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.

Keira Bell v Tavistock Gender Identity Development Service

After the case of Quincy (or Keira) Bell, it will be exceptionally difficult for a trans child under 18 in the UK to get puberty blockers. The High Court has decided that the evidence the Gender Identity Development Service (GIDS) had to justify prescribing puberty blockers was insufficient, and children were not capable of consenting to the treatment.

The court did not consider all the benefit that the trans child will get from puberty blockers. It may be possible for individual trans children and their families to take court action to get that relief. It may be that a better understanding of the benefits from puberty blockers, or simply a better way of explaining those benefits, will enable trans children to get the treatment they need. However they will have to go through legal proceedings to demonstrate sufficient consent, as well as to convince psychiatrists that the treatment is appropriate, and the ethical and practical concerns for each will be different.

The court’s judgment discussed at length the GIDS practice, which bent over backwards to protect any cis child and avoid transition. Families may simply go abroad and go private, and have far less protection, as one family referred to in the case did.

This is how the court made its decision. Continue reading

Pushing tomboys to change their gender?

The Department for Education has issued guidance on Relationships and Sex Education, and the Daily Mail started a culture war. “Teachers are told to stop pushing tomboys to change their gender”, it said. “Tomboys must not be encouraged to think they should change sex just because of the way they like to dress or play, schools have been told.”

I agree. I don’t like the word “tomboy”- girls ask, “Why call me a ‘boy’?” Just because they don’t like pink, or skirts, or even worse because they climb trees as well as liking ballet, does not make them any sort of “boy”. I disagree with all gender stereotypes, and find the adjective “harmful” tautologous. Oddly enough, neither the Statutory Guidance, nor the separate Guidance, uses the word. Where schools depart from statutory guidance, they “need to have good reasons”. Guidance is less binding. The Mail is wrong to call it “instructions”.

The Mail quotes out of context, from the Guidance.

You should not reinforce harmful stereotypes, for instance by suggesting that children might be a different gender based on their personality and interests or the clothes they prefer to wear. Resources used in teaching about this topic must always be age-appropriate and evidence based. Materials which suggest that non-conformity to gender stereotypes should be seen as synonymous with having a different gender identity should not be used and you should not work with external agencies or organisations that produce such material.

I don’t know whether that was written out of ignorance, or with the intention of permitting Mermaids to continue to provide resources. Mermaids never suggested that non-conformity was synonymous with having a different gender identity, only that some children really do have a different gender identity and they will flourish if allowed to transition. Trans people exist. We should be worried, if the guidance echoed transphobe organisations, suggesting that gender identity is a falsehood, the product of gender stereotypes, but it does not.

The Mail quotes the “Safe Schools Alliance”, so I looked them up. They are a transphobe organisation, currently taking legal action to get the Crown Prosecution Service to withdraw from the Stonewall Diversity Champions programme, and against Oxfordshire County Council because they believed the council’s guidance was too accepting of trans people. The first thing they say about themselves is that they are against gender identity policies they find too pro-trans. They do not disclose their funding. They are happy to damage Britain’s leading LGBT charity because of their loathing of trans. They object to “trans lobby groups push[ing] policies which allow males into female spaces”. Well, they call trans girls “males”. They want to prevent transition.

Enough of the propaganda. What do the Guidance and Statutory Guidance actually say? Continue reading

Is Alex trans?

Alex, aged 16, visits his psychotherapist. They discuss his relationship with his parents and friends. Alex identifies as trans and has worn a binder since age 14, but has, with his parents, chosen not to use puberty blockers as they have the side effect of lowering mood and energy. He is a high-achieving student at an all-girls school, and could be perceived as a young, shy, effeminate boy just before puberty. He suffers with fatigue, disrupted sleep, anxiety, eating difficulties, superficial self harm and mild obsessive compulsive disorder symptoms.

