to apply in the same manner as an adult, provided they had capacity to understand the consequences of recognition in their acquired gender.

4.38. Under this option, someone would have to test the child’s capacity. This could potentially be done, for example, by a registered medical practitioner, or by a practising solicitor.

4.40. A person under 16 has legal capacity to instruct a solicitor, in connection with any civil matter, where the person has a general understanding of what it means to do so. Someone aged 12 or more is presumed to be old and mature enough to have such understanding.

The section ends with question number 6, which asks consultation respondents to state which of the 5 potential options for transgender children under 16 they most favour.

Question 6 

Which of the identified options for children under 16 do you most favour? Please select only one answer.

 

option 1 – nothing for those under 16

option 2 – court process

option 3 – parental application

option 4 – minimum age of 12

option 5 – application by capable child

My response to the consultation

My initial thoughts to the above is as follows:

Option 1 –  nothing for under 16s, is unacceptable. Many of our trans children are living as their identified gender from primary school, including changing their gender marker in other systems including on their passport. Why then should they have to wait until 16 to have who they are fully recognised in law? When they have been living for years with a passport and other markers in their gender identity, why should their birth certificate be out of sync? Inability to update birth certificate adds to stress for trans children that their identity will be unwillingly disclosed and presents to them the reality that the state does not fully respect them until adulthood. Trans children exist, and waiting until 16 or 18 for proper legal recognition is denial of basic rights for these young citizens.

Denying rights to under 16s is at odds with the recent WPATH (World Professional Association for Transgender Health) statement on identity:

“WPATH advocates that appropriate gender recognition should be available to transgender youth, including those who are under the age of majority,”

Option 2 – court process seems like an expensive, bureaucratic, stressful and unneccessary requirement. I would like to learn more from Ireland, who has a similar requirement for 16-17 year olds which is currently under review.  Australia, which has just got rid of a requirement for trans youth to go to court for hormone treatment, provides a useful case study of this process.

CASE STUDY: Australian experience of a court based process

Australia until very recently required under 16s to go to court to gain approval for gender related medical care. Families and transgender children in Australia found the process of going to court stressful and upsetting. When one family were told that the requirement to go to court was being removed, one family reportedlywere unable to contain their tears of relief” with their child commenting “No longer will young transgender young people have to keep justifying who they were“.

World leading specialist in supporting transgender children, Dr Telfer, Director of the Gender Service at the Royal Children’s Hospital in Melbourne described the amount of time gender specialists were having to devote to guiding families through the court proceedings:

“Gender Clinic staff have had to spend considerable time on counselling families on what the court process would be like, Dr Telfer said.

“No-one wants to be in a courtroom. Usually it’s a place where you go when something is wrong.

The requirement for transgender youth to go to court was described as “costly, traumatic and unnecessary”.

The director of legal advocacy at the Human Rights Law Centre, Anna Brown, described the decision to stop forcing transgender children in Australia to go to court as a “stunning victory” for young transgender people.

“This will make a profound difference to the lives of many young trans people who will now be relieved of the burden of a costly and unnecessary court process”

“This bizarre legal anomaly was born of outdated attitudes to trans young people”

“Importantly, also, for the young people themselves, going to court can be hugely taxing,”

“This decision is a huge victory for so many young people and their families. The latest research shows that there are probably around 45,000 trans and gender-diverse young people in Australia, and this will save them enormous amounts of money, time and heartache.”

Australia has made the decision to move away from requiring transgender children to go to court. Why then would Scotland wish to impose this on Scottish trans children? Based upon the Australian experience, the Option 2 court process, is not the right decision for our children.

Option 3 – parental application seems instinctively a sensible option. With parental approval children like my daughter could get their identities fully legally recognised. This would however limit options for youth who do not have parental support, and such youth would either need to wait until 16 or would need to have recourse to an alternative option eg to the court option. I wonder whether there are many youth without any parental support for whom gaining a GRC pre 16 would be a major priority? I’d welcome feedback from trans youth or organisations working with trans youth.

Option 4 – minimum age of 12 is largely ruled out by the Scottish consultation, and I would agree that basing declaration on age, rather than capacity for decision-making, would be unworkable.

