Some of you might remember my daughter Katie, who collaborated with me on a book review a few years ago. She’s now twelve, she’s still opinionated, and, when the subject of the anti-trans-mythbusting I was doing on the blog came up in conversation with her, I had a spur-of-the-moment idea; what if I interviewed Katie on the subject of anti-trans myths? I wanted to see what her reaction would be to some of the ideas that were getting put forth.

I hadn’t expected Katie to be keen on the idea, but, in fact, she was; I went ahead without further ado before she could lose interest. I’ve posted the full recording here (it was too large for WordPress to handle easily), but, as it’s just about as polished as you’d expect from an unprepared interview of one untrained person by another untrained person recorded with only the equipment available on a mid-range laptop, I’ve written up a redacted version for this blog.

The interview

I started with the oft-raised concern that the increasing numbers of people choosing to transition are an indicator that people are getting pushed into transitioning.

“Well, that isn’t how that works,” Katie stated. “How it works is because transgenderism wasn’t accepted in the past; so it’s like, well, people wouldn’t be transitioning in the past because they weren’t allowed to. Now they’re allowed to, so they’re going to.

Can I just clarify that you are only trans if you yourself know that you are actually one gender instead of the other?” she went on. (I’ll explain to her about non-binary genders another day; at this point I didn’t want to break the flow.) “If someone says ‘oh, you’re trans because you like boy stuff more than girl stuff’… it’s the 21st century! There is no ‘oh, girls play with dolls and boys play with – I don’t know – sports and stuff’; that isn’t a thing any more! Boys can play with whatever they want… and trans people are the people who are physically one gender but mentally, actually, and truly another, and they get referred to as their true gender rather than their physical gender because that’s just simply how things work.”

“One of the fears,” I told her, “is that somehow doctors who specialise in transition medicine wouldn’t know all this.” I explained the concern that children with interests typically associated with the opposite gender might be misdiagnosed as trans and advised to transition.

“I’m pretty sure that a professional doctor would get taught not to do that,” Katie said, practically rolling her eyes. “You yourself are a doctor; you’ve been through… how many years of medical school?

“Five.”

“And I presume that a transition doctor would go through the same amount, right?”

I confirmed that this was the case, adding that doctors had years of specialty training after graduation as well.

Katie was not impressed by the concern that someone with that many years of training would be trying to talk unwilling people into transitioning. “Their job is to take people who want to transition and transition them, not to pick someone off the street and say ‘You’re trans now! Go be trans!’ even if they do like stuff that’s like ‘boy stuff’, not ‘girl stuff’… you’ll have to imagine the air quotes,” she added to the microphone. “Isn’t it just that someone who’s already trans but just hasn’t had the transition yet… isn’t it only they that go up and say ‘Can you transition me?’ You don’t just go in there and say ‘Hey, I’m a girl and I kind of like wearing trousers’ and get told ‘You’re a trans boy!’ That’s not how it works.”

I brought up the Littman study, an infamously badly-done study supposedly showing that young people are now subject to a new disorder called Rapid Onset Gender Dysphoria. Littman’s evidence for this was that, when she interviewed parents via anti-transitioning websites, they reported that their children only came out as trans after spending time with groups of new friends who often came out as trans at approximately the same time; Littman felt the likely explanation for this was that non-trans adolescents were being convinced they were trans by peer pressure. The flaws in that methodology seem glaringly obvious to me, but I do have some professional training in the basics of critiquing and interpreting studies, so I don’t know how obvious they are to the average person without training. I was curious to see what Katie would make of it.

“I think,” Katie told me, “rather than it being that a bunch of them had come out as trans and they’re like ‘Oh, well, you be trans too’… I think it’s less of that and more that they might not mentally think to themselves that they were allowed to be trans, but after their friend’s transition they might start realising ‘People do this, I myself personally allow myself to get transitioned’.

I mentioned Littman’s finding that the parents in the study reported that their children spent a lot more time on the internet prior to coming out, which, again, is supposed to be evidence of… something nefarious going on. What, I asked Katie, did this sequence of events suggest to her?

“They went on the internet,” she replied, “and, being the internet, it would probably have mentioned something to do with transness, they might have looked into that more, done a bit more research, ended up on some online group for people who think they might be transgender, and they would have properly discussed things there and then thought to themselves “You know what, I think I might be transgender.”

So, there you are, that is how obvious the flaws in Littman’s study are: some of them can literally be spotted by a bright twelve-year-old. (If you’re interested in a more detailed analysis, check out the multi-post analysis by Zinnia Jones on the Gender Analysis blog, starting here.)

The final topic I raised was the ‘Which Bathroom?’ debate. Katie gave this some thought, saying it was ‘a bit difficult’; she felt that, because ‘a bunch of the other people there might be uncomfortable with seeing other genitals’, it was better to have ‘the trans person shower or whatever in a private room separate from other people’ for anything involving nudity. However, she went on to make her overall opinion on the question clear:

“[T]hey should go with their proper true gender, not their physical gender,” she told me, “because, if you’re really going to stare at someone doing toilet stuff, you’re either a) a parent helping out a young child, which is reasonable, or b) why are you doing that that’s really creepy please stop.” I liked her framing; her response to people bothered by the prospect of possibly seeing trans people’s genitals was to place the issue not with trans people but with whoever was paying so much attention to other people’s genitals in the first place.

I brought up the fear that’s always brought up in these cases; the ‘what if a sex abuser pretended to be trans to get into a women’s public toilet and abuse someone?’

Katie’s immediate response was to object to the implicit idea that sexual abuse only affects women. “Let’s be honest here, this can go either way,” she told me. “That’s another discussion that isn’t right now, but I do feel like there’s a whole thing about how only women can be sexually abused… that’s not true.”