Will he be encouraged to transition? Will his psychotherapist examine any underlying issues which might cause him to identify as trans? Online, I read the therapist’s account of the session, then clinical commentary by two psychotherapists: Amanda Keenan, child and adolescent psychotherapist, who trained at the Tavistock clinic, and Margaret Rustin, child and adolescent psychotherapist who was head of child psychotherapy at the Tavistock for 24 years. The Tavistock runs the English Gender Identity Development Service, as well as other services. There are also maunderings from disgraced psychotherapist Robert Withers, which are more revealing about himself than the case.

Before transition, everyone thought he was really gay, really butch, but he began living as male, at first on the internet, when he felt he was being himself. He felt better, and wanted this for the rest of his life. Accordingly he socially transitioned. He tells his therapist how he hates conflict, and when someone shouts at him “My inner thoughts take the side of whoever shouts at me”, and then he thinks of himself as an idiot. He would like to talk back, but part of him forbids him to.

His psychotherapist suggests that coming out as trans gives him a narrative about what causes his problems, and wonders if the trans narrative makes a vulnerable part of him feel safer. The narrative shuts others down, and it is useful that school is “scared” about being transphobic. The narrative legitimates his feelings of hurt, vulnerability, fragility and anxiety, and there are lots of people (trans activists) backing him up.

Alex agreed when the therapist suggested his belief that he is trans prevents him from being in touch with that vulnerable part. The therapist suggested trying to find layers of meaning without intervening hormonally. They suggested his trans identification gave legitimacy to his “weirdness”. Alex agreed. They agreed to revisit at the next session.

Alex suffered years of stomach pains before his parents took him seriously, and his doctor diagnosed him with lactose intolerance. He is angry that when his brother had stomach pain after eating ice cream his parents immediately believed the brother.

Amanda Keenan says Alex is trying to avoid and defend against the challenges of adolescence. Some adolescents overachieve academically as a way of avoiding emotional conflict. Alex’s intellectualisation, thinking about his difficulties, might get in the way of learning from emotional experience. She considers his eating difficulties reinforce her sense that he finds it hard to digest emotion. His friends are like a gang, there to support and defend each other. She wonders if “Alex unconsciously provokes others to shout at him in the service of punishing himself”.

She finds him strongly defended. She says he wants control, and fears being in touch with feeling. Keenan says the therapist is in a difficult position, either to be blamed like Alex’s father, or being forced to support him like his friends?

Margaret Rustin “suggests that the dissonance between Alex’s sense of himself as a person and the perception of others was very painful to him. He is relieved when he can assert his sense of reality in opposition to what others think they see.” He assumes his therapist will be on his side in his conflicts with father and friends. She might see his symptoms “as evidence of aggression turned against the self due to anxiety about expressing it in relationships”. She notes the privilege children can get from being ill, and needing parental attention or NHS care.

At the end of the session, “the therapist suddenly notes his deflated tiredness, signalling the failure of the manic solution which a masculine identity had seemed to offer him, and which is so seductive when separation looms… I would suggest that behind the choice of a masculine identity is anxiety about femininity seen by Alex as inferior, passive, weak and depressed. His intellect (clearly a powerful one) is by contrast experienced as a male aspect of himself, able to have a voice and a position and exist in its own right, not needy and dependent.”

I don’t know whether Alex is trans, or whether he will transition. However I note that he is not on puberty blockers, and that therapists associated with the Tavistock are questioning his trans identification, and keen to find explanations of it.

What about Withers’ witterings? They are more revealing of himself than of Alex. He writes, “In my own experience, working with people who use the trans narrative to distance themselves from feelings of vulnerability in this way can evoke hard to reach feelings of hatred in the countertransference.” Counter-transference is the therapist’s feeling. Withers reiterates his false claim that ethics might prevent a therapist from exploring what is underlying a trans identification, and cites his own paper.

The whole paper is publicly available. While the heading is “clinical commentary by Robert Withers”, the therapist’s account and Keenan’s and Rustin’s comments are included. I find it reassuring. Suggestions that children are forcibly transitioned are belied by the care of the three child psychotherapists. If Alex is trans I feel he will be supported in his transition. If she is not, I feel she will be helped to navigate the difficulties of adolescence.

