The Erasure of Trans Children

transgender children erasure

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

This got me thinking of the erasure of trans children.

All too often trans children are completely erased from discussions.

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

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

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

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

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

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

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

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

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

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

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

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

 Submissions that referred to children more than twice:

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

These can be roughly divided into three categories:

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

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

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

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

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

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

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

 

Conclusion

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

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

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

Stop the erasure of trans children!

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

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

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

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

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

We must do better for trans children.

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

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

Trans children exist and they desperately need support.

Don’t leave them voiceless and invisible.

#SomeChildrenAreTrans #GetOverIt

Follow us on twitter @FierceMum and @DadTrans

 

Further info on the findings

Methodology

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

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

Limitations of the research findings:

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

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

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

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

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

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

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

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

Table: Organisations that refer once or twice to transgender children

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

 

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

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

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

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

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

 

 

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On Gender Stereotypes

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

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

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

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

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

Can you not hear how that sounds?

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

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

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

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

This accusation is thrown at parents like myself daily:

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

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

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

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

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

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

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

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

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

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

Trans children are no more stereotypical than any other children.

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

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

On Media Tropes of trans children

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

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

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

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

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

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

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

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

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

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

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

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

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

3. Narratives of the child and their parents

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

TransGender_Symbol_Color

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

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

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

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

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

It goes on to note:

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

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

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

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

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

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

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

The paper in question is:

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

 

Zucker (1999) 

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

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

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

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

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

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

Zucker 1999, the tests

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

Zucker 1999: Test 1: Slabey & Frey test

Test 1 Part A focused on Gender Discrimination 

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

Test 1 Part B:  Gender Identity

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

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

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

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

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

Test 1 Part C: Gender Stability

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

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

Test 1 Part D: Gender Consistency

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

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

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

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

Zucker 1999 Test 1 – Conclusion

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

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

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

Zucker 1999: Test 2 Boy-Girl Identity Test

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

Zucker 1999 Test 2 Part 1:

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

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

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

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

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

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

Zucker 1999 Test 2 Part 2:

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

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

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

Zucker 1999 Test 2 Conclusion

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

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

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

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

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

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

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

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

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

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

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

Zucker 1999 Test 3 Conclusion

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

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

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

Zucker 1999 in summary

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

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

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

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

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

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

UK Children’s Gender Service

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

Problem 1 – Quoting fabricated conclusions as though evidence

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

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

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

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

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

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

Problem 3 – Omitting reference to critical recent research

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

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

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

New research on transgender children’s gender identity

Olson 2015

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

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

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

Olson et al.’s research aimed:

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

Results:

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

Conclusion:

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

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

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

 See here for background and further details

Fast 2017

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

Abstract:

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

 

Summary

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

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

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

 

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

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

Trans power

Young brunette woman promoting marriage equality.

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

Trans Power List: Top Activists and Influencers

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

Where are the trans MPs?

Where are the trans judges?

Trans newspaper editors?

Trans media barons?

Trans billionaires?

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

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

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

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

scot flag

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

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

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

Key information:

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

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

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

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

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

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

Under 18s.

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

The consultation questions:

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

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

16-17 year olds.

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

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

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

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

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

Under 16s

The consultation moves on to consider under 16s:

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

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

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

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

Under 16s – option 2 – court process 

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

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

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

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

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

Under 16s – option 3 – parental application

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

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

Under 16s – option 4 – minimum age of 12

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

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

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

Under 16s – option 5 – application by capable child

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

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

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

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

Question 6 

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

 

option 1 – nothing for those under 16

option 2 – court process

option 3 – parental application

option 4 – minimum age of 12

option 5 – application by capable child

My response to the consultation

My initial thoughts to the above is as follows:

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

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

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

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

CASE STUDY: Australian experience of a court based process

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Seeking another opinion

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

Scottish Trans Alliance:

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

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

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

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

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

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

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

Preferred option

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

 

Flawed research evidence underpinning the consultation

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

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

ANNEX M: PARTIAL CHILD RIGHTS AND WELLBEING IMPACT ASSESSMENT

  1. What research evidence is available?

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

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

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

It refers to two deeply flawed studies:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

a) transgender children exist

b) transgender children have legal rights and need legal recognition

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

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

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

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

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

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

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

Diagnostic importance of starting puberty?

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

Here’s the Endocrine Guidelines 2017

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

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

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

gender dysphoria worsened with the onset of puberty”.

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

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

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

We will therefore look at this in detail.

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

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

It offers as a conclusion:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. Social Divisions

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

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

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

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

2. View of puberty

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

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

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

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

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

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

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

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

The desisters were not even distressed about anticipated puberty.

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

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

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

3. Sexual attraction

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

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

This finding is problematic on multiple levels.

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

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

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

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

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

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

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

Summary

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

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

What the Steensma et al. 2011 study actually proves:

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

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

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

What policy recommendations this study makes:

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

What policy recommendations this study can justifiably make:

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

Tanner 2?

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

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

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

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

Summary:

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

 

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

Vincent-the-Vixen-2Trans Children Myth Busting

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

For the first time we’ve published it here:

Background

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

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

Interview Th

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

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

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

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

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

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

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

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

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

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

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

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

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

Thirdly, get some support for yourself as a parent.

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

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

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

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

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

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

The most common ones are:

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

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

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

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

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

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

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

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

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

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

Which children’s’ books about gender would recommend?

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

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

For older children:
Lily and Dunkin – Donna Gephart

is blog has been verified by Rise: R4c1d40dc407da1a0ac3a1e615a7f7e16

About Truth & Tails:

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

 

 

 

NHS Failing Transgender Children

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

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

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

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

Where are our allies standing up for transgender children?

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

“Some Children Are Trans: Get Over it”.

somechildrenaretrans

Where is the challenge from the experts in the NHS?

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

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

In response to today’s Times piece they should:

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

I’ll even write it for them:

 

Press release:

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

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

Here’s a Tweet to go with it:

tavistep up

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

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

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

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

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

Introduction

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

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

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

 aus standard care

Key extracts from the document:

Evidence Based:

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

Numbers expected to increase:

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

Natural:

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

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

Affirmative care:

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

General principles for supporting trans and gender diverse children and adolescents

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

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

  • “Use respectful and affirming language”.

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

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

Children vs adolescents:

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

Psychological Support for a younger child:

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

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

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

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

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

Social Transition for a younger child:

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

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

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

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

Key roles for a clinician of younger child:

  • Supportive exploration of gender identity over time

  • Work with family to ensure a supportive home environment

  • Advocacy to ensure gender affirming support at school

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

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

  • Referral to endocrinologist ideally prior to onset of puberty

Supporting Adolescents:

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

Supporting Parents of Adolescents:

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

Fertility Counselling for Adolescents:

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

Commencement of puberty suppression

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

Commencement of gender affirming hormone treatment

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

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

Surgical interventions

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

  •  “delaying genital surgery until adulthood is advised”

Transition of care to adult care providers

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

 

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

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

 

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 🙂 )