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.

Advertisements

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

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

Introduction

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

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

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

 aus standard care

Key extracts from the document:

Evidence Based:

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

Numbers expected to increase:

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

Natural:

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

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

Affirmative care:

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

General principles for supporting trans and gender diverse children and adolescents

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

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

  • “Use respectful and affirming language”.

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

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

Children vs adolescents:

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

Psychological Support for a younger child:

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

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

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

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

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

Social Transition for a younger child:

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

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

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

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

Key roles for a clinician of younger child:

  • Supportive exploration of gender identity over time

  • Work with family to ensure a supportive home environment

  • Advocacy to ensure gender affirming support at school

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

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

  • Referral to endocrinologist ideally prior to onset of puberty

Supporting Adolescents:

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

Supporting Parents of Adolescents:

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

Fertility Counselling for Adolescents:

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

Commencement of puberty suppression

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

Commencement of gender affirming hormone treatment

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

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

Surgical interventions

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

  •  “delaying genital surgery until adulthood is advised”

Transition of care to adult care providers

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

 

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

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

 

Australian Standards of Care Part 2

Why the Australian Guidance Matters

(and why we need it in the UK)

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

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

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

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

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

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

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

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

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

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

Contrasting the Australian Guidance with the UK’s approach

Introduction

 

Australia

UK

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

 

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

 

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

General principles for supporting trans and gender diverse children and adolescents

 

Australia

UK

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

 

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

 

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

 

 

Supporting trans and gender diverse children

 

Australia

UK

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

 

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

 

 

Social Transition for younger children:

 

Australia

UK

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

 

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

 

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

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

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

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

i) Supportive exploration of gender identity over time

 

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

 

Supporting trans and gender diverse adolescents

 

Australia

UK

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

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

 

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

 

Number range and relevancy of referenced evidence

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

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

 

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

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

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

The evidence review:

(a) was based on biased terms of reference,

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

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

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

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

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

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

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

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

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

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

 

An Open letter to MPs on the UK Gender Recognition Act

Dear MP,

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

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

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

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

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

Self-identification has already been adopted for 2 years in Ireland, with take up by only 240 individuals, with zero significant impact on non-transgender people. My daughter is not an adult and this change would have no direct impact on her until she reaches adulthood – but the upcoming review of the act is relevant for her right now in two important ways.

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

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

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

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

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

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

Please also see the following useful resources:

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

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

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

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

Warm regards,

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

 

The Reality behind the Myths about Trans Children: An Interview with Truth & Tails

Vincent-the-Vixen-2Hey there loyal reader,

We were recently interviewed by the lovely Truth & Tails, 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.

In the interview we share our experience of raising a Trans child, including advice for other parents, some myth-busting about the realities of transgender children, and the reasons for starting this blog.

You can read the interview here: Truth & Tails Interview

 This 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.

 

 

 

A plea for better transgender research on the perpetual myth of ‘desistance’ and the ‘harm’ of social transitioning

desistance-is-futile

Parents of transgender children search high and low for evidence to guide them on how to best support their child. Clear evidence is rare, with the majority of the available research being of dubious quality.

Despite the poor quality, and low relevance, of much of the older academic literature, writers continue to refer to  this and use it as evidence for sweeping and unjustified claims relating to transgender children, particularly relating to ‘persistence’ and to the potential harm of early social transition.

A new paper on this topic was published in 2016 (Ristori and Steensma – Gender Dysphoria in Childhood).

This paper, at first glance, looks to be a very recent overview of the evidence. However the article is based on no new research, instead it uses a number of older studies on which to base its conclusions and recommendations on transgender children.

As a parent of a transgender child, I’m familiar with the older studies that are summarised in this new paper.

The majority of the listed studies (whose conclusions inform this 2016 paper) were published prior to 1988, namely Bakwin 1968; Lebowitz 1972; Zuber 1984; Money and Russo 1979; Green 1987 etc. These papers were based on data from even earlier (50’s, 60’s, 70’s), collected at a time and in a social context so very different from the present, in an era when the day to day experience of being a transgender child was unrecognisably different to how it is in contemporary Britain.

These studies were undertaken in a context where transgender identities were viewed as ‘pathological and delusional illnesses’ to be ‘cured’ and in a context where any form of gender non-conformity was rejected (e.g. the focus on ‘the sissy boy syndrome’). Significantly these studies made no effort to distinguish between gender non-conforming and transgender children.

For these reasons, studies on children published prior to 1988 are not a strong guide for how to best support transgender children three decades later and can be discarded as evidence.

Only three of the listed studies were conducted post 1988.