Option 5 – application by capable child is attractive in theory but I question how it would work in practice. It would require an administration layer including professional gate keepers, requiring our children to submit to an assessment, and I wonder who would be willing to test a child’s capacity for this purpose. This might result in a very small number of medicalised gate-keepers and subject to waiting lists, delays and arbitrary protocols. There’s also a very serious question about how to ensure such professional are able to assess a child’s capacity in a sensitive and appropriate manner – those of us with trans children are well aware of the level of transphobia and ignorance about trans children so common across the UK.

Seeking another opinion

I decided to reach out to the Scottish Trans Alliance who provided their view on the options for under 16s

Scottish Trans Alliance:

“We’re currently in favour of Option 3 – the ‘parental application‘ option – where under 16s would be allowed to change gender on birth certificate on submission of a simple statutory declaration with signed parental consent. This would mirror how name changes on official documents are already done for under 16s.

We think that if a young trans person under 16 has unsupportive parents then the most urgent problems they will be facing are likely to be whether they are safe from transphobic emotional abuse at home and whether they are able to wear clothes they want and use the verbal pronouns they want. We think that it is rare that a child under 16 with unsupportive parents will be in a confident and safe enough position to risk trying to change their birth certificate against the wishes of their parents.

We think that nearly all under 16s who have been able to successfully start living fully in their gender identity (and therefore are at the point where it would make sense to change their birth certificate to improve their privacy) will have at least one supportive parent. However, it is important that there is a way of ensuring that an unsupportive parent is not able to block the wishes of the young person and their supportive parent. If a court process is needed to resolve a family dispute about whether a young person should be granted a GRC, then we think the court ought to be obliged to uphold the wishes of the young person provided they have capacity to understand the consequences of legal gender recognition.

While Option 5 – the ‘application by capable child’ option – sounds on the surface like a more empowering option than parental application, we have concerns that it may lead to problematic gatekeeping by doctors/solicitors who could be scared to approve the capacity of individual trans young people. It could result in say a 13 year old with supportive parents having to try to prove their capacity to a trans-ignorant doctor only to be told they are too young to understand the consequences and that they have to wait as their parent can’t give consent on their behalf. That could be a very stressful and disempowering experience.

Not allowing under 16s to change the gender on their birth certificate leaves them at risk of schools not taking their gender identity and right to privacy of their gender history seriously. Under 16s usually don’t have bank accounts or many letters sent to them so proving their identity without showing a birth certificate is harder for under 16s than for trans adults. This means trans people under 16 are at greater risk than adults of privacy violation, and transphobic harassment as a result, due to their birth certificate outing them as trans. The intensity of media hostility and resulting negative social attitudes towards trans youth and their families makes privacy rights particularly essential.

Changing birth certificate would have no impact on ability to access hormone blockers but could make a life enhancing difference to moving to a new school without being outed.

It’s worth noting that parents of trans young people under 16 can already change their child’s gender on their passport and medical records so it makes sense to bring birth certificates into alignment with these other official documents.”

Preferred option

Having reviewed the proposed options, and consulted with other stakeholders, the best option for under 16s seems to be Option 3 – parental application.

 

Flawed research evidence underpinning the consultation

Before concluding, I would also like to share my views on the annexes to the consultation which contain some worryingly flawed ‘evidence’ that if accepted as presented could seriously undermine trans children’s rights.

The Scottish consultation document presents ‘research evidence’ on transgender children in annex M part 4.

ANNEX M: PARTIAL CHILD RIGHTS AND WELLBEING IMPACT ASSESSMENT

  1. What research evidence is available?

4.1 There is evidence that children can experience incongruence between their assigned gender and their gender identity early in life. One study indicates the average age was 8.

4.2 There is a limited evidence base about whether children will continue to experience these feelings in the longer term. Follow-up studies indicate overall that for 85.2% of the children, their distress discontinued either before or early in puberty. 8 However, the rates in the individual studies varied widely. For instance, a 2008 study indicated that in 39% of children the feelings did continue beyond the onset of puberty9 whereas older studies from before 2000 had very much lower rates for children continuing to experience distress after the onset of puberty. It is thought that pre-2000 studies have included children who would not now be considered to be experiencing gender dysphoria. The studies may also be affected by the small clinical population of children with gender dysphoria – studies looking at whether gender dysphoric feelings persisted had a total population of 317 people.

Part 4.2 in particular misrepresents the current body of evidence and is danger of undermining the Scottish consultation through establishing a prejudicial approach to children gaining legal recognition.

