Some thoughts on the Cass review

The interim Cass report is deeply worrying for trans children and parents who desire their good.

The Cass interim report does not say, any child being refused puberty blockers they desire “should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing”. That is, it does not sufficiently recognise that refusing treatment may also do harm to a child.

Puberty blockers (PB) or cross-sex hormones (CSH) are called a “life-changing intervention”, but the life-change can be for good, helping a child avoid the wrong puberty, and that is not sufficiently recognised by the Review yet.

Doctors and patients, here, may have different aims for treatment. Doctors may wish to alleviate immediate distress, and see inhibiting development of sexual characteristics as a bad thing. But children and parents want their distress alleviated too, and both reasons are good and sufficient to justify prescribing.

That said, there is a lot of good in the report. Local services should help with distress and other conditions such as “autism spectrum disorder” (sic), though CAMHS, child and adolescent mental health services, are underfunded. There should be more expertise, and shorter waiting lists. The report says “assessments should be respectful of the experience of the child”.

The report says there should be more systematic research on outcomes. There its problem is with medical ethics. A doctor should act for the good of their particular patient, and not others. This limits research, which is for the good of the whole community, not for the particular patient. The NHS asks for consent to research, but research is not its principle aim. The review’s recommendation of a “learning health system” where treatments are under academic review is a revolutionary change, which might benefit patients.

Paragraph 1.7 worries me. It says there is disagreement on whether children can be really trans, so that they need to transition, and whether questioning gender is just part of growing up. Possibly both can be true for different children. Read with 1.14, it shows a failure to see the value of affirmative care. No doubt some staff have said they feel “under pressure to adopt an unquestioning affirmative approach”, but the main pressure is the other way. The High Court used Keira Bell’s case, and a highly unorthodox approach to evidence in judicial review, to shut down the prescription of puberty blockers. The mainstream media is hostile to PBs. There are any number of practitioners groups which take an unquestioningly hostile view of trans treatment.

If there is “predominantly an affirmative, non-exploratory approach” to care, why do only a fraction of those children referred get prescribed PBs? The Court of Appeal in the Bell case heard evidence it was only 16% of patients discharged in 2019/20, of whom only half had started CSH.

But I like Dr Cass’s letter to the children saying they need more services. Some good could come of the report. If evidence is systematically collected it will include evidence of successful transitions and flourishing lives.

I read it because of the Observer editorial, which takes an absolutist anti-trans position: they think PBs for children are always wrong. The vast majority of those on PBs go onto CSH, says The Observer, against the evidence cited above. To them, even though people revert because of transphobia, even though reverters retransition, a single detransition is evidence that no trans child should receive treatment. To them, all the wrong is in giving PBs. They don’t believe children can be really trans. Cass at least admits the possibility.

Dr Cass tells the children that there will be opportunities to get involved with the review. Trans children and their parents should take all opportunities. The haters certainly will.

Nikki da Costa

The interview of Nikki da Costa on Radio 4 this week, giving her an unchallenged platform to attack trans people and trans rights, was reprehensible, but I will not be complaining. Before making a case against the interview, I make a case for it in order to see what I have to refute.

Da Costa argued that the law on conversion therapy should be delayed to make sure it was drafted properly. She claimed there was a risk that a therapist or parents who correctly challenged a teenager’s conviction that they were trans, who wanted to “really explore, slow down and check what’s happening”, could be at risk of accusations that they were engaging in conversion therapy, and an innocent person could be dragged through the courts.

What risks are there when a child presents as trans? The risk da Costa identifies is a risk to cis children, who are wrong to claim that they are trans. They could be gay or lesbian. Being autistic might make them unable to see they would be better off living in their birth gender. What if they “go down a medicalised pathway” and then revert? She did not say, but meant, their breasts or testicles, their voice, fertility and body hair distribution, could be irreversibly damaged.

It is hard to get cis people to admit there might be a risk to trans people too. Going through the wrong puberty, when it is theoretically avoidable, is traumatic and causes life-long avoidable problems with passing. Our acceptance should not depend on whether we pass or not, but passing makes a trans person’s life easier and gender dysphoria less. There is great anger and misery among the cis community when someone reverts, because the cis people think that proves they were never trans, but delaying transition seems unproblematic to them, however painful it is to us.

Getting them to accept that the trans child is traumatised is difficult. They care far more about the theoretical cis child in danger of unwise transition. So the question for cis people is, how can therapists appropriately “explore” the child’s needs? “Explore” is a neutral term, which they think entails challenging the child’s conviction they are trans. We know the therapist should want to “Really explore,” find what is right for the child and help them towards it, but this is threatened by the suggested prohibition of non-existent cis-to-trans conversion.

And then, generally I want journalists to bring to light allegations children might be at risk, even if against the consensus. Thalidomide was marketed for morning sickness for four years, affecting at least 10,000 children many of whom it killed, before it was withdrawn as a treatment. The trouble is that the few reverters have too great significance for them. To realise that some people are trans and transitioning benefits us is more empathy than they can manage.