Two of these were Canadian studies conducted under the leadership of Zucker: Drummond et al 2008 – Zucker is one of the co-authors – and Singh 2012.  Singh is a protégé of Zucker and based this publication on data collected by Zucker.

https://www.ncbi.nlm.nih.gov/pubmed/18194003

https://tspace.library.utoronto.ca/bitstream/1807/34926/1/Singh_Devita_201211_PhD_Thesis.pdf

If you’ve done even cursory reading on the subject of transgender children you’ll probably be aware that Zucker’s approach, once the accepted mainstream, is now widely discredited. Those of us who care deeply for the well-being of transgender children have significant reservations about anything he has shaped. His recent statement “if your 4 year old said they were a dog would you feed them dog food”, has done nothing to help us feel our child’s best interests are his concern. At long last even the academic establishment have begun to turn their backs on him. At the recent US-WPATH convention, Zucker’s first speaking slot was disrupted by a protest and walk-out, and the second was cancelled, with the US-WPATH organising committee apologising for having invited him in the first place.

There are many, many problems with Zucker’s approach and his data, and it is clear even from his own publications that his studies lumped together children who were non-conforming and those who were transgender (with Zucker not distinguishing between the two, as he did not, and does not, really believe in the existence of transgender pre-pubertal children). Many children in his samples were below threshold for diagnosis of Gender Identity Disorder (GID).

Zucker’s data is highly suspect, and not useful in guiding parents on how to best support transgender children. It can safely be discarded as evidence.

A brief note on Gender Identity Disorder, or GID. This was a measure that was used to diagnose children and distinguish them from those who had no discomfort with their sex at birth. Note that Gender Identity Disorder is itself a contested concept. For many, being transgender is not a disorder, and increasingly it is being removed from psychological text books – these papers use the term GID, and it makes sense to use the same terminology here, if only as  useful shorthand, however that doesn’t mean we like or support the acronym or the concept of diagnosis -in fact the opposite.

In this new Ristori and Steensma 2016 paper we are therefore left with just one study post 1988 that does not rely on Zucker’s data, namely Wallien and Cohen Kettenis 2008. https://www.researchgate.net/publication/23449293_Psychosexual_Outcome_of_Gender-Dysphoric_Children

Like many fellow parents, I have read this Wallien and Cohen Kettenis 2008 study closely (and also much of Steensma’s PhD which looked at the same data available at http://dare.ubvu.vu.nl/handle/1871/40250). The abstract for the 2008 paper states that the study found a 27% persistence rate. I like to look through the actual data (presented in a clear summary table in the main article of the Wallien and Cohen Kettenis 2008 paper). I was surprised by what I read.

They started with a sample of 77 children.

19 of these children were not classified as reaching the criteria for GID to begin with.

Interestingly zero of the children from this non-GID group (not transgender to begin with group…) were transgender at follow up. It is not at all surprising to me that children who were referred to a gender clinic for non-conformist behaviour but did not meet the criteria for GID would not end up transgender later on. It is surprising however that this conclusion, that is clear in the data table (zero percent of non-GID children end up as transgender), is not mentioned once in the paper or in the abstract. Seemed strange to me to omit this obvious finding. The only reason I could think of to avoid mentioning this clear finding is if the author wanted to lump together non-GID children with GID children in their analysis.

There were 58 children in the original sample who were assessed as meeting criteria for GID at the start. From this sample, 16 were not contacted, leaving 42 children who could be traced. 6 were unwilling to be interviewed but allowed their parents to be interviewed – the study adds these to the desistance group based on very unsound reasoning (it states that since the demographic of this sample of 6 matches the demographic of the desister sample (in terms of nationality, family income) these 6 can be added to the desister category. This assumption lacks both logic and research ethics, so these 6 need to be omitted.  That leaves 36 children (both with GID at the start and willing to be interviewed later on) upon which the study needs to rely.

From these 36 children, 21 were counted as persisters. 15 were counted as desisters. We can do some very basic math on this. 21/36 persisters, 15/36 desister. This study shows that for children reaching criteria for GID, 21 (58%) persist and 15 (42%) desist. Yet this 58% persistence figure, that appears very clearly in the data table, is not mentioned anywhere in the paper or the abstract. Nor is this 58% persistence statistic mentioned at all in the recent 2016 paper that uses this paper as evidence.

In a later follow up study on the same cohort, researchers found that some of the supposed ‘desisters’ had re-entered the service at a later point and so were not really desisters and that the persistence rates found ‘would likely be higher in reality’. So this study itself suggests a persistence rate of higher than 58%.

Given how clearly the two above conclusions are in the data table (zero persistence rate amongst children who were not classified as GID to begin with, and 58% persistence rate in children who were classified as GID to begin with) I was astonished that this paper could be published in a reputable journal without the peer reviewers or editor asking the author why they omitted these two findings and instead reported a 27% persistence rate (which can only be deduced if you include the children who were not GID to begin with in the sample and if you assume the children who were not contacted or unwilling to be interviewed were all desisters). Perplexed by this I looked up the journal, and saw that this article appeared in a special edition with the editorial by Zucker. You couldn’t make it up.

Certainly these 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).

Yet this 2016 paper does indeed use the percentages in this range of outdated and unreliable research studies to draw strong conclusions stating confidently that “the conclusion from these studies is that childhood GD is strongly associated with a lesbian, gay, or bisexual outcome and that for the majority of the children (85.2%; 270 out of 317) the gender dysphoric feelings remitted around or after puberty”.