It refers to two deeply flawed studies:

  1. Ristori, J and Steensma T.D “Gender dysphoria in childhood” in International Review of Psychiatry, Gender dysphoria and gender incongruence, Vol 28, 2016 Issue 1.
  2.  Wallien and Cohen-Kettenis “Psychosexual outcome of gender-dysphoric children” Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423

We have previously addressed and demonstrated the lack of credibility of these exact studies here.

Conversely, new evidence, that has not been presented in the consultation Annex, suggests a very significantly higher rate of transgender children continuing to identify as transgender as adults and has been reviewed by us here.

4.3 There is also evidence that the more extreme a child’s gender dysphoria was before puberty, the less likely it was that their feelings will recede with the onset of puberty. For those who have reached puberty and continue to experience distress, evidence indicates that their distress then tends to intensify and that depression or self-harming behaviours are also more common in ages 12 and over. It is understood that physical changes caused by puberty may intensify the levels of distress experienced.

4.4 Available evidence suggests that factors arising around the ages of 10 to 13 may help explain changes in how a child feels about their gender: · the changes in social roles between boys and girls as their gender role become more distinct; · the anticipation or experience of physical changes as a result of puberty; and · their first experience of experiencing falling in love and discovering their sexual identity.

4.5. Evidence indicates that there is a difference of experience between boys and girls. 13 Although more boys are referred to gender identity clinics, some studies suggest that gender dysphoria is more prominent in girls.

Part 4.4 relies on one specific flawed study that absolutely does not evidence the claim presented here.

Steensma T.D et al (2011) “Desisting and persisting gender dysphoria after childhood; A qualitative follow up study” Clinical Child Psychology and Psychiatry Vol16 issue 4”

There is no evidence in this single referenced study that a transgender child changes identity between the ages of 10 and 13 as misrepresented here. This is grossly misleading and risks undermining support for trans children in Scotland gaining legal recognition. We have previously discussed the flaws of this specific paper in some detail here.

4.6 There is evidence that transgender young people are more than twice as likely as non-trans people to be diagnosed with depression (50.6% compared to 20.6%14) and with anxiety (26.7% compared to 10%). There is evidence that this most likely arises due to their experience of discrimination, lack of acceptance, and the abuse they may face and is not an inherent feature of their being transgender. 15 There is also evidence that transition to living in their preferred gender and being supported with gender confirming medical interventions may help improve mental health, in many cases reaching levels experienced in the general population.

It is clear that discrimination and lack of acceptance is damaging to trans youth. The government has a responsibility to tackle this, including through enabling trans children like my daughter to gain full legal recognition. Not allowing full legal recognition to children also sends out a damaging signal to those children and to wider society that transgender children are not worthy of respect or rights.

4.7 Scottish Government officials met members of LGBT Youth Scotland groups aged 13 and over. Their view was that legal gender recognition must be made available to people younger than 16. A person should be able to transition and live in their acquired gender before they have to take their qualifications or go to university. They felt that this would better support their rights not to be discriminated against, for example, at school. A high proportion expressed the desire for their parents (or other people with responsibility for them) to be involved and supporting them through the recognition process.

4.8 LGBT Youth Scotland gave evidence to the Women and Equality Select Committee inquiry into Transgender Equality which setting out the views of transgender people aged under 1817 about the benefits of legal gender recognition in terms of reducing discrimination and improving their mental health.

There is a concerted effort in the UK, as elsewhere, to deny transgender people basic human rights. This campaign is particularly targeting transgender children, the most vulnerable of transgender people, and those with the least power and voice. It is critical that this consultation focuses on listening to transgender children and to those families who support them. Trans children are a small and very marginalised group, and their voices must not get lost in the wider consultation. It is not acceptable to tell transgender children that they have to wait until they are adults before they can be recognised in law.

Appendix A TRANSGENDER CHILDREN – EVIDENCE OF NUMBERS EXPERIENCING GENDER DYSPHORIA OR DISCOMFORT WITH THEIR ASSIGNED GENDER

Appendix A presents a confused view of the difference between transgender children, and children who are gender non-conforming. It alarmingly includes reference to studies from the discredited Zucker, and makes multiple references to “opposite sex behaviour”. It is worrying that a public consultation on gender recognition should have included such a muddled understanding.

Conclusion

Transgender children are one of the most marginalised, voiceless and powerless groups in society. I encourage all who care for transgender children to complete this consultation, and for question 6 I recommend selecting Option C – parental application.