An open letter to my MP, about the British Government’s threat to trans rights

I write to you because I am extremely concerned about recent ministerial statements about gender recognition. The ministers show a lack of understanding of the law and of medical understanding of gender dysphoria. In particular, gender recognition on the basis of the trans person’s self-declaration will pose no threat to women’s single-sex services, as English law already recognises trans people in our chosen gender for most purposes. I am concerned that the ministers’ misunderstanding threatens a restriction of my rights in law as a trans woman. The ministers propose to restrict medical treatment for trans children, and so do not show proper respect for medical expertise or children’s needs.

On 3 March 2020, in response to a written question, Elizabeth Berridge said in the House of Lords,

Those seeking to rely on the protections and exemptions contained in the Equality Act 2020 [sic] must be able to do so with confidence and clarity. The Equality and Human Rights Commission’s statutory codes of practice on the Equality Act 2010 explain the provisions of the Act and the EHRC is responsible for updating these codes as necessary.

This Government has been clear that we must take the right steps to protect safe single-sex spaces for women and girls; their access should not be jeopardised. Some women’s organisations have expressed concern that predatory men may abuse the gender recognition system, intended to support transgender adults. We have heard these concerns and are considering carefully our next steps.

On 22 April, in a speech to the Women and Equalities Select Committee, Liz Truss said,

The final point I’d like to make, Madam Chairman, in this initial part, is on the issue of the Gender Recognition Act. We’ve been doing a lot of work internally, making sure we’re in a position to respond to that consultation and launch what we propose to do on the future of the Gender Recognition Act. We will be in a position to do that by the summer, and there are three very important principles that I will be putting place.

First of all, the protection of single-sex spaces, which is extremely important.

Secondly making sure that transgender adults are free to live their lives as they wish without fear of persecution, whilst maintaining the proper checks and balances in the system.

Finally, which is not a direct issue concerning the Gender Recognition Act, but is relevant, making sure that the under 18s are protected from decisions that they could make, that are irreversible in the future. I believe strongly that adults should have the freedom to lead their lives as they see fit, but I think it’s very important that while people are still developing their decision-making capabilities that we protect them from making those irreversible decisions. Of course some of these policies have been delayed, Chair, by the specific issues around Covid but I can assure you that alongside the Covid work, our officials continue to do those things to make them happen.

Both ministers refer to the protection of single-sex spaces, and Elizabeth Berridge specifically states “concern that predatory men may abuse the gender recognition system”. This misunderstands the way the Gender Recognition Act 2004 and the Equality Act 2010 work, and how psychiatrists understand gender dysphoria. For almost all purposes, we have self-declaration of trans people already.

The International Classification of Diseases provides a definition of gender identity disorders including transsexualism, which is defined as,

A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex.

The Diagnostic and Statistical Manual of the American Psychiatric Association defines gender dysphoria as follows:

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

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics).

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

3. a strong desire for the primary and/or secondary sex characteristics of the other gender.

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

In both definitions, the patient’s desire or belief is paramount. I am a trans woman because I believe I am. There is no other way of diagnosing: only what the person says and does. We transition, because we cannot avoid it, because we want it more than anything else in the world.

In terms of using single sex spaces, the presence of trans women was tolerated long before either Act. When I saw my psychiatrist in 2001, he gave me a card stating that I was undergoing treatment for transsexualism and it was part of the treatment to dress female and use women’s spaces. I never had to show it to someone. Before I saw the psychiatrist I spent a long time preparing to transition, because I was scared, and felt the need to check out whether I could bear the hostility and discrimination. So I expressed myself female and went out- to the supermarket as well as the gay pub, including women’s loos. People tolerated me. I only wanted to pee. I am not sure what law applied, then.

The law now protects people as soon as we decide to transition. It is in the Equality Act 2010 s 7:

A person has the protected characteristic of gender reassignment if the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex.