For children who are consistently, insistently and persistently stating a clear transgender identity, the available research simply does not show “that for the majority gender dysphoric feelings remitted around or after puberty”. This is very poor research and analysis – our transgender children deserve better.

The best that an ethical and responsible researcher should conclude from the available studies is that there is a lack of effective research data available, and further research (that clearly distinguishes gender non-conforming from transgender children) is desperately needed.

Another subject that this 2016 paper focuses upon is the different options for how to best support transgender children, including consideration of a gender affirmative approach (the approach clearly endorsed by the leading US pediatric organisation). Here the 2016 paper quotes a finding that appears time and again in recent academic publications – the concern that socially transitioned children (who haven’t had permanent medical interventions) would be traumatised if they needed to later transition to a natal gender identity. The 2016 paper states that “the fact that transitioning for a second time can be difficult was indeed shown in the qualitative study by Steensma et al. (2011) where children who transitioned early in childhood reported a struggle with changing back to their original gender role when their feelings desisted, with the fear of being teased or excluded by their peers reported as the main reason for this”. This conclusion, which is the key listed reason to avoid a gender affirmative approach, is based on a single study.

This study by Steensma, included discussion of two natal girls who had not at any point socially transitioned to male – the two girls had changed their gender role and adopted less feminine clothing, but neither had changed their name, neither had changed to a male pronoun, they had not told their classmates they identified as male, they had not told classmates to call them a boy – in short they had clearly not socially transitioned. The trauma that is reported occurred when they changed their behaviour or gender role back to a more stereo-typically female behaviour/role/clothing and was not linked to ‘transitioning’ back to a female identity (they could not transition back since they did not socially transition to male in the first place).

It is unethical for the original piece of research (again by Steensma) to quote this as an example of the harm of social transition, and it is lazy and unethical of later researchers (like this 2016 paper) to quote Steensma’s finding without re-examining the original case. There are now hundreds (or thousands perhaps) of socially transitioned children, and parents are regularly being told that our children would be harmed if they needed to later (before medical intervention) transition a second time. This advice is based on the irrelevant conclusions of a tiny sample within a study made up of flawed data. The conclusion simply has no relevance on social transitioning.

Caring parents of transgender children are desperate for clear evidence on the pros and cons of different approaches, and are of course interested in issues including the likely persistence rate (for children who are consistently, insistently and persistently stating a transgender identity to start with) and also the potential harm if socially transitioned children needed to later (pre-permanent medical intervention) transition again. On these issues families with transgender children are greatly let down by the available academic research.

Criticisms of often mentioned 80% desistence figures have been written numerous times in blogs, presentations, conference seminars and non-academic publications.

http://www.huffingtonpost.com/brynn-tannehill/the-end-of-the-desistance_b_8903690.html

https://gidreform.wordpress.com/

http://transadvocate.com/the-new-york-magazine-lies-to-parents-about-trans-children_n_18875.htm

http://juliaserano.blogspot.co.uk/2016/02/placing-ken-zuckers-clinic-in.html

http://www.slate.com/blogs/outward/2016/01/14/what_alarmist_articles_about_transgender_children_get_wrong.html

However correct and damning, these critiques in non-academic publications appear to hold little influence on those medical professionals whose opinion shapes the care that transgender children receive (at least in the UK context).

We need a clear critique of the current evidence (and how it has been and should be interpreted) to be written by an academic and published in a respected peer reviewed journal. Until that happens, parents of trans children will continue to have deeply flawed ‘evidence’ (like this 2016 paper) foisted upon us.

I know some researchers out there are very aware of the lack of effective evidence on persistence and outcomes for transgender (as opposed to non-conforming) children. Such researchers are undertaking much needed new research – which will be extremely useful to families in future decades.

To help parents and families right now, we would much appreciate a peer-reviewed journal article clarifying why this new research is so very much needed, and why the studies listed in this 2016 paper are not an effective evidence base on which to ground strong conclusions on likely desistence and harm of social transition.

An Open Message of Solidarity to Parents of Trans kids in the USA

Yesterday our family watched in sadness and fear Trump’s callous and cruel actions against transgender children.

We, and fellow parents of transkids in the UK wanted to reach out in solidarity with parents of transkids in the US, to let you know that we are thinking of you, and to send you words of love and strength and support from across the Atlantic.

Some of the battles we face are different; many are so very similar. Most importantly we share in common our pride and admiration for our amazing transgender children. They deserve so much better than they are getting at the moment – we can, we must, and we will change the world, to make sure that the struggles our children face today will be resigned to history books by the time they reach adulthood.

The world is gradually moving in the right direction. For so long the USA (in some areas) has been ahead of the UK, a beacon of what we can hope for in terms of acceptance, affirmation and support for transkids. Clearly Trump now is trying to move the world backwards, but this tide is not going to turn. Together, with courage, love and support we will continue to change our world.

We were particularly moved to reach out by words of fear and sadness from three brave and truly inspirational parents of trans children – Debi Jackson, Marlo Mack and Ron JR Ford (the former two speaking together on the phenomenal ‘How to be a Girl’ podcast and the latter speaking about his daughter from the steps of the Whitehouse). All three of these courageous and ground-breaking parents mean such an indescribably great deal to our family. They have put themselves out there (and in a way that we have felt unable).

