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Read on for new (as yet unpublished) ‘desistance’ statistics from Australia (Spoiler: it may be as low as 4% ‘desistance’).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

 

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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

is blog has been verified by Rise: R4c1d40dc407da1a0ac3a1e615a7f7e16

About Truth & Tails:

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

 

 

 

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

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A response to Endocrine Society Clinical Practice Guideline for transgender health

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

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

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

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

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

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

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

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

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


Section A: Summary

i) Gender identity has a “durable biological underpinning”

From the position paper:

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

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

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

Data are strong for a biological underpinning to gender identity”

ii) Treatment is medically necessary

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

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

iii) Counselling can support social transition

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

iv) Recommend puberty blockers

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

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

v) Start puberty before blockers

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

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

vi) Diagnosis

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

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

 

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

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

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

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

Specify if:

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

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

vii) Criteria for blockers

Adolescents are eligible for GnRH agonist treatment if:

1. A qualified MHP has confirmed that:

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

2. And the adolescent:

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

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

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

viii) Criteria for gender affirming hormone treatment

Adolescents are eligible for subsequent sex hormone treatment if:

1. A qualified MHP has confirmed:

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

2. And the adolescent:

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

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

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

ix) High satisfaction rates for cross-sex hormone treatment

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

x) Cross-sex hormones by informed consent

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

xi) Gradually increasing dose of cross-sex hormones

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

xii) Hormone treatment is safe

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

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

Federal and private insurers should cover such interventions”

xiii) Fertility counselling prior to blockers

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

xiv) Fertility

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

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

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

xvi) Delay genital surgery until adulthood

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

xvii) Lack of support may interfere with positive surgery outcomes

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

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

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

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

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

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


Section B: Questions on guidance

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

1 – Pre-pubertal children

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

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

Question area 1:

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

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

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

Question area 2:

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

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

3 – Monitoring onset of puberty

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

Question area 3:

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

4 – Side effects of blockers

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

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

Question area 4:

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

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

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

Question area 5:

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

6 – Blockers always required before cross sex hormone treatment

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

Question area 6:

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

7 – Medical Risks associated with sex hormone therapy

Table 10. Medical Risks Associated With Sex Hormone Therapy

Transgender female: estrogen

Very high risk of adverse outcomes:

  • Thromboembolic disease

Moderate risk of adverse outcomes:

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

Transgender male: testosterone

Very high risk of adverse outcomes:

  • Erythrocytosis (hematocrit . 50%)

Moderate risk of adverse outcomes:

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

Question area 7:

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


Section C: Concerns with guidance

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

1. Reference to gender non-conforming children

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

Concern 1:

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

2. Harm of second social transition

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

Concern 2:

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

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

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

This statement is not supported by robust evidence.

3. Social transition impacting persistence

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

Concern 3:

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

4. Inclusion of debunked desistence statistics

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

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

Concern 4:

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

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

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

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

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

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

Concern 5:

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

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

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

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

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

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

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

6. Cross sex hormones prior to age 16

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

Concern 6:

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

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

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

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

Conclusion and recommendations:

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

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

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

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

 

References:

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

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

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

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

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

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

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

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

 

 

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

 

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

church6

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

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

Here’s a quote from the introduction:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here are two quotes from the first paper:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Recommend puberty blockers

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

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

Start puberty before blockers

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

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

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

Criteria for blockers

“Adolescents are eligible for GnRH agonist treatment if:

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

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

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

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

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

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

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

Here’s a longer quote

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here’s the Endocrine Society:

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

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

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

The Endocrine Society concludes:

“a durable biological underpinning to gender identity”

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

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

See this from the American Academy of Pediatrics:

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

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

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

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

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

This analysis concludes thus:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I commend them for caring for my transgender child.

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

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

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

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

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

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

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

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

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

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

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

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

 

Finding my fierce

lion

 

My heart is racing

My mouth is dry,

I bite my lip, I try not to cry

The pressure is sinking me,

My head will soon pop,

The criticism, the hate,

When will it stop

 

A headline, opinion, radio debate,

Another scare story, platform of hate

Day after day another attack

The mindless celebrity, the scientist quack

All spouting distortion, spitting out lies

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

About surgery, hormones, desistance, trends

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

 

“There is a durable biological underpinning to gender identity”

This isn’t a choice

 

But I feel so alone

I can’t find my voice

 

I see how you stare on the playground each day

Eyeing the dress, judging the way

That I raise my family

It couldn’t happen to you

With your conforming children

You’d know what to do

If your child cried about gender in bed every night

If your child was depressed, saw no hope in sight

If you held them as they sobbed in your arms

Asking you to love them just as they are

 

The hate almost breaks me, it makes me despair

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

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

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

I feel so hopeless, so alone, fragile and weak

If no one will stand up, I need to speak

I need to find courage

It must be somewhere deep

If I don’t come up fighting

I’ll lie here and weep

 

But the thing is

Now

they are happy

I wish you could see

They know who they are

They just want to be

Left alone to live their life

without fears

Without pointing fingers,

and whispers and jeers

 

You want me to squash them,

make them feel small

Tell them there’s no space for them

in this world at all

But the world is bigger than you can know

There’s room for trans children to grow

Up into adults who will succeed and thrive

Who will be happy

Thankful to be alive

 

I see their spirit, their courage, their heart

They need vocal allies, me for a start

They need sturdy defenders,

stood by their side

Telling the world they are perfect,

they don’t need to hide.

So I will stick up for them,

fight the battles to come

I will find my fierce,

my strength,

be a mum

 

NHS Failing Transgender Children

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

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

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

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

Where are our allies standing up for transgender children?

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

“Some Children Are Trans: Get Over it”.

somechildrenaretrans

Where is the challenge from the experts in the NHS?

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

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

In response to today’s Times piece they should:

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

I’ll even write it for them:

 

Press release:

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

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

Here’s a Tweet to go with it:

tavistep up

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

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

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