So as soon as a person decides to transition they are protected, and for purposes of changing rooms and toilets we go to those of the gender we are expressing. We self-declare: I am a trans woman, because I say that I am. I should not be discriminated against as a trans woman, whether or not I have a gender recognition certificate. I express myself as a woman, and so should be treated as a woman.

But we can still be excluded from women’s spaces, under the Equality Act 2010 schedule 3 paragraphs 28-30. We can be excluded if it “is a proportionate means of achieving a legitimate aim”.

Elizabeth Berridge echoed concerns about predatory men, but Layla Moran MP answered those concerns comprehensively, in 2018. In a debate she said,

Let us assume that someone wants to go into a women-only space for nefarious purposes. That [gender recognition] would be quite a stupid thing to do because, apart from anything else, if an offence was committed it would show evidence of premeditation, which would increase the person’s sentence. Also, had the certificate been gained for the sole purpose of entering such a space to commit a crime, that would be a separate crime under ​the Fraud Act 2006. If someone was intent on harming women, that would be one of the stupider ways of doing it.

Gender recognition does not affect any of these matters. Section 9 of the Gender Recognition Act states the person’s gender becomes the acquired gender, as does the sex, but this is “subject to provision made by this Act or any other enactment or any subordinate legislation”. That includes the Equality Act.

Before the Gender Recognition Act, I got a passport saying that my sex was “F”, and a driving licence indicating in the driver number that I am female. The guidance now on passports is here, and on driving licences here. A transgender person only needs a letter from their doctor to change their passport, and a statutory declaration or deed poll changing their name to change their driving licence. We do not need a GRC.

So, why do people get gender recognition certificates? In 2004, a friend got one because it entitled her to claim her state retirement pension early, and at the time it affected whether people would enter a civil partnership or a marriage, but after the Marriage (Same Sex Couples) Act 2013 that no longer applies. I got my gender recognition certificate because it was there. The law could officially declare that I was a woman, so I wanted that. However the current procedure is generally recognised as intrusive and expensive.

Because the junior minister is echoing groundless fears about “predatory men” and the Secretary of State refers to “checks and balances” I fear that my rights to be treated as a woman may be reduced. The law helps mold society’s response to trans people. Discrimination law protects me, and creates a moral injunction to treat me decently. Talk of how my rights may endanger women reduces that. Because of the campaigns against trans women I have suffered personal abuse and threats on line.

I want you to express these matters to the ministers, explaining that their fears are groundless, and ask them to assure me the rights of trans people will not be curtailed. I would like you to express your personal views to me, and answer these questions: would you oppose any diminution of trans rights under law? Would you support reform of gender recognition, to dispense with the requirement of evidence beyond the trans person’s word, formally sworn or affirmed, as Theresa May promised in 2017?

I am particularly concerned about the Secretary of State’s remarks about the treatment of children. She says that she wants to protect under 18s from irreversible decisions. This shows a fundamental misunderstanding of treatment for trans children and young people.

It should not be for the law or the government to interfere in medical decisions for children. These decisions should be made by doctors, parents and the children themselves according to Gillick competence in the best interests of the children. Irreversible decisions are not made by children. The NHS can treat under 18s with puberty blocking hormones, which are reversible. For evidence of this, for example consider the Australian standards of care and treatment guidelines.

Social transition of transgender children, not necessarily involving any hormone treatment, improves their mental health.

Please may I see you about this. During the lockdown, are you holding surgeries by video conference?

Transitioning as a child

When child H, then aged three, was brought to school dressed as a girl, the school referred the family to social services, alleging that the foster carers may be fabricating and inducing mental illness in the children. Eighteen months later in June 2017, when H began attending, the school requested that she wear a boy’s uniform, but H and the foster parents did not comply. In July 2018, social services started care proceedings, and the social worker Lisa North alleged the foster carers had a “preoccupation with an encouragement of gender dysphoria”. On 9 May 2019 the judge completely exonerated the foster carers, praising them as child-focused.