Additionally, in the accompanying comments box for the consultation it would be useful to mention some basic facts:

a) transgender children exist

b) transgender children have legal rights and need legal recognition

c) transgender children face enough challenges, discrimination and hostility already – legal recognition should not be an additional burden for them

The consultation documents mention the “clear evidence that people aged 16 do live full time in their acquired gender and want this to be legally recognised” and yet are silent on  on the existence of transgender children or their desire and need for full legal recognition under the age of 16 year.

This right, if enabled, would not be pursued by every transgender child. Parents would not take this option on a whim. This option would be most appropriate for transgender children who have already been living in their identified gender for many years, who likely already have all other identity documents including their passport updated to their identified gender. To deny these children full legal recognition until 16 is a gross betrayal of their rights.

Yet transgender children are one of the least powerful and most marginalised groups in our society. We know that transphobic groups are actively campaigning against the provision of rights to transgender children. The needs and the voices of transgender children may not be heard in this consultation.

It is vital that families of transgender children feed in to this consultation, including those outside of Scotland, making it clear that transgender children do indeed exist and do deserve full legal recognition. Inputs from transgender adults and allies who care for transgender children will also be critical, as supportive families of transgender children are already overwhelmed with the barriers we have to overcome to enable our children to get the rights and the protections that other children take for granted.

Input from any transgender children and young people who are willing to share their thoughts and words would be especially valuable, perhaps explaining what an updated birth certificate would mean to them, or how they feel about being denied the right to full legal recognition.

The consultation can be completed here. It closes on March 1st 2018

The end of the ‘desistance’ myth?

australia 4

 

Read on for new (as yet unpublished) ‘desistance’ statistics from Australia (Spoiler: it may be as low as 4% ‘desistance’).

The 85% ‘desistance’ myth

Anyone with even a cursory awareness of issues relating to transgender children will have heard the 85% ‘desistance’ myth. Some old and flawed research studies, that lumped together large numbers of gender non-conforming cisgender children with transgender children, claimed astonishingly high levels of supposed ‘desistance’, ie children who held a cisgender (not transgender) identity after puberty. These studies are flawed in many ways, including in their analysis, where they assumed that children who could not be contacted or declined to be interviewed were all so called ‘desisters’. These statistics often relied upon older data from the 1970s and 1980s, a period in which societal acceptance for transgender people in the West was a long way behind where it is today. The 85% ‘desistance’ myth has been widely criticised:

See here from Zac Ford;

See here from our own ‘growinguptransgender’ blog;

See here from Brynn Tannehill;

See here and here from Kelley Winters;

See here from Julia Serano;

See here from Kristina Olsen and Lily Durwood;

Nevertheless, it is difficult to get rid of an old statistic, no matter how discredited, when there is not a better one available. Hence many of us have been eagerly awaiting new figures from the United States, where longitudinal research on a cohort of transgender children is currently underway.

The myth that will not desist

Despite the clear evidence and analysis that the research studies underpinning the 85% ‘desistance’ statistic are deeply flawed and unreliable, academic paper after academic paper on transgender issues continues to repeat this old discredited 85% figure. It is easier to present the mistakes of the past than to engage in this topic, especially where the research is not specifically focused upon gender dysphoria in children, and where the author is required to discuss persistence only as part of a wider survey of the literature. However discredited the 85% ‘desistance’ figure is, it keeps getting published as there is not (until now), a better ‘desistance’ statistic to put in its place.

Endocrine society continues the myth

The 2017 Endocrine Society guidelines still refer to the 85% figure, though they do at least note that  non-conforming children may be included in those older studies and acknowledge that persistence rates may well be different in future studies.

“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.”

The above paragraph is disappointing from the Endocrine Society. If a statistic is known to be useless then it is better to have no statistic at all than a wrong one.

In the words of Brynn Tannehill:

“the 84 percent desistance figure is meaningless, since both the numerator and denominator are unknown, because you have no idea how many of the kids ended up transitioning (numerator), and no idea how many of them were actually gender dysphoric to begin with (denominator).

Scottish Gender Recognition Act (GRA) Consultation

The newly released Scottish Gender Recognition Act consultation has taken an even more disappointing approach than the Endocrine Society – they do not make it clear that the 85% ‘desistance’ rate is widely discredited and they combine it with other statements about gender changes at around puberty that are based on fundamentally flawed research (see below).