As a trans person I see this interview as someone attacking trans rights and casting “transgender ideology” as a threat to children, at least needing balanced by someone in favour of trans, and ideally dismissed before it is aired. Listening to da Costa, I hear the ludicrousness of it. No-one will be “dragged through the courts” as an innocent party. The difficulty of proving conversion therapy is too great. No-one will be inhibited from exploring the child’s, or adult’s, desire to transition. But I don’t think cis people will have heard it that way.

Before complaining I want to make a case under the BBC’s own guidelines, and I don’t think it will work. I might make a case about the relative balance of opposition to protection of trans people against trans people standing up for our rights, but to do that would have to listen to the programme for an hour a day, and that is too much. The BBC publishes no record of who they interview, or about what, separate to the recordings.

It’s not balance to platform haters attacking trans, but you can’t convince the cis of that. There was terrible difficulty stopping the BBC from platforming climate change deniers, because of “balance”. After all, lots of highly paid lobbyists oppose action on climate change, as do many Times and Spectator columnists.

Da Costa went on to say Boris Johnson is a conviction politician, and the burden of doing the right thing over Brexit and Covid weighed heavily on his shoulders. Ridiculous! I cry. He has hobbled the British economy, and as he demanded “let the bodies pile high in their thousands”, 30,000 in January 2021 alone. But from the “Conservative” point of view of Nikki da Costa, he was seeking the good of the British people in abolishing regulations and going about our business unrestricted and unmasked.

The Conservative wants the sovereign individual to be free from legal restriction. Theirs is an individualist view. We on the Left see that a person is not free if they are not paid a living wage, may be sacked or evicted at whim, or are forced to risk infection by a deadly disease. It makes no practical difference whether an exporter is restricted by British law, or by French law, in exporting to France, so those in favour of private enterprise see British law should facilitate rather than inhibit the exporter and work with France to agree the rules rather than create different rules. However the radical Conservative only wants to repeal rules in British law, and apparently does not see how law may be for the common good.

In the same way da Costa’s opposition to conversion therapy law seeks freedom for the individual, rather than collective security the Left offers. For those on the Left, trans people are part of the Community, the We the People law should protect. Our wellbeing matters as much as cis people’s, or therapists’. For the Right, we do not. We can be simply portrayed as a Threat.

1 April: da Costa was on Today again, saying the same falsehoods. She says if trans conversion was illegal, therapists would be inhibited from exploring underlying issues. Rubbish. All that would be problematic would be a complete closed-minded denial that the patient was trans, or that transition might benefit them. Even then, they might not reach the discipline tribunal, let alone the criminal court, unless they attempted to change the child from being trans.

Doctors can give medical treatment to trans children

Trans children can be treated for their gender dysphoria, says the Court of Appeal. This is a huge relief to parents and children. It is for the NHS to decide whether the treatment should be available at all. It is for doctors, parents and children together to decide whether puberty blockers should be taken in individual cases. The courts cannot set out how doctors should approach future cases.

The case of Gillick established children under 16 could make their own decisions about treatment if the doctor thought they were mature enough to do so. At the time, contraceptive treatment for children was controversial. The Court of Appeal restores the ability of mature, competent children under 16 to make decisions for themselves, supported by their parent and doctors. This affects all children and all treatment, not just puberty blockers.

There are eleven million children in Britain. In 2019, 2519 were referred to the Gender Identity Development Service, GIDS. They faced a delay of up to two years before assessment. Of the children assessed in 2019, 161 were referred for puberty blockers.

The High Court had accepted the evidence produced by the anti-trans campaigners, even though it was controversial. They decided that when adolescents started puberty suppression, only 1.9% did not go on to cross sex hormones. Even if that were true, it could have been because the children were truly trans and properly consented. It did not apply to patients of the GIDS. 1648 patients were discharged in 2019/20, and of a random sample of 312 of them, 16% (49 children) had been referred to endocrinologists for puberty blockers, but only 55%, 27 children, were approved for cross-sex hormones. Two of the 49 did not commence treatment, and five were discharged without being referred to adult gender services (so would not get CSH on the NHS).

So a tiny proportion of those who will eventually transition happily were referred to GIDS, and of those only a few were treated. The system shows great reluctance to treat trans children, and the courts should not impose more. The doctors prescribe puberty blockers to alleviate the current distress of gender dysphoria. The children and parents seek it in order to avoid the characteristics of the assigned sex, and gain the characteristics of their true sex: allowing this is the way the distress can be relieved.

Doctors and parents together assess whether a child can understand to consent to treatment. It’s hard to see what a judge or other lawyers could add. The legal question is fairly simple: does the child understand the treatment, and does the doctor consider it is in the child’s best interests. The judge does not know the child better than the doctor does. So a court application might forestall a future legal challenge to the decision, but cannot give additional certainty that the decision is right, only delay, worry and expense.

The High Court gave guidance on when treatment might be permissible. The Court of Appeal said the High Court could not do that. At para 56 they quoted Lord Scarman in the Gillick case, saying a legal rule giving certainty about when a child could consent would be inflexible and could obstruct justice. If such certainty is necessary it should come from legislation after a full consideration of all the relevant factors. Courts only hear the evidence brought by parties to a particular case.