We came across these inspirational parents at a time when our own family was questioning if, and how, to accept our young transgender daughter and we were desperately searching for answers and knowledge that couldn’t be found in obsolete psychological journals. From half-way across the world, the experience of these families and their children almost exactly mirrored that of our child. We no longer felt like we were alone in the world. It was their lived example, and shared stories in podcasts, blogs, videos, and interviews, which gave us the necessary confidence to support our daughter and fight for her right to be accepted for who she is. It also helped us to search for others closer to home where we found support from the amazing parents in Mermaids UK.

Deciding to accept and support our daughter was, in hindsight, so clearly and obviously the best decision ever. Our trans daughter is now the happiest, most confident and care-free child, so different from her life before.  We truly don’t know if we could have found the strength to do this without the example set by the three of you and your families, who had trodden that very same path before us and made the way that much clearer.

From the bottom of our hearts, Thank You, for all that you do. From the two of us, and from all the other parents of trans kids in the UK we appreciate you; we are indebted to you; we stand by you; we are so proud of you and to the US #transkids superheroes including Jazz Jennings and Gavin Grimm who are role models to our child.

While we all felt alone once, know that you will never be alone again. In this defining battle for civil rights in the 21st Century, we stand shoulder to shoulder, fighting for our children on this side of the world as you are fighting on yours. Together we will keep changing the world for the better.

All our love and a big hug from fellow parents from the UK to all parents of trans kids in the USA (and anyone, anywhere, in the world with #transkids)

 

p.s. If you ever visit the UK, we will make you very welcome.

 

X

 

If you haven’t seen these you should definitely check out:

How to Be a Girl Podcast at GenderMom.com by Marlo Mack (@gendermom)

“That’s Good Enough” speech by Debi Jackson (@the_debijackson)

JR, Father of Trans Daughter, Speaks at #ProtectTransKids Rally [and mum Vanessa!](@VanessaFordDC)

Gender Revolution: A Journey With Katie Couric  National Geographic Documentary

Mermaids UK Supporting Children Young People and their Families (@Mermaids_Gender)

HRC (Human Rights Campaign) and their amazing Guide for Supporting and Caring for Transgender Children

If you want to keep up with our blog please do subscribe. You can find us on twitter and follow @DadTrans (We do this thing together, but Mum mostly writes the blog and Dad mostly does the social networking bit 🙂 )

 

Transgender children need Stonewall’s support: SOME CHILDREN ARE TRANS. GET OVER IT!

Feedback on Stonewall ‘A Vision for Change’ – Parent’s perspective.

We warmly welcome Stonewall’s commitment to transgender advocacy. This consultation is a very timely opportunity to build a strong coalition to fight for the rights of transgender people. There is much good in the document.  Alongside appointment of a Trans Advisory Group in 2015, and recent recruitment of a Head of Trans Equality, it demonstrates Stonewall’s new commitment to Transgender equality adding the missing T to their excellent work on LGB.

Stonewall has had a lot of trust to recoup with the Trans community. It is right that this document was not written by Stonewall itself but by the arms length Trans Advisory Group. Written by Trans people for Trans people the Vision statement provides a foundation and mandate for action.

There does however appear to be a missing voice – that of transgender children and their parents.  As non trans people, parents of transgender children (unless trans themselves) are unable to attend the five planned consultation meetings. The two-week window to feed back comments in writing or by phone, is also short, and those with busy lives (and I think this would include all parents of trans children), may find it difficult to input.

Following publication of the Vision on Monday evening, we spoke to other parents with transgender children, mainly those supported by Mermaids, which helped to shape our thoughts on the document. We shared these with other parents and then submitted detailed comments (below) to Stonewall. We also sent a copy to Susie Green CEO of Mermaids.

Please note, this feedback is intended to complement rather than detract from the much needed work outlined in the Vision. We’ve focused upon the references to trans-children (or their absence where we think they need inclusion) . While critical, the comments come from a good place. We are simply parents who want to do the best for their children.

We’re now asking  for advocates from the Trans community to read this feedback, and take forward these comments, in person if possible, to the consultation meetings we are unable, as parents, to attend. 

Transgender children are one of the most vulnerable groups of transgender people. Transgender children cannot themselves lead or achieve the changes that they need. Supportive parents of transgender children are in a unique position to raise the voices of our children, and need to be explicitly included in this dialogue.

Supportive parents of transgender children are some of the most well-informed, passionate and motivated allies for transgender people, but we are often unable to speak publically (to protect our children). We need allies like Stonewall. Working in partnership we will achieve far more than working in isolation.

We hope this can be the start of a dialogue and partnership between parents of transgender children and Stonewall.