In the section 4 “What research evidence is available” the Scottish GRA consultation document states:

4.1 There is evidence that children can experience incongruence between their assigned gender and their gender identity early in life. One study indicates the average age was 8.

4.2 There is a limited evidence base about whether children will continue to experience these feelings in the longer term. Follow-up studies indicate overall that for 85.2% of the children, their distress discontinued either before or early in puberty.

However, the rates in the individual studies varied widely. For instance, a 2008 study indicated that in 39% of children the feelings did continue beyond the onset of puberty whereas older studies from before 2000 had very much lower rates for children continuing to experience distress after the onset of puberty. It is thought that pre-2000 studies have included children who would not now be considered to be experiencing gender dysphoria. The studies may also be affected by the small clinical population of children with gender dysphoria – studies looking at whether gender dysphoric feelings persisted had a total population of 317 people.

4.3 There is also evidence that the more extreme a child’s gender dysphoria was before puberty, the less likely it was that their feelings will recede with the onset of puberty. For those who have reached puberty and continue to experience distress, evidence indicates that their distress then tends to intensify and that depression or self-harming behaviours are also more common in ages 12 and over. It is understood that physical changes caused by puberty may intensify the levels of distress experienced.

4.4 Available evidence suggests that factors arising around the ages of 10 to 13 may help explain changes in how a child feels about their gender: · the changes in social roles between boys and girls as their gender role become more distinct; · the anticipation or experience of physical changes as a result of puberty; and · their first experience of experiencing falling in love and discovering their sexual identity. “

The references (evidence base) for point 4.2 in the Scottish GRA consultation relies on the two deeply flawed and uncredible studies of Wallien and Cohen-Kettenis (2008) and Ristori and Steensma (2016), two papers whose multiple weaknesses we have previously addressed.

Point 4.4 also refers solely to another Steensma study (2010) that we demonstrate to have multiple flaws. The ‘evidence’ is outrageously weak and fundamentally unreliable, and should not have been quoted in the Scottish GRA consultation document.

This false information forms a key part of the information upon which Scottish stakeholders are to make decisions on the appropriateness of rights to legal identity recognition for under 16s. Stating 85% ‘desistance’ has the risk of influencing Scottish stakeholders away from supporting the rights of transgender children and adolescents.

The UK NHS Children’s Gender Identity Service continues the myth

Dogged adherence to the discredited 85% ‘desistance’ figure on the behalf of the UK Children’s Gender Identity Service continues to have serious and damaging effects on transgender children in the UK. A recent publication (Costa 2016) by two experts at the UK Gender Service, makes it clear that belief in this flawed ‘desistance’ rate is the key factor underpinning their insistence on a ‘watchful waiting’ (also known as delayed transition) approach.

“Treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults”

“The percentage of children initially diagnosed with gender dysphoria who display persistence of the condition ranges from 12–27%, indicating that the majority of children meeting gender dysphoria criteria do not have persistence of the condition by the time they have entered puberty.”

“Most importantly, this approach is based on the evidence is that only a minority of those with untreated childhood gender dysphoria will identify as transsexual or transgender in adulthood, while the majority will become comfortable with their natal gender over time”

“A second approach considers it crucial not to interfere with the child’s development. ….the basis of this strategy is the absence of clear-cut predictors of gender dysphoria persistence in adulthood and the evidence that a substantial percentage of gender-variant behaviour in childhood will not culminate in adult gender dysphoria”

The service continue to quote this statistic to parents of insistent, consistent and persistent transgender children, telling them that their specific children will almost certainly shift to a cisgender identity at puberty – statements that have the risk of discouraging parents from listening to, accepting and loving their child.

Many of us have been hopefully looking to the United States for some better figures on ‘desistance’. But as we have looked West, some new figures have emerged from Australia.

November 2017 game changer: landmark Australian court case on transgender rights

A recent landmark court case in Australia described as “the greatest advancement in transgender rights for children and adolescents in Australia”, successfully removed a requirement for court approval for the prescription of cross sex hormones for gender dysphoric adolescents.