They quoted the House of Lords in Burke’s case: “The court should not be used as a general advice centre”. It should not make wide-ranging decisions about difficult ethical questions, only about the particular question between the parties.

The NHS had given detailed rules on the management of the GIDS, including when puberty blockers might be prescribed. The High Court had found these rules to be lawful. Therefore, there are restrictions on the evidence the court in a judicial review could hear. The anti-trans campaigners had lodged their expert evidence late. They never sought permission to lodge it. The Court of Appeal said in a judicial review the court would usually prefer the evidence of the defendant.

The High Court had gone beyond what a court should do. Keira Bell has made unguarded comments about appealing, and anti-trans campaigners will continue to attack the GIDS by any means available, but it appears this particular attack has failed for now.

This is a feminist victory. The Gillick case, which enshrined children’s rights to necessary contraception and abortion, is safe for now. Feminism wins when in alliance with LGBT+. Everyone loses when “feminists” or “LGB” split from LGBT+ rights.

The decision.

Abigail Shrier

It’s always good to read stories of successful transition. S was a tomboy, prodigiously athletic and daring. He wanted to be a boy when he was about four. He cut his hair with scissors. His mother wondered if he was lesbian. He tried dating a boy, aged about 14, but did not feel it. He had an athletic scholarship to an Ivy League university, had a crew cut and wore a suit and tie. He came out to his parents, and they opposed him, so strongly that he stopped talking about transition. He had to work in an unpaid internship, for a year, and then had some trouble finding work. His father suggested he should try “appearing less unusual”. But he got a job in legal services.

J had two lesbian mothers. He was talented at ballet, and found a troupe which allowed him to train as a man. He has had chest masculinisation, and says this is the best day of his life.

Both J and S have had to cut off contact with their parents. The stories are told as horror, of vanishing into an “oubliette” on line, of delusion and mutilation, by transphobe author Abigail Shrier in “Irreversible Damage”.

Shrier does not believe in trans. She claims only 0.01% of the population has gender dysphoria. This is wrong by an order of magnitude: about 50,000 people in Britain are on waiting lists for gender clinics or have transitioned, 0.1%. In 2000, it was about 0.01%, because other people were too frightened or in denial. These are adults, making our own choices.

Interviewing parents who opposed transition to such an extent that their children have cut off all contact, she hears that trans internet eggs youth on into transition, coaching them in what to say, and manipulating them with conditional positive regard, denouncing them as “frauds” if they act according to assigned gender stereotypes. Well, yes, we do discuss coming out to parents, including what to do if we meet uncompromising denial, but a young trans person in the groups writes,

It’s generally understood that everyone is going on their own path. I can think of several people who were/are questioning and may really be seeking more self expression or more agency in their lives. They brought a lot to the groups.

Oddly enough, we are not predators, seeking to ensnare and deceive cis teens into mastectomy. What could we possibly gain?

As Shrier’s sympathies are entirely with the denialist parents, she makes them look much worse than an objective witness might. The last mention of one couple is them ranting about how they paid for their son’s private school and university, rent, health insurance and phone charges, as if that entitles them to have him return their calls. Perhaps they saw money as a substitute for loving curiosity about their son’s needs.

Shrier is an opinion columnist for the Wall Street Journal, and much of her book “Irreversible Damage” is a standard conservative moan about how teens aren’t like they were in her day. Instead they “slip down a customised internet oubliette, alone”. She was born in 1978, and pities those born after 1990 for having different experiences: they must be in danger. She wants to limit sex education: I hear her sharp intake of breath as she writes of children who know what demisexual or nonbinary is. “They may even have learned these at school, from a teacher.”

The same horror, which she expects in her readers, is in this line: “As a ‘trans boy,’ G had friends- lots of them.” The scare quotes are of course hers.

Abigail’s stories are full of conservative moralizing. S’s brother was in a car crash, prescribed opioids, and when he was taken off them suddenly, he turned to heroin.

There is praise from the standard anti-trans campaigners: Helen Joyce of The Economist, Ken Zucker, Ray Blanchard and Michael Bailey. There is also Ayaan Hirsi Ali, beloved of conservatives for criticising Islam, branching out.

Shrier says she anonymises accounts by changing names and minor details so that the trans people can’t accuse their parents of treachery.

Shrier pays tribute to “genuine” trans adults, who, she says, are honest and courageous. She accepts their description of a body that feels all wrong, just not when younger people not yet transitioned or only recently transitioned give it. For the conservative, eventually the truth is undeniable, but she fights it every step of the way.

She distinguishes true trans from “trans activism”. Apparently you can’t be true trans if you speak up for trans rights. That makes no sense at all, for anyone willing to think about what she is saying.

Anything to prove trans is wrong will do. At one point she crows that only 12% of AFAB trans want phalloplasty, but later says the operation leaves some people with incontinence and permanent pain.

The Times, of course, gave a breathlessly admiring review: Shrier’s book is explosive, punchy, analytical and written with zest, and “controversial” even though it repeats the Times’ strict orthodoxy. Oddly enough the reviewer corrects Shrier’s statistic to 0.1% of the population being trans, but otherwise repeats her distortions.

