Here Dr Sam Hall, GP and trustee for The Clare Project, gets behind the headlines with a studied look at the issue
(names have been changed to protect individual identities)
Gender critical protagonists are on the warpath about puberty blocking drugs in trans teenagers. Their use has been likened to Nazi experimentation, main stream news outlets are giving column inches to their misplaced and often uninformed fury, parents seeking this treatment for their child (and the children themselves) are often subject to harassment, and clinicians who prescribe it fear for their livelihoods and reputations. Using hormone blockers to help young people with gender dysphoria is a widely accepted yet controversial practice. How have we ended up here? In a place where a medical treatment which we know works, is relatively safe, and can save lives is also the subject of such fierce debate in non-medical circles that across the pond in some US states, legislation is being considered to prevent its use outright. And in the UK, the single clinic providing this treatment is under intense scrutiny from the media and its own commissioner, NHS England.In the USA, land of extremes, paediatricians dealing with trans teenagers are readily prescribing hormone blockers to young people with gender dysphoria, and consider the treatment as gender-affirming. The position is that this treatment, if desired by the patient, is likely to reduce minority stress – a term that describes chronically high levels of stress faced by members of stigmatized groups – and all the consequent mental ill health that accompanies it. A recent article published in Pediatrics, the journal of the AAP (American Academy of Pediatrics) in Feb 2020 confirms this view. It describes a cross-sectional survey of a cohort of over 20,000 trans individuals aged 18-36, looking at the impact of hormone blockers.
Interestingly, over 80% of respondents when asked said they did not or would not have wanted puberty suppression. So let’s start with unpacking that statistic – most trans people if asked, will say that had they been offered puberty suppression, they would not have chosen it. This is what we call retrospective data, it does not replace real time info about trans teens right now, but it does give us some idea of numbers, and why today’s scaremongering is both misplaced and dangerous. Dangerous because of the 17% who said they would have wanted hormone blockers, only 2.5% actually got it. And that 2.5% were much less likely to think about killing themselves. Moreover, this statistically significant mental health benefit followed them into adulthood. In other words. these kids do better.
We know that trans people suffer significantly higher rates of suicidal ideation (thinking about suicide), higher rates of attempted suicide, and higher rates of completed suicide, than a comparable cisgender population. We know that much of this mental ill health stems from the stigma and suffering that accompanies a trans identity, and we know that for many, having gender-affirming treatment such as taking cross-sex hormones, and for some, surgery, can relieve these symptoms. This survey also tells us that if puberty suppression is offered to those who desire it, their mental health outcomes in the longer term are significantly better. This feels like a no-brainer to me. So why are we even having this discussion in our national media, on TV and radio, in on line forums and chat rooms, right wing religious circles, and political parties? This study is yet more evidence that the current treatment pathways for trans children and young people as well as adults, are the right ones.
For a young child, in a supportive environment, the solution to gender dysphoria is far less complicated than we imagine. Just allow them to be who they are. This approach is widely endorsed as being the most successful in terms of the child’s wellbeing, and for most parents that is the only real concern. Surprising though, how difficult this can actually be for families, schools, parents and siblings to achieve, even if they are on board with their young person’s need to be seen as a different gender to the one they were assigned at birth. Sometimes the judgements that come thick and fast are internal, sometimes external, but it’s never the child who has a problem. Transition is not complex for them. The younger the child, the less the shame; a change in attire, perhaps a different name, the agreement that the child will switch pronouns and gender. These simple changes are happening all over the country without our knowledge or input. They really are not difficult, and should be readily embraced, especially since the results are so empowering, unless of course people are nasty. Helen, mother of Leah, age 13, doesn’t really understand why, but thinks this may be because people feel deeply challenged about themselves and their own identity when faced with a trans person. The need to deadname, persecute through language and otherwise denigrate trans people seems to be inversely proportional to an individual’s own solidity of sense of self.
Leah is by far and away the more ‘girly’ of Helen’s two daughters; twirling and dancing in princess dresses from nursery age, Helen says Leah herself has never shown any sign of identifying as male. At 3 years old she questioned why she had been given a penis at birth “didn’t the nurse know I was a girl?”. Leah is one of the lucky ones. There is concrete evidence that a supportive family and school surroundings result in a well-adjusted child with fewer mental health issues. A year and a half later her mum took her shopping for girls’ clothes for the first time. The start of primary school signaled a cognitive dissonance, Leah went into her reception year in a boys uniform, but was presenting exclusively as a girl at home. Although her parents grieved (especially her father) the loss of their ‘son’, it was their daughter’s wellbeing that drove them to take the brave step of allowing her to transition in year 2 at primary school. In fact, says Helen, it probably would have happened sooner if Leah had had her way. “She was always very clear that she was a girl”. She had a fantastically supportive teacher and the school did a lot of preparation, including training all their staff.