Key Recommendations

  • Explicitly acknowledge the existence of transgender children in this document and explicitly acknowledge your support for transgender children. (Comment 1, C4, C8, C9, C21, C32).
  • Work with parents of transgender children to improve critical sections of this document. (C2, C14, C24, C25).
  • Work in partnership with parents of transgender children, and invite both a parent of a transgender teenager, and a parent of a transgender child to join the steering team, with an explicit remit to represent the concerns and needs of transgender children. (C15, C22, C30, C33)
  • Acknowledge the significant challenges (prejudice, hate, discrimination) faced by transgender children. (C5, C10, C11, C12, C13, C26).
  • Propose concrete ways in which Stonewall will help transgender children. (C3, C6, C7, C20, C23, C27, C28, C30, C31),
  • Avoid repeating and reinforcing prejudicial and damaging attitudes towards transgender children in this document. (C16, C17, C18, C19, C29
  • Embrace this opportunity to build a coalition with a group of very motivated trans allies (supportive parents of transgender children).

Detailed Comments

Comment 1 (C1):P. 4. Shared Mission: The mission statement does not seem to include trans children, one of the most vulnerable trans groups. Add ‘schools’ to ensure it is clear that trans children are important trans people.

C2: p.5 The document is ‘driven by trans people and achieved by trans people’. My daughter is a vulnerable and important trans person. She cannot drive the changes that she needs. As her parent I need to be her advocate. Trans-children are a group who are uniquely unable to drive and achieve the changes they need. Allies for trans-children (of whom parents and organisations like Mermaids are an important component) need to be part of this dialogue and this agenda, otherwise the important needs of trans-children will be overlooked (as seems to have been the case in this document). Do you have a member of the steering group on the panel as an advocate for trans-children? Of course all trans adults were once trans children, but the experiences and problems of trans-children (particularly those who are early transitioners and openly trans) may be quite different to the experiences and problems that adults had in a different time when they were children.

C3: Amplifying voices. Important to add here that Stonewall will raise the voices of those who can’t speak openly. This is particularly relevant for children and their parents, who are very isolated and can’t speak openly as we need to protect our children.

C4: p. 6 Transforming institutions. Says improving services and workplaces. Suggests people become trans at age 18. Absolutely needs to include schools as the institution where our trans-children spend most of their time. Change to “Improving services, schools and workplaces’. Avoiding mentioning schools (and therefore children) here perpetuates a culture of denial of the existence of trans-children. Bullying at school (including by teachers and other parents) can be horrific. A transgender child was recently shot at school (in the UK) simply for being trans after months of sustained bullying. Schools cannot be omitted here.

C5: p. 12 Representation in media. Media coverage of trans-children is horrific. Yet this is not even mentioned. Harmful media messages about trans-children not existing causes direct damage to trans-children.

C6: Network of allies – National campaign to educate the general population doesn’t mention the need to educate the general population about trans-children, around which there are so many misconceptions and so much fear.

C7: p.12 Challenge transphobia – research needs to encompass the experiences of trans-children.

C8: Language – the document has not once used the term ‘trans-children’. This is part of a wider societal culture of fear and prejudice where the existence of trans-children is denied. If even a stonewall trans advocacy document cannot be brave enough and say ‘yes there are trans children’ then what hope have we got. Using the term ‘young people’ and avoiding the term trans children very much suggests that being trans is a choice that can be made by competent (Gillick competent) teenagers/young adults. My child is certainly a child. They have not chosen to be trans it is who they are. Avoiding the term trans-children is insipid and perpetuates a culture of denial of trans-children’s existence.

C9: p. 15 Institutions. In the heading the word school is again omitted (it definitely needs adding). In the subtext the term ‘in school’ finally appears. First implicit acknowledgement that trans-children exist in the document?

C10: p.16 Criminal justice. No mention of social services investigating parents who support their child in their gender identity. No mention of justice system discriminating against parents who support their child in their gender identity. Both critical issues for transgender children and supportive families (especially in child custody disputes). Nor indeed is there any mention here of the legal rights of transgender children themselves.

C11: p. 17 Faith schools worth a mention here as a particular area for discrimination.

C12: p. 17 There are specific challenges for trans-children in the healthcare system that are not acknowledged here.

C13: P, 17 Sport. Some sporting bodies have trans policies that require information on hormone levels in order to compete, some require “evidence of SRS” or a formal assessment by a board. This clearly is unreasonable for trans-children and creates situations were trans children are prevented from accessing sport either through explicit exclusion or implicitly made unwelcome.

C14: p.18 Young people and education. This section is extremely weak. By far the weakest section of the whole report. I can make some comments but this really needs a significant overhaul and input from a wider group of trans child advocates.

C15: The weakness of this section makes me wonder how well the current working group is representing the experience and needs of trans-children. Do you have any members of the working group nominated specifically to represent the interests of trans-children. A parent of a trans-child (where the parent may or may not be trans themselves) would be an important addition to a working group otherwise the voices of trans-children will be lost (as I fear they have been in this current draft).

C16: Why is this section talking predominantly about gender stereotypes, and about gender expression, and gender roles and colours/toys/clothes. This is extremely worrying.