Gender Martyr

Rob Hoogland has been jailed, and the extreme Right are up in arms against it. He was jailed for refusing his child medical treatment which doctors said was necessary, and denying the child’s medical condition, then holding the court in contempt for two years. On being jailed, he expressed remorse and said he had been used as a pawn, and “played”, by transphobes opposing all treatment of trans children.

The child, whose real name I don’t know, socially transitioned at school for a period of years. He did not feel able to tell his parents, and his parents justified his suspicions by completely opposing his treatment. He was assessed by doctors including an endocrinologist who set out a course of treatment. Hoogland refused to co-operate, so the hospital decided they knew best the medical treatment the child needed, and would treat the father’s consent as unnecessary under the law.

Hoogland continued to act up. He was adopted by the hard right, as he says as a pawn for them to use to oppose gender affirming care, and in 2019 the court ordered him to use male pronouns when referring to his son.

In March he was arrested, and, overwhelmed by a sense of his own righteousness backed up by the wealthy, powerful transphobes, he stayed in jail rather than consenting to admit his son’s medical needs. At the hearing on Friday, he finally expressed remorse, so his sentence was reduced to six months.

If the British Columbia Supreme Court publish the judgment, I will have a look at it. However, otherwise, I can only find reports of the case on the nutcase transphobe/ hard right press: New York Post, “Christian Concern”, and a host of tiny websites. “Trans ‘Justice’ has gone haywire” blares some worthless transphobe on some site. No, transphobes feel entitled to ignore medical advice, the needs of their children, and the orders of the court.

What about the detransitioners? ask the phobes. Well, what about the retransitioners. The phobe conditional positive regard- lovebombing any trans man who will detransition, withdrawing the love if they break increasingly stringent rules- works with incessant societal transphobia to make some detransition.

There’s a lot of transphobe money around. Rob Hoogland’s crowdfunder raised $56,000. So the judge ordered him to donate $30,000 to a charity.

The phobes don’t care how many lives they ruin. Trans children can just go hang. Poor Hoogland regrets how the phobes manipulated him, now. Hysterical phobes are milking the story still. There’s a picture of a pair of fists grasping jail bars, the fists brightly lit against blackness in the cell, which hardly reflects Canadian prison conditions now.

I really should not go on Twitter. This morning over breakfast I read a New York Times opinion article about Planned Parenthood, how Margaret Sanger, its founder, was a racist eugenicist, and how the charity should reckon with this blighted heritage. There’s an aside near the end about how language might exclude trans and nonbinary people, and phobes Jesse Singal and Hadley Freeman choose to emphasise this as if PP no longer cared about women. “Misogynistic!” I found that when I ill-advisedly clicked on a link on a facebook trans group.

The obsessive haters in Britain have chosen yet another new name. This time the same tiny group of phobes have decided to call themselves “thoughtful therapists”. Perhaps Robert Withers, the Andrew Wakefield of trans health, is one of them. They oppose law on trans conversion therapy based on the Memorandum of Understanding, even though it is signed by the British Association of Counselling and Psychotherapy and nineteen other health, counselling and psychotherapy organisations. It’s like the American Academy of Pediatrics being condemned by some nutcase far right Christian group with “Pediatrics” in their name.

I hope the robust commitment to rehabilitation of the Canadian justice system does Rob Hoogland some good.

Listening to the transphobes

The Nuffield Council on Bioethics has launched an open consultation on treating gender dysphoric children and adolescents, to which anti-trans campaigners may easily respond. The working group does not include a single trans person. Dr Ruth Pierce has written a detailed critique of the project and its inadequacies. I had a look at the questions.

Nuffield produces reports on ethical issues in bioscience and health. It is funded by the Nuffield Foundation, the Medical Research Council and the Wellcome Trust. This page has links to its work on gender identity. This is its call for evidence.

They start by asking what gender dysphoria is, explaining that some people think it is a medical condition- genetic, hormonal, neurodevelopmental or psychiatric; some think it a social construct, and some a “normal variant of gender expression”. They don’t want a single agreed view, but want to understand how different views affect the approach to care and treatment.

Trans is what some people are, just as gay is. Attempts to suppress our personality fail. Attempts to prevent us from expressing ourselves through transition may succeed, though at the cost of great psychological distress.

Gender dysphoria is the distress at having to conform to the wrong gender, or at living with transphobia including internalised transphobia.

Those anti-trans campaigners who imagine they are left-wing feminists conceive of transgender as a threat to AFAB children: to those who want to transition, whom they call girls, threatened by infertility and physical changes preventing them from living their lives as “adult human females”; and to cis girls generally, from trans girls, whom they characterise as a threat to privacy or even a sexual threat. They cannot believe that transition could ever be right for someone.

However, trans people exist. Transition benefits us. Medical treatment with hormones and surgery at the very least helps us pass better, so to function better in a transphobic society, and at best cures the gender dysphoria arising from our bodies being wrong. Before transition I hated my body. Now I love it.