Leah has been going to the Tavistock & Portman GIDS (gender identity development service) in London since she was about 7 years old. Helen says that their thrice yearly visits have felt like an extended assessment of them as a family and of Leah as a person, with a thinly veiled expectation that she will somehow ‘revert’ to identifying as male. But she never did in the first place. To Leah, being a girl is her normality, although she is perhaps increasingly aware of the difference between herself and her close female friends, all of whom have journeyed alongside her through primary and into secondary school, and who are fiercely protective of her when it comes to transphobic remarks which are still all too common in the ‘playground’. For the last few years, as puberty approached, Leah has shown signs of anxiety and fear related to the potential changes her body might undergo if nothing were to be done to prevent it. She has been fixated on hormone blockers since she became aware that they were an option, and is now six months in to what she sees as absolutely essential treatment in terms of her future wellbeing. She had articulated this to both her parents and the clinicians she sees at the clinic on many occasions, but their reluctance to prescribe was palpable to Helen. “We felt as though Leah had to prove herself as transgender time and again”. Rather than being accepted as the girl she is and having her future as a woman facilitated and supported, the attitude from clinicians appears to almost be one of defeat as they finally acquiesced and prescribed the puberty suppressing drugs. This level of negativity from the only provider of children’s services in the UK has to change. If children later change their minds and decide to revert to the gender they were assigned at birth, we need to view this as a rich and varied journey of self-discovery in the context of a society addicted to a gender binary, rather than seeing a pattern of medical error, misdiagnosis or even that horribly judgmental descriptor “detransitioner”.
In fact, the blockers are a bit of an anticlimax to Leah. She needed to, and does, feel ‘safe’ from the ravages of a male puberty, most especially the fear of her voice breaking, something she sees as a potentially horrifying consequence of testosterone coursing through her body. Thankfully there has been no sign of this, and now that her puberty is being suppressed she can relax. But no. Helen says Leah is on to the next goal. Breasts. As all her peers start to develop, this slight and elfin-like teenager is ready to become a woman, and there is no doubt in Helen’s mind that taking oestrogen will need to happen sooner rather than later.This is where Leah and other children like her come unstuck. The T & P clinic is way behind other providers in the world, especially in Europe and the US, where cross-sex hormones are given alongside blockers, to allow these children to develop contemporaneously with their peers. The London clinic will not consider oestrogen until Leah is 16, by which time she will be a long way behind. The idea behind this delay is to make sure the child has enough time to consider the decision and reach an age which is considered more conducive to adult consent. And yet the clinic also say that they do not view puberty suppression as a neutral option, one that presses the ‘pause button’, giving kids and their families a break from the distress. They see it as a positive step leading to certainty about transition. As if the blockers themselves make it more likely that the child will continue to be trans rather than give up and give in, as appears to be their hope. Helen recalls being told that “there is an argument that puberty should be allowed to progress in order to measure the impact of hormones on your child as many young people change their minds after puberty”. She felt they were suggesting that a good burst of testosterone would ‘sort Leah out’, and that their hope was in allowing her natal puberty to manifest, and somehow ‘cure’ her. It doesn’t really make sense, in medical terms, or in the light of this attitude, to make these teens wait for their hormones. If the puberty blockers have sealed Leah’s fate, why not get on with the next step? Further studies are needed, and some are underway, but individual children like Leah should not be human guinea pigs in the meantime.
There has been a meteoric rise in trans visibility over the past 10 years, with increasingly vocal advocacy and allyship for a previously hidden and ridiculed population of people. A rise in visibility which has provoked a backlash of overt transphobia, but also sometimes subtle and invisible; the denial of existence and rights is in a large part what contributes to the high levels of mental ill health. Of course, there is also dysphoria, a deep sense of discomfort, even hatred of one’s body, which in extreme cases may lead to attempts to self-mutilate. Children as young a four have been reported as suicidal.
There is no doubt that enforced gender norms based on genital biology have a large part to play in the distress these children feel. Gender itself is a largely societal construct, a fact that is agreed by people who are otherwise at loggerheads. Trans people are to some extent, victims of rigidly applied gender norms and social mores, which cannot be broken down fast enough in my opinion. But this will take decades, or possibly even centuries, and in the meantime punishing the victims by denying the best evidence treatment amounts to persecution of the cruellest kind. We are already sacrificial lambs at the altar of gender – don’t torture us as well…
Dr Sam Hall, GP and trustee for The Clare Project
Mermaids is a British charity and advocacy organisation that supports gender variant and transgender youth.
Allsorts Youth Project listens to, supports & connects children & young people under 26 who are lesbian, gay, bisexual, trans or unsure (LGBTU) of their sexual orientation and/or gender identity.