Social Services, seeking evidence for care proceedings, commissioned a consultant paediatrician, Dr Gupta, to consider the account of events they had prepared and assess whether there was “factitious or induced illness”. That is a defined category, with a developed theory of what it is and how it may be established. The theory gives twelve factors establishing FII, all of which Dr Gupta said applied in this case, even though she did not see the children. Social Services then issued care proceedings, alleging that the foster parents have manipulated children’s gender and diagnosis of additional needs, which is considered the highest division of emotional abuse. The children remained at home while the courts obtained expert evidence.

The foster parents had three of their own children, and were caring for five more. Though not related by birth or adoption, the children saw themselves as brothers and sisters. One of them, R, aged 12, had been referred to the Tavistock gender identity clinic and was living transitioned to female. R had ADHD and autistic spectrum disorder. H and C, H’s six year old brother, had both suffered abuse and neglect from their birth parents. C had had several injuries in falls while in foster care.

A psychiatrist, Dr Hellin, assessed the foster parents and found the mother had no sign of personality disorder or mental illness, but that her identity and sense of self and of competence is very much based on her role as a mother carer and the proceedings have attacked this making her feel very insecure vulnerable, self-doubting and frightened. The father was psychologically resilient, and involved with the family, and there was no sign of FII. Both were “reflective” about the issue of gender dysphoria.

Another consultant paediatrician, Dr Ward, considered the children’s medical records though did not see the children herself. She concluded that R, the elder trans girl, and another child had no inappropriate referrals or medical treatment but that H’s brother C had had accidents because of inadequate supervision.

Of H, she used male pronouns, saying H required consistent, positive and nurturing care because of trauma and physical abuse by the birth parents. The foster-carers were over-anxious about H’s health and development, and sought second opinions. With hindsight, the investigations were not clinically indicated, and there is evidence that the foster-carers had given misleading information when they suspected cerebral palsy: if the court agreed, that would be fabrication, not merely the behaviour of an anxious parent.

H had not yet been referred about gender dysphoria. Dr Ward wrote, a significant proportion of pre-pubertal children who display differences in gender identity revert to their biological gender in adolescence. Failure to seek medical support and opinion leaves H at significant risk of emotional harm as a result of being presented in school as a girl. Failure to seek medical attention in relation to this problem represents neglect of H’s emotional and physical well-being. However the gender specialist who reported on H disagreed.

Dr Ward thought K, a girl aged 4, who had also been abused by her birth parents, was normal and healthy, but that the foster-carers interpreted her response to the abuse as mental health problems, and there was “concern” that they overinterpreted, exaggerated or misreported behaviour, which led to referrals. The foster-carers seemed focussed on potential diagnoses, which might lead to K falsely perceiving herself as disabled.

I will quote the judge’s summary of Dr Pasterski’s introduction in full.

“Dr Pasterski is a chartered psychologist and gender specialist with 23 years of experience in conducting gender identity assessments in children and adolescents. In her report she identifies that there have been recent changes to the diagnostic criteria for gender dysphoria and that research on mental health and transgender children have shed light onto critical historical misunderstandings related to clinical presentation in gender dysphoria. Firstly, that children who present with gender dysphoria are likely to desist in their cross-gender identification and secondly that gender dysphoria is inherently associated with high rates of comorbid psychopathology. She notes both have been shown to be false. She identifies that these misunderstandings arise from two particular factors. Firstly earlier studies which showed that up to 80% of children desist in gender dysphoria included children who presented with gender incongruent behaviour but did not necessarily state the wish to be or that they were the other gender. Thus children displaying gender variance may have been wrongly diagnosed with gender dysphoria. As a result of this treatment protocols previously incorporated a watch and wait approach which had prevented truly dysphoric children from transitioning which had likely resulted in increased rates of depression and anxiety. As Dr Pasterski puts it ‘Put simply, many who have shown to desist were likely not dysphoric and psychopathology in those who persisted was likely due to forbidden expression of their true gender identity.’ Current guidance suggests that supporting a child who clearly and consistently states that they wish to be the other gender in their preferred gender role is associated with improved mental health and well-being.”