Anyone asserting that transition is always or mostly wrong is therefore denying reality, and their views should be discounted. However as Ruth Pierce shows the Nuffield press release quotes the approbation of extreme anti-trans campaigners.

Nuffield then asks what social factors are most relevant to the discussion on gender identity, and names a number of possibilities. On “intense sexualisation and objectification of women” I would add rape culture and pervasive sexual violence, but not primarily as having an effect on the trans boys but on the anti-trans campaigners. Many who once were feminist have been traumatised by that sexual violence, and they imagine that trans boys are fleeing it rather than expressing their true selves. It blinds them to the phenomenon of the trans boy who benefits from transition.

Nuffield names “increased visibility of trans individuals in public life”. Well, yes. Rather than trying to conform to the assigned gender, we realise transition might be possible. I felt I could not transition, because the trans women I knew seemed to be having awful lives. When I met some who seemed to prosper, it seemed possible that I could make a go of life as a trans woman, and so I decided to transition.

It does not mention the public transphobic campaigns of the Republican party in the US and the Conservatives and their allies here. That terrifies trans children, and makes them attempt to conform to their assigned gender. It causes mental anguish and even illness. We live in an atmosphere of extreme transphobia. That Nuffield names homophobic bullying but does not explicitly name transphobic bullying shows that they are trying to find a mid point between trans people and the anti-trans campaigners, rather than finding what is right for the children.

Nuffield then asks whether the evidence base justifies the use of puberty blockers and gender affirming hormones (which they call “cross-sex hormones”). I don’t know. There are great difficulties with producing evidence that these treatments are beneficial- the privacy of the trans people involved, the rarity of treatment, and the reasons why treatment is given. Trans children want PB and GAH because they want the right sex characteristics and not the wrong ones. Gender clinics justify treatment as a way of alleviating distress at the time of treatment, not anticipated problems and benefits in the future. That fits Nuffield’s next question- what should be the purpose of PBs?

How should trans children be treated? Before asking this, by way of context, they refer to “desisters”. I would draw attention to people who detransition under the extreme transphobia of society, and later transition again.

Nuffield asks, “Should children be encouraged or supported to transition socially?” Of course. It is the only way to find whether they will prefer life transitioned. But look what Nuffield has to say. Social transition “makes it difficult for young people to change their minds, and in fact increases the likelihood of later medical transition”.

Social transition of cis children is torture. It does not work. This way of presenting the issue makes transition look like a bad thing. The point is, for trans people, social transition makes our lives better. We do it under the pressure of worse transphobia than in Britain now. Nuffield is echoing transphobic talking points.

Nuffield then asks about a range of harms, even those which might be seen as harming those who do not desist, such as, loss of fertility. Stem cells can be made to develop into gametes. That is the way to address loss of fertility. They posit “the negative consequences of disrupting physiological puberty, given the role it might play in the formation and development of a consistent gender identity”. That is mere speculation, simply a more formal way of saying “Don’t indulge them. They’ll grow out of it.” BUT WE DON’T.

This is what Ruth Pierce means about the distress of facing these endless questionnaires, surveys and consultations. I want to cry. Why can Nuffield not see?

Then they ask about consent. They go into detail on the doubts expressed by the judges in the Bell case. They ask, “Do you think that children and adolescents have the capacity to consent to PBs and CSH?” No, scream the anti-trans campaigners. Trans people don’t say there are no risks, just beg the cis gatekeepers to consider the risks of not treating.

Again, the questions make the anti-trans case. “Is there anything distinctive about PB and CSH that they warrant a different standard of consent?” No, not really. All treatment has risks. Should a fifteen year old girl have an abortion? What if she regrets it, and is incapable thereafter of becoming pregnant? There is nothing distinctive, because this is treatment which can have great benefit. Many claims of risk are fearmongering and evidence-free speculation. But transphobes are so wise, and disinterested, in their calls for “transparent public debate”.

My sarcasm is a defence mechanism.

Nuffield asks if there’s anything else you want to say. Getting the distinctions and similarities clear in your mind, clarifying why phobes’ objections are irrelevant, is a particular skill. Not all trans people have that skill. Facing demands for explanation, we might just give up. Nuffield will produce a report over many pages, with many considerations weighed and taken into account, but for us it’s quite simple.

Transition saved my life. It may save others.

I am not going to answer this consultation. I dare to hope someone will express the potential benefits of PB and GAH in such a way that it will be clear to any disinterested person that they should be given, and that only considering the alleviation of current distress to justify treatment is unethical.

Puberty blockers for trans children

Trans children who were receiving puberty blockers before the Bell case can continue getting them if the parents consent. This win is thanks to the Good Law Project’s Trans Defence Fund.

Dame Nathalie Lieven was one of the judges in the Bell case, and says that nothing she says departs in the smallest extent from the Bell judgment. Rather, she has decided that where a child was receiving puberty blockers (PBs) before the Bell judgment, and the parents consent to continue, the NHS can prescribe them on the basis of the parents’ consent.