C17: Of course gender stereotypes are unhelpful – this is not an issue that is specific to trans-children, nor specific to trans-people – it is a broad issue affecting everyone. There is no reason to have a section on gender stereotypes in a section on trans-children. My trans-daughter thought she couldn’t be a pirate captain as she is a girl – so yes gender stereotypes are a problem for everyone, including for trans-children, but this is not the issue to be focused upon in a section on how Stonewall can best support trans-children.

C18: Likewise, there is no reason to talk about gender expression or toys, or clothes,0 or gender roles, or fitting with gender stereotypes in this section. This plays into a deeply harmful cultural narrative that assumes ‘transgender children’ are not really transgender but just like wearing different clothes or toys or colours or don’t fit with traditional stereotypes and are being pushed (by transgender activists) into being transgender when they are really just non-conforming. This is all irrelevant for transgender children like mine who don’t give a damn what toys or clothes they have as long as they are recognised as a girl. For trans-children like mine who knew they were trans way before they had any understanding of gender stereotypes.

C19: The section here on ‘people exploring their gender identity and how they fit with traditional gender stereotypes’ is deeply patronising and unhelpful. Would you put this stuff in the adult transgender section? I don’t think so. Talking about gender non-conforming or questioning children who reconcile their questions’ is deeply unhelpful and plays into a cultural narrative that discredits children knowing who they are, and talks about it being a ‘phase’. Gender non-conforming children who reconcile their questions are not trans-children – they do not need emphasis here. I like the stonewall poster ‘some people are trans/gay – get over it’. I’d like more bravery here ‘some children are trans – get over it’. There seems here to be fear to acknowledge the existence of trans-children. This hesitancy wouldn’t be reasonable in the adults section of this document, and shouldn’t be present here. There are trans-children in this world, and they face serious issues (hate, discrimination, prejudice).

C20: This section needs to discuss the serious issues that trans-children face, and talk about how Stonewall is going to help this extremely vulnerable group.

C21: Furthermore, the term ‘young people’ is too vague. As mentioned above, the term ‘transgender children (no matter what their age)’ would be better. Or perhaps ‘transgender children and transgender teenagers’. Otherwise it seems like this document is denying the existence of transgender children (and if you don’t acknowledge they even exist, how are you possibly going to help them?).

C22: The section on LGBT mentions the hostility or confusion towards the trans community within the LGB community. As a parent of a young trans child I’m aware that a minority of trans adults are themselves sometimes ill-informed or and unsupportive to the needs of trans-children. Some trans adults are sceptical of the need to support and help trans-children. There cannot be an automatic assumption that trans adults will always understand or advocate for trans children, and I think it is worth acknowledging.

C23: p.19 The key recommendation on how stonewall is going to help my transgender child is to avoid gender stereotypes. This belittles the genuine challenges my transgender child faces, and is not in any way a good enough recommendation given the mountain of challenges my child will face before they reach adulthood.

C24: This section needs starting again.

Service Providers

C25: p.22 This section does not acknowledge the particular challenges in the Gender Identity service for children. There are many specific issues that could be acknowledged and addressed if this was developed in consultation with those who support transgender children. This needs to consider how the system works for children of all ages, not just for those old enough to access medical interventions. Fostered trans children and young people face particular challenges and aren’t mentioned in the document.

C26: Particularly this section does not consider the issues around the gatekeeper role that the children’s GIDS service plays to approve or deny access to medical interventions. Practices that are (hopefully) considered unacceptable in adult services are standard in children’s services, with much questioning of why the child has chosen that they would prefer to be a girl, intrusive questioning about genitals, parents being blamed for ‘causing’ their child to be transgender, children being told they are not dressing or acting sufficiently in their affirming gender role to be properly transgender, or children being told they are not sufficiently upset with parts of their anatomy to be properly transgender. Panels of medical professionals make decisions for which there is no appeal. This is in addition to timescales and protocols that are arbitrary and damaging. In addition, in a monopolised and unaccountable system, parents of transgender children are afraid to complain for fear it will damage their child’s support. There needs to be a system put in place for complaints from parents about the children’s GID service to be effectively dealt with.

C27: Also the final wording ‘New models of care, which don’t require psychiatric diagnosis as their foundation, should be explored’ brings to mind the wording of the government response to the Women’s and Equalities select committee report which was full of issues ‘to be explored’. Not a helpful thing to bring to mind, when what is needed is action not ‘further exploration’.

C28: p.24 A better section. Note, this is the only page in the entire 37 page document which uses the term “trans children”. The text is fine, though a bit vague on what are the very many problems and what are the issues that Stonewall plans to help tackle.

It needs to talk more about the crunch issues ‘right to wear uniform, right to use toilet, right to be addressed by preferred name and pronoun (without a deed pole or Dr’s permission), right to change gender marker on record, right to be safe, right not to be persecuted, responsibility of school to protect from bullying, responsibility of school to help other pupils understand, right to socially transition at any age without medical permission etc etc. The current text is too vague and avoids many key issues.