Dr Pasterski thought gender dysphoria could not be fabricated or induced. R was content to present as a girl, consistent with a diagnosis of gender dysphoria. It was appropriate to support her in her authentic, preferred presentation.

H appeared to be a content, alert and socially engaged little girl. She identified herself as a girl. It was right to allow her to present as she wished, even though she had not seen the GIC: there is a risk of harm from unnecessary gender related investigations (para 59 iii). The children were free to be themselves, and removing them from their loving, settled and engaging home would harm them.

The independent social worker reported that the children were well-cared for, that the foster parents worked well with social services and health professionals, following professional advice. The children were fully integrated as a family. She thought the foster-mother was closed to the possibility of H or R reverting to male, and that early transition made it more difficult to explore gender identity- that is, she disagreed with the gender specialist.

The local authority requested permission to withdraw the court proceedings. The foster-carers objected that simply withdrawing proceedings, without the court finding the facts of the case, might lead to an unjustified cloud of suspicion over them.

The law says that where it is clear that there is no basis for care proceedings the court should allow social services to withdraw their application, but where it is arguable that there should be an order about care the court should find the facts. Court proceedings create a cloud of uncertainty, intrusion and stress, bad for the welfare of the children.

The judge concluded that it was so obvious that care orders were inappropriate that no further factual findings were necessary, and in the interests of the children the court proceedings should end. This is a complete exoneration of the foster parents. To the extent that there may be individual examples which either do amount to, or could be construed as, examples of inaccurate reporting, or over medicalisation or lack of supervision they are isolated outliers in comparison to an otherwise overwhelming evidential panorama of appropriate parenting. The children are prospering, and the foster carers are good, child-focused parents.

He decides, at para 75 iii, that concerns about the early social transition of the two trans girls were “compellingly rebutted” by Dr Pasterski. Dr Ward only gave isolated examples of over-medicalisation, but the “overwhelming weight” of evidence shows the foster carers are good parents.

So this is an example of trans girls properly cared for by loving foster carers, having to undergo court proceedings because of social workers and school staff taking concerns about the trans girls’ transitions too far, though at para 81 the judge could not condemn them: they were merely less well informed than Dr Pasterski. The judge says “The concerns were comprehensively dispelled”.

The Daily Mail’s headline about this is grudging, giving undue prominence to the social workers’ concerns: Judge backs parents who allowed their four-year-old son to live as a girl and sent him to school in a girl’s uniform – despite social workers accusing them of ‘actively encouraging’ their child’s transgender identity. Note the misgendering.

The judgment is available here.

A Mermaids training session

Mermaids is the charity caring for trans children and teens in the UK. Recently, their training session was recorded, so you can listen to it and hear how reasonable it is. There are also transcripts.

The man who clandestinely recorded it clearly thought he was being so brave going undercover, challenging the trainer. There was a shock, horror article about it in the Times. When you listen to it, you can see that any gender critical person who was not prejudiced about trans people, would find it unobjectionable. The Times article is a complete distortion of what is said.

The trainer, who is lesbian, proves the Times wrong. “Trans ideologists are spreading cod science,” says the headline- no, her statistics are clear. She starts by talking about “gender reveal parties”. We find out what is between the foetus’ legs, and it becomes he or she, and so we get pink or blue clothes. “Lots of children don’t fit those boy and girl boxes.” Lots of things are on a spectrum. People have different heights and skin colours. On a scale of 1 (Princess Barbie) to 12 (GI Joe) the trainer puts herself as a 5. Yet the Times claims the two extremes are the only alternatives given. It is a deliberate misrepresentation of a subtle argument that gender varies between everyone, not just trans people; and some people are gender fluid, being one style at one time and one style at another. “We’re not all one thing,” she says.