How else might it be managed? The court could appoint CAFCASS, the Children and Family Court Advisory and Support Service, to prepare a detailed report and the judge would make a decision based on that. It is hard to see how social workers could add anything when parents, doctors and the child involved all wanted to go ahead with treatment. A social worker would be no better than a psychiatrist in judging a child’s maturity and understanding. In this case, CAFCASS was not appointed.

The Bell case still stands, and when it is appealed in June 2021 the “expert” testimony, brought by the anti-trans campaigners, will stand. The court’s findings about the psychology of trans children are findings of fact, which the appeal court will not challenge. GIDS, the Gender Identity Development Service, should have led better evidence, and does not get a second chance.

Before the Bell case, GIDS prescribed PBs on the basis of the child’s consent. The Bell case decided the child was not capable of consenting.

XY was registered at birth as a boy. She is 15. She had always only been interested in girls’ toys and clothes. At primary school she tried to conform to a more male stereotype, but became withdrawn and miserable. She came out to her parents as trans aged 10. Once she transitioned socially at school her confidence grew, and she became much happier. She changed her name by deed poll in 2016, and had seven assessment interviews with GIDS, who also saw her parents, together and separately.

She has never been diagnosed as having an unresolved mental health issue, and she is not autistic, the judge says. An autistic child will face greater barriers to getting the PBs s/he needs.

XY’s Mum, AB, did extensive research on PBs. She was fully aware of potential side effects. The girl started on PBs in July 2019, when she was 13 and had commenced puberty, because the parents did not want her taking unnecessary medication, but the puberty changes were causing considerable distress. They decided not to undertake fertility preservation. At any point before she starts CSH, cross sex hormones, she can stop PBs and freeze sperm, but that would involve developing male secondary sex characteristics. She and her parents have continued to attend GIDS.

The girl’s GP has continued to prescribe PBs. Some other children’s GPs have not. The anti-trans campaigners, represented by Bell’s solicitors, attempted to butt in but failed, in part to protect XY’s anonymity.

The court asks, can the parents consent to PBs, and are PBs in a special category of medical treatment requiring an application to the court?

Parents have a duty in English law to protect their children. Courts can take children away or make decisions for the children, instead of the parents, if it is in the child’s “best interests”, but do not do so lightly. Doctors ask parents to make the most serious decisions about their children’s medical treatment.

The Bell case made it considerably more difficult to demonstrate that a child was capable of consenting to medical treatment, especially PBs. GIDS did not make a further assessment of whether the girl was competent to consent to PBs, so the court treated that question as undecided. If the child was still able to make their own decision, even after the restrictions imposed by Bell, could the parents’ consent be relevant?

Here, the court decides that where the child is capable of consenting, the parents cannot override the child’s decision. But they still have a duty to make a decision in the child’s best interests where the child cannot or will not decide.

The judge says the doctor can rely on the parents’ consent, because the child has not objected to it. I find it inconceivable that GIDS would prescribe CSH or PBs when the child was not enthusiastically in favour. But there has been no further assessment, by the court, social workers, or psychiatrists whether the girl is capable of consent as defined in the Bell case, so the child’s ability to consent is unclear. In that case, where the child and parents both consent, and treatment has started already, the doctors can prescribe PBs.

The court considered whether the Bell case as it stands makes PBs a special category of medical treatment which requires court authorisation, or where it is good practice for doctors to seek court authorisation. Whether it is good practice should be an issue of medical ethics for the General Medical Council. However the law depends on a line of cases on sterilization, where a pregnancy would be disastrous and contraception was not possible. Some of those cases related to women over 18, where parental consent would be irrelevant.

The court looked at two Australian cases. Previously, parents and trans children seeking PBs or CSH had to seek court approval, but after Kelvin’s case, they do not. An Australian judge said loving, caring and committed parents who are intimately aware of their children’s difficulties and deal with their concerns know their children better than a court ever will. They went the opposite direction from the English court in Bell.

GIDS pointed out they were subject to regulatory oversight, from the NHS and ethical rules. There is a review of GIDS looking at treatment of trans children, the Cass review, expected to report this year. The judge observes that whether PBs are therapeutic for trans children is strongly disputed by academic experts, and is a matter for research, not litigation.

The judge decided that PBs are not in a special category where the parents can not consent, and the matter has to come to court. The matter should come to court if the doctors think the parents are being pressured to consent or the doctors disagree amongst themselves. In practice one parent or one doctor can veto treatment, and it must come to court.

Children who had not started PBs before the Bell case are now restricted by NHS guidance.

Once a child reaches 16, the parents cannot consent for them. Bell, who was 17 when she started on T, passionately argued that she could not consent to it, and the law, at least for the moment, agrees. But children 15 or younger on PBs now can continue to get them, based on their parents’ consent, and the courts possibly will not interfere with the Cass review. It is a small win for trans children.

The Good Law Project described the case and published the judgment here.

Tavistock inspection

The Gender Identity Development Service has been inspected and called inadequate. However, much of the inadequacy relates to insufficient funding, staffing and support from other health services. There is no evidence that anyone has been referred for puberty blockers or cross sex hormones who should not have been.

Puberty blockers for trans children

Do puberty blockers for trans children work? What would success look like?