C29: Again the section blurs the ‘children exploring gender identity’ and transgender children topic. The adults section does not devote space to adults questioning gender identity – it focuses on what are the needs of trans adults. The children’s section should similarly prioritise the needs of transgender children (many things that will help transgender children in schools will also help gender questioning children, but to merge the two adds to the confusion around whether transgender children exist (ie some people want to put all children into the gender questioning category, as if you have to be an adult to be actually transgender – pretending they don’t exist is deeply unhelpful for addressing the needs of transgender children.

C30: p. 26. Great to hear about the #Stonewall education research project. Would be good to see commitment that this will mean understanding the experience of transgender children of all ages, in both primary and secondary school. It will be unlikely that this research will be appropriate to directly speak with primary school children like my daughter, in which case this research will explicitly need to reach out to and include the parents of transgender children, otherwise an important voice will be lost.

C31: The Stonewall training will sit alongside existing stonewall LGB trainings. I imagine (I do not have expertise here) that most LGB trainings are aimed at secondary school age? For transgender children, unlike LGB children, there are transgender children in schools and pre-schools from as young as age 3. How is the Stonewall education programme being adapted to ensure transgender components support primary age transgender children? Many schools are in denial about having young transgender children (until they have a young child transition, at which point they go into panic and melt down).

C32: Unless you have a clear policy on the existence of transgender young children, you will not be able to support the schools that are unconvinced of the existence of transgender young children.

C33: p.26 Great to see this commitment to work with #Mermaids. I’m a member of Mermaids and fellow parents who I have met through Mermaids have been the only support at all we have had on this very lonely journey as a parent of a transgender child. We need organisations like Mermaids and Stonewall to work together to help our transgender children.

Thank you for taking the time to read this submission.

We look forward to hearing more about the consultation.

BBC sponsor vicious attack on transgender children

This evening BBC2 broadcast a programme “Transgender kids: who knows best” ‘challenging the new orthodoxy that promotes affirmation (acceptance) of transgender children’.

As a parent of a transgender child, I am accustomed to the hate, fear and ignorance that we regularly face from the media. But I wasn’t prepared for this show from the BBC. I am left shaking, tearful and sick to the stomach.

I don’t think anyone can properly understand how tough it is to be a parent of a transgender child. To face the continual onslaught from the media, from those who hate or deny the existence of transgender people. To have your parenting, your judgement, your child, debated, critiqued, ridiculed.

The show seems to have been designed to cause maximum harm to #trans children and their families. I can hardly begin to tackle here the number of areas in which the show was inaccurate, misleading, demonising, damaging and plain false.

I’ll share just a few of the main problems with the programme.

The show regularly confused gender identity with behaviour. There were multiple statements discussing whether or not it is ok for a boy to like Barbies or for a girl to like playing football . This is nonsense and terrible journalism. Of course girls are allowed to like climbing trees. Of course boys can like dolls. This is a description of behaviour or interest (and based on outdated stereotypes of ‘cross gender behaviour’). No-one with any sense would say a boy who likes Barbies is automatically transgender. My transgender daughter (who said consistently from a young age she is a girl) has never had any interest in dolls. Behaviour does not equate to identity.

I am horrified that the BBC presented as fact the widely discredited 80% desistance figure (that 80% of gender dysphoric children do not end up transgender). This is so very important, an absolutely key statistic that has been thoroughly and repeatedly shown to be false, and yet the BBC presents it as uncontested fact. How dare they? I am so sick of lazy journalists repeating this debunked research without fact checking or seeking to understand the underlying motivations.

The show also presented as ‘fact’ the lie that the majority of gender dysphoric boys are likely to end up gay, and in doing so repeatedly insinuated the gender affirmative approach is homophobic. Competent researchers, academics and physicians conclude that gender identity and sexual orientation are two different things. In any event a transgender child is as likely to be gay as any other child.

The reason why outdated and discredited research studies came up with figures like 80% desistance (and most gender non-conforming boys end up gay rather than transgender) is that they included in their sample children who were gender non-conforming (boys who liked dolls, who never said they were a girl). It is zero surprise that boys who like dolls, who like playing with girls, usually do not grow up to be transgender. On the other hand, children like mine, who from the moment they could properly speak insisted ‘no mummy, I am a girl’ are very likely to continue to identify as a girl into adulthood. The leading US paediatric organisation recently published guidance saying that competent physicians can easily tell transgender children apart from gender non-conforming children, the key is the child’s identity, not their behaviour or toy preferences. Why was this clear conclusion from the most respected US paediatric organisation not even mentioned? Because the BBC chose to frame the debate as between the threatening ‘transgender lobby’ and ‘gender experts’ like Zucker and Blanchard. There was no clear indication that both Zucker and Blanchard have been thoroughly disgraced – not by a biased transgender lobby, as presented but instead by more modern researchers who found their methods and approaches to be both scientifically flawed, intrinsically biased and ethically dubious. Where was information from Dr Olson in the US (a respected expert), who recently published on the excellent mental health outcomes for children who have been supported in their identity by their families?