As part of the multiple court proceedings for that case, a “battery of reports from experts” were commissioned by the court. Dr Michelle Telfer, a world leading specialist in transgender children’s health,  of the Royal Children’s Hospital in Melbourne (and one of the authors of the new Australian Guidelines) was one of the key expert witnesses called to produce evidence from the Australian Gender Service. This evidence is summarised in the publicly available court report for the case titled ‘Re: Kelvin’ that was released this week:

FAMILY COURT OF AUSTRALIA RE: KELVIN

“The fifth intervenor, the Royal Children’s Hospital Gender Service in Victoria is a specialist unit comprising of a team from multiple disciplines including Paediatrics, Psychiatry, Psychology, Endocrinology, Gynaecology, Nursing and Speech Pathology. Since its commencement in 2003, the Gender Service has received 710 patient referrals including 126 between 1 January 2017 and 7 August 2017. 56. 96 per cent of all patients who were assessed and received a diagnosis of Gender Dysphoria by the 5th intervenor from 2003 to 2017 continued to identify as transgender or gender diverse into late adolescence. No patient who had commenced stage 2 treatment had sought to transition back to their birth assigned sex. No longitudinal study is yet available.” <page 8 points 55 and 56>

“Senior counsel continued: In addition, we have evidence from Dr Telfer which has made its way into the case stated at paragraph [55] about the experience of the gender service of the Royal Children’s Hospital over a period from 2003 to 2017, which also encompasses, therefore, new medical knowledge and, in particular, at paragraph [56] Dr Telfer’s affidavit – I’m sorry the case stated, picking up from Dr Telfer’s affidavit, the case stated records as a fact that 96 per cent of patients treated for gender dysphoria at the Royal Children’s Hospital continue to identify as transgender into late adolescence and so one sees some evidence there about persistence of gender dysphoria. Again, we would say that data is new. (Transcript, 21 September 2017, p 66, l 37 – 45)” <page 33 point 160>

Let’s focus on the the critical line:

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

This evidence is stating is a 96 percent ‘persistence’ rate into late adolescence. This implies a 4% ‘desistance’ rate. This may mean that only 4 percent of children diagnosed with Gender Dysphoria might shift to a cisgender (not transgender) identity. This represents a wildly divergent statistic than the 85% ‘desistance’ myth, and much closer to the anecdotal findings of those who have experience parenting, working with and supporting transgender children.

Here’s the words of Marlo Mack, a parent of a trans child:

“As the mother of a young trans daughter who has spent the past six years interacting with hundreds of families with kids like mine, the notion that detransition is rare strikes me as a statement of the obvious. In fact, the “80 percent of these kids change their minds” statistic feels a lot like Trump’s inauguration crowd size claims. If 80 percent of these kids are really desisting, where the hell are they? You’re telling me they’re there, but I’m just not seeing them. I’ve actually never met one.”

What would a 4% ‘desistance’ mean in practice? 

The Australia statistic refers to persistence “until late adolescence” (they can’t yet have longer term data – and we will have to wait until this cohort of young people grow into middle age). However, given that even many of the flawed studies on ‘desistance’ acknowledge that those who are transgender at late adolescence will almost all persist through adulthood this provisional 4% ‘desistance’ figure should cautiously be taken as an important data point.

This has potentially huge implications for policy. For how our society listens to, respects and supports transgender children. For how the media portray transgender children. For how specialists, including the UK Children’s GIDS talk to parents about transgender children. Remember the UK NHS website still looks to the outdated, flawed research and says:

“Across all studies approximately 16% continue with their gender identification”

It is time to put the 85% ‘desistance’ myth in the bin where it belongs.

The Australian 4% ‘desistance’ figure has not yet been formally published, and until we have peer reviewed analysis they should be treated cautiously. It is however derived from data collected from the 710 individuals who have been seen from the inception of the Melbourne gender service in 2003 and has been provided as evidence in legal proceedings. It should be treated as the most representative  data point we have to date for likely outcomes of gender dysphoric children.

While we await data from the longitudinal studies being led by Kristina Olsen and others in the United States, let us discard the 85% desistence figure that is known to be junk science. We know how much damage the 85% ‘desistance’ figure causes. Let’s call an end to this harm.

Let’s start with the upcoming UK Gender Recognition Act consultation.

To the Women and Equalities Select Committee, to the Secretary of State for Equality, and to all engaged in planning the UK GRA consultation document: – do not repeat the failings of the Scottish consultation document – do not use the discredited ‘desistance’ figure that is not only unreliable, but is shown by this new Australia data to be grossly inaccurate and misleading.