Dr Polly Carmichael, director of the GIDS, started a study on PB in trans children in 2011. The Bell judgment reports that a paper was being finalised, but one of the authors had not yet responded to issues raised by the peer-reviewers. A sociologist, Michael Biggs, has published a critique of the study which anti-trans campaigners would find devastating.

Ideally, a critique would have psychological and medical expertise Biggs lacks. He appeared transphobic before he started digging: he reports that three MSc students, whom he mocks as “woke”, told him to educate himself on trans children. He quibbles about the word “study”, preferring to call it an “experiment”, because PB has not been licensed, as if he has never heard of a “drug trial”. He quibbles that “it was not a proper randomized trial”, even though such a trial would not be possible: you notice when you undergo puberty, and people around you notice too. He acknowledges that parents were going abroad for PB when it was not available in the UK. Disingenuously, in one railing against PB in children, he says the sample was too small. However, he has found at least part of the results, from newspaper articles, comments by Dr Carmichael, and from Freedom of Information requests. He says the data show no psychological benefit from PB.

GIDS does not follow up its patients after they turn 18. Well, it’s a young people’s service, and a medical service providing treatment rather than a service studying trans teenagers. Medical intervention (including follow-up) should be for the good of the patient, not primarily to increase knowledge. However, if we are to justify PB, we need success stories.

The Court in Bell heard evidence from a trans man, now 20, who wished that PB were started earlier, as that would have prevented the need for breast surgery.

Biggs comments on the first person to get PB because he was trans, who at 35, Biggs says, was depressed and “could not sustain a romantic relationship”. The report is here. It says “He was functioning well psychologically”, and that “At age 29, he had a serious relationship with a woman, which lasted for 5 years.” Five years is more sustained than some 35 year olds might have managed. It notes bone mineral density was within normal range, yet Biggs chooses to highlight that as a risk of PB.

I found Biggs’ pdf linked from the “Bayswater Support Group”, which pretends to be for parents “looking for the best support for our children”, yet only gives resources opposing transition. It is the same old stuff, from the same old anti-trans campaigners, repackaged yet again with an irrelevant name. It is attached to “Easyfundraising”, which has recorded £7.70 raised and five supporters as of 7 December.

Whether B’s case is a success or failure might depend on who is looking, and what details they choose to emphasise. I have chosen details to make Biggs’ critique look bad. I am trans. Yet his selective quotation of B’s case shows his bias.

What might success look like? Adolescence can be a horrible time, even if you are heterosexual and more or less fit conventional gender stereotypes. Gays and lesbians find it harder. And then there is trans. The comparator for the trans child is not the more or less happy straight or gay twenty-something, now in a relationship and starting a career, but the child of parents like Mrs A who originated the Keira Bell case. Having had their desire to transition uncompromisingly resisted, are children happier? If they were, would we not hear more from them?

Possibly not. They might not want the attention. But- the only one the new/old hate group can point to is Jessie Maynard, who was 16 in 2016, and wrote then that she was happier than she would have been trying to pass as a boy. However she was never assessed by GIDS. Could they not approach her for her thoughts now?

Some detransitioners write blogs, tweet, and campaign. That is brave of them. More are getting together. Soon they may be seeking damages from GIDS.

If everything really is wonderful, might some who transitioned as teenagers come forward now? The bravery would be even greater. They may pass and be living in stealth, and not want to come out as members of a hated and stigmatised group. But without their stories, it may prove impossible for any more teenagers to benefit from the treatment they had.

If someone is trans, there are only bad choices. You can muddle along in the assigned gender. This is painful and uncomfortable. You can transition. It’s a choice of denying your true self, or being your true self and exposing yourself to all the hate and prejudice.

If you transition, you can take hormones and have surgery, and make your body approximate to that of the acquired gender. It’s a problem that too much hope is attached to this. It takes years, and during the process people tend to think that it will sort all their problems, only to find at the end that it has not. We need realistic expectations of what such treatment can achieve. So, again, we need the stories of transitioned people.

That of the actor Elliot Page is not enough. He/they is particularly talented, and has enjoyed success. Compare him to other actors with similar prominence at the time of his announcement. More ordinary teens are unlikely to have similar careers. Still, it’s good for him to come out, as part of a process of normalising trans, and I am glad he feels able to transition.

Gender variant children are not ill, and do not “desist”

What does it mean to say that gender variant children are not ill? What are the problems with studies which assume they are, and can we learn anything from those studies?

Some studies purport to show that trans children “desist”, and become cis as they mature, so should on no account be treated as trans. “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender-nonconforming children” by Julia Temple Newhook and others shows the problems with these studies and their assumptions. Nine academics in diverse disciplines including medicine, psychology, social work, gender advocacy, education and paediatrics considered and tore apart those studies, and gave an alternative way forward.

Based on the studies, the media suggest that 80% of trans children will identify as cis in adolescence or adulthood, so should not be treated as trans as children. However, the research is flawed. It is based on a definition of “Gender Identity Disorder in Children” from DSM IV, which included behaviour, rather than “Gender Dysphoria”, diagnosed by cross-gender identification and distress with physical sex characteristics and associated gender roles. It failed to recognise the WPATH principle that transgender identity is a matter of diversity, not pathology.