I am horrified with the segment on the distinction of men’s and women’s brains. No-one is genuinely claiming that transgender girls have a girl’s brain filled with kittens and roses as totally distinct from a boy’s brain filled with trucks and beer. The phrase ‘girl’s brain in a boy’s body’ is a colloquial shorthand that some transgender people have used to explain that they feel their identity is an innate part of themselves and not a choice or a whim. No-one means this literally. And the brain is one of the least understood parts of the body, there is a lot we still don’t know. Claiming that transgender advocate are perpetuating old fashioned gender stereotypes and propagating restrictive gender boxes is utter nonsense – I tell my transgender daughter that she can play with any toys she likes, I have no time for minimising her potential through old fashioned sexist stereotypes.

The show presented Zucker and Blanchard as experts – it did not explain how widely discredited their work and their approaches are. When it did highlight criticism, it presented it as criticism from ‘transgender advocates’, not including the criticism from respected academics who criticise the quality and robustness of their research and their conclusions. Who exactly is a ‘transgender advocate’ was never explained – it was presented as the fearsome, mysterious group, so powerful and threatening (if this lobby is so very strangely powerful, why are transgender people’s rights so regularly trampled on in life and in the media?).

The show presented the lie that the ‘transgender lobby’ is all powerful and that it is now ‘dangerous’ to question the gender affirmative approach. Quite the most ridiculous part of a ridiculous programme. A prime-time BBC show totally attacks and misrepresents issues surrounding transgender children, fitting into a context wherein transgender children and their families are continuously attacked in the UK media. There have been 3 Daily Mail headlines in the past 3 months viciously attacking transgender children and their families, and misinformation and transphobic views are regularly aired across all media. We are a victimised and scared minority – to present us as a powerful and threatening group is the worst blow of this awful, awful show.

The show presented the lie that families are being pushed and pressured into telling children that they are transgender. This is the very opposite of my experience. It is extremely tough to make a decision to support your child in their gender identity in today’s society. Any parent who makes this difficult step (which we do not do lightly, no one would want this difficult path for their child) will be regularly told by friends, family, the media, colleagues, total strangers even, that we are wrong, or even that we are abusive. People who do not understand the issue quote to us meaningless statistics like ‘they are probably just gay’, or ‘just let them play with dolls and stay a boy’ (to which I say, she doesn’t like dolls, but being acknowledged as a girl is the difference between her being happy and confident, and her being sad, depressed and rejected).

I cannot understate the damage that this show has already done. Shows like this decrease acceptance, tolerance and understanding, and increase suspicion, fear and prejudice to an already extremely marginalised and vulnerable group. The misinformation in this show feeds into an extremely hostile wider media, encouraging more abuse. It prompts parents to tell their child not to play with mine, in case our child is mentally ill or us parents crazy. It motivates ignorant people to complain to the police or to social services about parents supporting their transgender child (something that has happened to far too many families of transgender children).

Shows like this also directly undermine the confidence of vulnerable transgender children and young people. It makes it harder for transgender youth to find hope that the world is truly moving in a direction whereby they can be accepted as normal and live their lives without fear or prejudice. It makes it harder for families of happy, well-adjusted transgender children to have the confidence to speak out and share our stories. Stories that need to be heard. Stories of how our children have flourished since being accepted as their identified gender – how they have friends, how they have happy, well-adjusted lives, how their future is bright. The way the #BBC misled the Canadian parent into allowing her young transgender daughter to be part of this awful vicious show is exactly why most parents of happy and well-adjusted transgender children in the UK will never speak publicly. Which is a shame as it means parents who are struggling to find the courage to support their children are left in the dark as to the many positive stories.

My heart goes out to those transgender teenagers and young adults seeking support and understanding from their families – this show will make it less likely their families will understand. My heart goes out to parents who are in the position I was in a few years ago, knowing how deeply unhappy my transgender child was, yet myself struggling to find the courage to support them in their identity against a hostile, judgemental and ignorant world. I have zero regrets, my daughter is so happy, and is enjoying her childhood like any other child without her gender identity being her focus (as it was before she socially transitioned). To those parents who think that supporting their child is the right thing for your child – take courage, reach out to those few of us who have been where you are now, and know that your love and care for your child matters more than the judgements of others.  Reach out to organisations like #Mermaids, a lifeline to parents who feel truly alone.

 

Born in the right body

child-and-parents-blog

When you were born you were perfect;

strong, healthy, just a bit too yellow.

We thought you were a boy;

We now know you are a girl.

Our kind, clever, beautiful daughter.

Happy, confident, healthy.

You are still perfect – our perfect girl.

 

You are not a girl in a boy’s body.

This is your body, and you are a girl.

Your body is just like your new friends’ who are also trans girls.

You have a perfect trans girl’s body.

Never let anyone tell you otherwise.

 

As you get older, maybe you will want or need to change some part.

I know you don’t want a beard

But what you do with your body is entirely up to you.

There is no right way to be.

You are loved and perfect as you are.

 

You were not born in the wrong body.

Remember your uncle’s knee didn’t work and he had to go to the hospital to fix it?

No one says he was born in the wrong body.

You know your grandma needs to take medicine because her hormones aren’t right.

No one says she was born in the wrong body.

 

You are a perfect girl, with a perfect body.

And we love you to the moon and back,

and always will.