The Times mocks talk of jelly babies, but it would help participants become playful and so permit them to think in less rigid ways. As the audience shows, everyone knows the extreme stereotypes, which are strongly emphasised by the culture. Gender identity is different from sexuality, but neither may be controlled. Some people are intersex.

Jan tells her own experience. She had no problem being a tomboy, but in the early seventies was terrified of people knowing she was lesbian, as a child, but being a boy who likes “girlish” activities is different. GI Joe is a stereotype, cultural not innate, but “when people buy into it it becomes real”. She began to define trans and cis, but the interloper interrupted, and put her off track. Then she defines non-binary and gender fluid. Some people identify as queer, and some people hate the term. People can socially transition without transitioning medically. No-one need know a trans person’s operation status. Trans women can be gay or straight- a straight trans woman is attracted to men. Younger people are far more comfortable with gender fluidity.

She speaks movingly of when she internalised homophobia. “There are places where I would be in danger, and people… who hate me because of who I am.” That is, lesbian. It’s like carrying a heavy weight. She wants being queer, or trans, to be not an issue any more. She explains pronouns and misgendering, how painful it can be.

She gets gender incongruence slightly wrong. It’s not a psychological condition in the draft ICD, but that ICD has not yet been approved. There is evidence of a biological underpinning to trans. There are positive role models visible in society, lesbian and trans. She refers to brain research, and googling I found this. Always there is new research. 1% are trans, she says, though not how many of them transition.

She explains the history of Mermaids, supporting trans children and their parents. 40% of those children cannot be out at home, so schools should support them. She explains the Equality Act and the difficulties LGBT people can face from family and society. Maybe 10% of the population are bigoted against us, so the rest should be mindful of that and speak up for us.

When a child is fully supported to lead their own transition, their mental health is the same as their peers’. When the child is prevented, their mental health suffers. Because parents are resistant, and GPs may be unsympathetic, schools can refer people to the Tavistock and Portman clinic, the Gender and Identity Development Service for under 18s. After a long series of assessments, where medically indicated, a child may be given puberty blockers. Low doses of cross sex hormones are not given to children under 16, and rarely to older children. The youngest child seen is 4.

Attendees should research further, at the Tavistock website and Stonewall. They should challenge stereotyping, and be able to tell children about available support. Children can change their name officially, and choose a name to be known as in school. Staff should be told of transition on a need-to-know basis, and it should be treated matter-of-factly: just as a woman may change her name on marriage, so a child may change gender presentation. Mermaids can help schools with any necessary policies.

Janice Turner in the Times clearly finds all of this unobjectionable, as she attacks things Jan the trainer did not say. The man making the recording tried to challenge the trainer, claiming that her suicide statistics were wrong, and that she had based them on a survey of 27 self-referred people, though she had referred to the Stonewall School Report, which says at page 7 that 45% of more than 592 trans people had tried to take their own lives. He claims that the suicide statistic is used to put pressure on schools, and minimises the evidence of suicide attempts. He is not an honest reporter. The second recording ends abruptly, and it is not clear what happened after that.

Similarly, the transcripts are made by anti-trans campaigners, and are littered with inaccuracies. For example, where the anonymous recorder spoke of “dysmorphia” the transcript records it as “dysphoria”. There are also sarky asides- where the trainer is assertive, it calls her “really really cross”. It says [long, looooooong pause for us all to reflect on whether it’s wise to challenge Mermaids woman further. Clearly no one else is prepared to take her on] Actually, it is at most five seconds.

The transcripts are misleading. They put in headings which are not on the audio, such as Help kids to socially or even legally change their name. You don’t need to tell the parents. In fact, feel free to ignore their authority! You would think a feminist would have heard of Gillick competence: children can decide whether their parents should hear about their medical treatment. Mostly, though, the transcripts do not seriously distort the message of the trainer, if you ignore the headings.

Audio recording part 1 part 2.

Googledocs transcript part 1 part 2.