Behaviour: in DSM IV, “intense desire to participate in the stereotypical games and pastimes of the other sex” was one of the criteria. So, a little boy who liked skipping, and playing with “playmates of the other sex”, might be whisked off to the gender clinic for an assessment, and, suitably shamed and frightened, two years later he would report that indeed he had desisted.

We are not ill. We do not need to be made well. We certainly do not need to be made normal. So much of our treatment attempts to make us fit in, to be acceptable to “normal” people. However, there are huge advantages to being “normal”: being seen or treated as weird sucks. Seeing us as ill can mean wanting to make us well: wanting us to be happy conforming to gender stereotypes, ideally those assigned at birth, and if that proves impossible, gender stereotypes and an approximation of the sex characteristics of the other sex. Wanting to be accepted, we may go along with that.

Children exploring gender in a transphobic society face great pressures, and the older studies incidentally describe that. They show that statements of gender identity or gender dysphoria in childhood may indicate similar feelings in adulthood.

Three of the four defective studies included children who did not have a diagnosis of GID, but had simply been referred to a gender clinic. Three assumed any participant who could not be assessed for follow-up had desisted, even though it was possible that they still considered themselves trans, but did not want to medically transition with hormones or surgery. All reassessed children in their teens, one as early as 14, which gives no idea what they will be like as adults. Perhaps they felt unable to transition by that age, but transitioned later. Therefore, the reported desistance rate is hugely inflated.

The parents of the children in the studies brought them to a clinic, indicating they thought there was a problem, but where parents validate their children’s gender identity the children are likely to have a different, arguably healthier, life-course.

The studies used the term “desistence”, which originates in criminology. Gender variance was seen as sick. Being cis was seen as normal. So transgender identity was only viewed as valid if static and unwavering throughout life. Few trans people do not waver sometimes, in the face of family and societal pressure to be normal.

The studies referred to the children as “boys and girls” based on their assigned gender. Their identity was less important. There was no acknowledgment of nonbinary identity. They were too keen to call people “desisters”- for example, an AMAB person aged 18 “still desired to be a woman, with breasts and the possibility of giving birth. However, he (sic) considered himself 50% male and 50% female.”

The studies assumed a stable gender identity is a positive health outcome, so pushed children towards that, but where gender identity is fluid or slower to develop the child may still be developing in a healthy way. Different identities are a different way of seeing onesself, under different levels of self-knowledge and differing vulnerability to differing pressures from others. The journey of self-discovery may be lifelong.

The language to describe identities improves. I had not heard of nonbinary when I transitioned.

Some people imagine that desisters grow up to be gay and not trans. Again this is a way of seeing a person who may be nonbinary and androphile or gynephile. If people do not fit categories, then it is the categories that must change.

There was intensive treatment of the children, with questionable goals. Healthy children may have their self-esteem damaged by being brought into stigmatising diagnostic and treatment settings. Treatment was often designed to lower the odds that they would grow up transgender, or to “reduce GID persistence”, claiming transsexualism, with social stigma and a lifetime of medical treatment, is undesirable.

However, as some children become trans adults, these efforts to make us fit a more normal box can be traumatic. The Netherlands clinic discouraged social transition before puberty, though it can make children happier. Children’s rights to autonomy and self-determination were subordinated to clinicians’ concepts, beliefs and desired outcomes.

Did the children feel some obligation to go along with treatment and participation in the research, as a condition of having their gender variance taken seriously?

Temple-Newhook and others say,

These ethical concerns raise questions about the validity of research with children whose parents believe they have a medical problem, who are subjected to a high level of testing and treatment, who are disallowed or discouraged from asserting their own gender identity, and who are being raised in a broader society that often punishes perceived transgressions of male and female boundaries.

When children think being gay or trans is seen as bad, they often pretend not to be. The social pressure is intense, and cruelly shaming.

The older studies did not consider that attempting to delay or prevent transition could be harmful to the patient’s self-respect and sense of self. They assumed unknowable future adult needs should supersede known childhood needs. Contradicting that, the older research mentions “a de-transitioning girl and her mother who expressed gratitude for her opportunity to live as a boy for a time, and felt that if she had been forced to live as a girl for her entire childhood, that her mental health would have suffered.”

It is not true to suggest that “a potential future shift in a child’s gender identity is a justification for suppressing or redirecting their assertion of identity in childhood”.

From a developmental perspective, a child who is repeatedly discouraged when she earnestly insists on being called “she,” is learning, on a fundamental level, that (1) she cannot trust her own knowledge of herself and, (2) the adults she depends on may not value her for who she knows herself to be.

Trans children and adults are not sick. We need affirmed for our innate worth as diverse humanity.

The study, by Julia Temple Newhook, Jake Pyne, Kelley Winters, Stephen Feder, Cindy Holmes, Jemma Tosh, Mari-Lynne Sinnott, Ally Jamieson & Sarah Pickett, is available here.

Hat tip to Reubs J Walsh.