To stakeholders in Scotland: It is not acceptable that the consultation documents include this junk 85% ‘desistance’ statistic, without fair acknowledgement that it is widely discredited. If the real ‘desistance’ figure in the UK is even remotely close to the 4% ‘desistance’ provisionally found in Australia, the 85% figure is not just junk science, it is grossly misleading and actively harmful. It is not hard to see that ill-informed stakeholders across Scotland are much less likely to support the rights of transgender under 16 if they are told that 85% will shift to a cisgender identity. If those same stakeholders had been told that the latest findings demonstrate only as few as 4% of transgender children may later shift to a cisgender identity, it is feasible the consultation would come up with very different results. It is incumbent upon those in Scotland to make up for this disgraceful error, and make sure the rights of transgender under 16s are respected in the forthcoming revised Scottish GRA.

To Michelle Telfer and colleagues from the Australian Gender Service: thank you for providing this data and for providing evidence based advocacy on behalf of transgender children. The 85% ‘desistance’ myth causes so much damage in so many spheres. Please can you publish your data, even in its raw form, within a peer reviewed journal. Please give more information on the sample size, how many were pre and post adolescence, the ages of your sample group; It is crucial to ensure the 85% ‘desistance’ myth is not repeated in WPATH Standards of Care 8, dooming another generation of transgender children to disbelief, delay and denial of care.

To Gail Knudson and Board Members of WPATH: Please consider how you can ensure WPATH SOC 8 does not continue to perpetuate discredited statistics like the 85% ‘desistance’ myth. This causes real harm. Where evidence is flawed it must be discarded. To include statistics that are unreliable, and that in light of initial findings from Australia, may be wildly incorrect, is unethical and causes extensive harm.

To the UK NHS Tavistock Children GIDS. Please adapt and learn from the example of Australia where a specialist from the Australian children’s gender identity service is advocating, including in court proceedings, for the rights of transgender children.

Please consider publishing the data that has been collected. We need more information and analysis on how the UK figures compare to Australia and other children’s gender identity services worldwide. Publish your data.

To parents of transgender pre-pubertal children who have been repeatedly told that your specific insistent, consistent, persistent transgender child will almost certainly shift to a cisgender identity at puberty, despite the clear lack of examples of this happening with any enormous frequency. Now is the time to listen to your children. Now is the time to demand better from those who are meant to care for and support them.

References

Costa, R. Carmichael, P., Colizzi, M. (2016) To treat or not to treat: puberty suppression in childhood-onset gender dysphoria Nature Reviews Urology 13, 456–462

FAMILY COURT OF AUSTRALIA RE: KELVIN (2017)

Ford, Z. (2017) Think Progress: ‘The pernicious junk science stalking trans kids

Growing up Transgender, A plea for better transgender research on the perpetual myth of ‘desistance’ and the ‘harm’ of social transitioning; 2017

Growing up Transgender, Australian Gold Standard of Care for Trans Children; 2017

Growing up Transgender, Diagnostic importance of starting puberty; 2017.

Hembree, W., Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen; Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice GuidelineThe Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903,

Mack, M. (2017) ‘Hit by trans friendly fire

Olsen, K. & Durwood, L. (2016) ‘What alarmist articles about transgender children get wrong

Ristori, J and Steensma T.D (2016) “Gender dysphoria in childhood” in International Review of Psychiatry, Gender dysphoria and gender incongruence, Vol 28, 2016 Issue 1.

Scottish Government (2017) Review of the Gender Recognition Act 2004 A Consultation,

Serano, J. (2016) ‘Placing Ken Zucker’s clinic in historical context‘.

Steensma T.D et al (2010) “Desisting and persisting gender dysphoria after childhood; A qualitative follow up study”, Clinical Child Psychology and Psychiatry Vol16 issue 4

Tannehill, B. (2016) Huffington post: ‘The end of the desistance myth

UK NHS Gender Identity Service Website, ‘Continuing and not continuing studies; accessed November 2017

Wallien and Cohen-Kettenis (2008) study “Psychosexual outcome of gender-dysphoric children” Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423 study

Winters, K. (2016) transadvocate.com: ‘The New York Magazine Lies to Parents about trans children

Winters, K. (2017) Australian ’60 Minutes’ report Misrepresents Trans Youth Medical Care

 

 

Post script: Risks of not providing treatment

The Australian court transcripts also include this section on Risks:

Risks of not Providing Treatment

  1. Failure to provide gender affirming hormones results in the development of irreversible physical changes of one’s biological sex during puberty or the development of changes that lead to the need for otherwise avoidable surgical intervention such as chest reconstruction in transgender males or facial feminisation surgery in transgender females.
  2. The prolonged use of puberty blockers (stage 1 treatment) has long term complications for bone density (osteopenia) namely osteoporosis and bone fractures in adulthood. Best practice is to limit the time an adolescent is on puberty blockers and then commence oestrogen or testosterone. Delaying stage 2 treatment for those on puberty blockers also results in psychological and social complications of going through secondary school in a pre-pubertal state which is inconsistent with the child’s peers. [2017] FamCAFC 258 Reasons Page 5
  3. The distress caused by Gender Dysphoria can lead to anxiety, depression, selfharm and attempted suicide.
  4. Individuals with Gender Dysphoria who commence cross sex hormone therapy generally report improvements in psychological wellbeing. An affirmation of their gender identity coupled with improvements in mood and anxiety levels typically results in improved social outcomes in both personal and work lives.
  5. For a transgender male, manifestations of increased body hair and deepening of the voice are generally considered by them as positive.
  6. For transgender females if stage 2 treatment is not administered another risk is linear growth beyond their expected final height.
  7. Some patients receiving treatment for Gender Dysphoria have reported purchasing hormones over the internet or illegally obtaining hormones through prescriptions written for other people. They have also reported that oestrogen and testosterone are cheap and freely available over the internet or through friends or acquaintances. Accessing hormones in this way is dangerous for several reasons including the risks of complications from blood borne viruses such as Hepatitis B, Hepatitis C and HIV contractible with shared use of needles and syringes and the taking of inappropriate dosages of hormones which can be life threatening.

 

Puberty Blockers (GnRHa)

sherlock data

Safe and reversible

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

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

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

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

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

Adolescents are eligible for GnRH agonist treatment if:

1. A qualified MHP has confirmed that:

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

2. And the adolescent:

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

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

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

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

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

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

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

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

“puberty suppression medication is reversible”

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

 

Criteria for adolescents to commence puberty blockers

1. A diagnosis of gender dysphoria in adolescence

2. Medical assessment including fertility counselling

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

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

Australian References:

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

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

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

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

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

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

 

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

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

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

Recent claims from the UK Gender Identity Service

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

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

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

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

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

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

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

Slide text:

“Rationale for the blocker: Are all aspects reversible?

The blocker as a diagnostic aid

The blocker as time to explore, understand, consolidate

The blocker as reversible treatment

Experience some puberty? Tanner stage 2

Stage of puberty not age

Transcription of audio  for this slide:

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

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

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

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

Next slide text:

Balancing evidence and Practice

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

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

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

Transcription of audio  for this slide:

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

Next slide text:

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

2 stopped treatment

Transcription of audio  for this slide:

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

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

Next slide text:

Summary

T1 Outcomes show

Overall no change in psychological functioning (YSR and CBL)

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

No change in self-harming thoughts or behaviours

No change in Gender Identity or Gender Dysphoric feelings

No change in perception on primary or secondary bodily characteristics

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

Transcription of audio  for this slide:

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

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

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

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

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

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

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

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

How are GIDS backing up their hunch?

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

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

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

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

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

i) Cohen‐Kettenis et al (2008) 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Benefits and Risks of treatments for AGIO

Puberty delaying hormones. These have the following benefits:

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

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

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

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

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

“My work has been misrepresented”

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

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

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

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

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

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

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

“There is a passage in your blog:

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

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

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

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

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

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

In summary

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

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

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

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

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

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

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

So what have Tavistock GIDS published on puberty blockers?

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Diagnostic importance of starting puberty?

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

Here’s the Endocrine Guidelines 2017

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

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

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

gender dysphoria worsened with the onset of puberty”.

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

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

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

We will therefore look at this in detail.

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

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

It offers as a conclusion:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. Social Divisions

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

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

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

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

2. View of puberty

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

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

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

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

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

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

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

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

The desisters were not even distressed about anticipated puberty.

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

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

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

3. Sexual attraction

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

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

This finding is problematic on multiple levels.

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

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

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

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

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

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

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

Summary

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

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

What the Steensma et al. 2011 study actually proves:

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

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

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

What policy recommendations this study makes:

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

What policy recommendations this study can justifiably make:

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

Tanner 2?

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

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

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

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

Summary:

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

 

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

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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.