She turned her attention back to the question, which she thought was an interesting problem. “Since things like that [toilet cubicles] are closed off anyway… hmmm…. since the majority of those people [just to be clear, she meant people trying to use toilets of a gender opposite to their birth genitals, not trans people] would be actually trans, we should just go with what will help the majority and put in whatever current measures we have to stop things like that. Surely instead of stopping people faking trans to sexually abuse people, we should stop sexual abuse? That’s the point we need to stop. We shouldn’t worry about all the separate categories.”

I brought up the point that I discussed in my previous post. “If a man wanted to walk into a women’s toilet for purposes of sexually abusing someone, why would he have to pretend he’s trans when right now no-one is actually stopping you to check what sort of genitals you have anyway before you go into the toilet, and it would be incredibly rude if they did?”

Katie thought that was a good point. “Say they’re not trans; that’s just an inconvenience because no-one wants to have their genitals seen. And if you are trans, it’s like that would just feel so personal; it’s like they’re questioning your right to go into those toilets because of your transgenderism.” She agreed that a man who was determined to get into a women’s toilet to abuse someone would do so regardless of rules.

“Once again,” she summed up, “the problem isn’t anything to do with transgender. I’m really not sure how to tackle [abuse], but that’s a separate discussion.”

 

Some further thoughts

I did this interview partly because I love hearing my daughter’s thoughts on issues. But there’s another reason that I only fully articulated to myself as I wrote this up, and it relates to something I’ve realised about the anti-trans movement.

For many people, the attraction of the anti-trans movement is that it frames itself around the idea of protecting others. Transphobics claim that trans rights put cis [the term for non-trans] women and girls at risk of assault and put cis children and adolescents at risk of being somehow convinced to have transitions they’ll regret. While these claims don’t stand up to examination of the evidence, they’re powerful because they sound superficially plausible. And that allows transphobics to paint their views as necessary protection for others, rather than as prejudice or ignorance.

Now… my daughter, as a female adolescent, is at the intersection of the two groups anti-trans-rights lobbyists convince themselves they’re protecting. It doesn’t stop there, either. She’s thought for years that she’s probably gay, though at only twelve she’s still working out her sexuality. She’s almost certainly autistic (she’s on the waiting list for an official diagnosis). She’s struggled with physical aspects of female puberty. She’s struggled with discomfort with her body for reasons unrelated to being trans. She has mental health issues that make her potentially vulnerable. Apart from not being butch, she is pretty much the poster child for someone who, according to anti-trans rhetoric, would be at risk of dire consequences if trans rights are increased. Anti-trans lobbyists are using the existence and problems of thousands of young women as an excuse to deny thousands of other people their rights, and one of the young women they think they’re protecting is my daughter.

Well, I wanted to give my daughter a voice in that. And, as it turned out, that voice is firmly in favour of trans rights. My strong, funny, smart, complicated, wonderful daughter isn’t afraid of trans rights. She isn’t fazed by the existence of trans people. She doesn’t feel that making life more difficult for trans people will somehow solve her problems, because she understands that her problems are nothing to do with trans people or their rights.

When I finally did articulate this in my mind, I put it to Katie. How, I asked, did she feel about the thought that people opposing trans rights were doing so in an attempt to protect people like her? She cocked her head to one side and addressed a firm message to anyone holding those views.

“I appreciate your concern,” she stated, “but shut the frick up.”

(A very brief message to anyone who doesn’t know the background: The letter to which I’m replying is here, and was posted by JKR after numerous concerns about her views on transgender issues. The backstory about the concerns is… pretty much everywhere on the internet, so if you haven’t already seen it just search.)

 

Dear J.K. Rowling,

OK, this feels… seriously strange. I’m writing this to you but also to others reading or following the current discussion (I do plan to post this publicly on my blog) so it seems strange addressing it to you when I know that, realistically, out of all the people who might read it, you’re one person who almost certainly won’t. But I’m doing so because thinking of this as something you could potentially read keeps me focused on the fact that what I write here isn’t just addressing a collection of views and statements I disagree with, but a human being with real feelings about this.

So. I’m writing this because, having followed the story so far about things you’ve said on transgender-related subjects, I’ve now read the letter you posted on your website. And, whatever else I’ve thought about your views on this topic and how you’ve expressed them, I think that letter was an incredibly brave attempt to open up about something that’s really hard for you and about which you have genuine concerns, and I also know you speak for a lot of people who feel the same way.

And I also disagree with almost every point you made.

So what I want to do… well, I struggled to put this into words, but then realised you’d already done it for me. You wrote:

All I’m asking – all I want – is for similar empathy, similar understanding, to be extended to the many millions of women whose sole crime is wanting their concerns to be heard without receiving threats and abuse.

That’s it. That nails it. I want to be able to hear your concerns and extend sympathy and understanding and also extend that same empathy and understanding to the many, many trans people out there who also desperately need their concerns to be heard and understood without being met with threats or abuse. I want to keep that sympathy and understanding for all concerned at the forefront of my mind as I talk about the points you raised and explain why I disagree. And I hope that, even though you yourself will almost certainly never see this letter, at least some of the people who feel the same way as you will be willing to read what I write in that same spirit and to try for a greater overall understanding.

There’s so much in your letter I want to talk about, and it’s going to take me more than one post to do so. But in this post I’m going to skip straight to your last point, because it’s the nub of the whole thing. What you’ve voiced, here, is a fear that a lot of people hold. And I think that fact gets obscured sometimes by the way these same concerns are so often used as excuses by bigots to justify anti-trans agendas held for much darker reasons; in the midst of the damage those people cause, it’s easy to forget that many people quite genuinely are scared of the scenario you’ve just voiced here:

At the same time, I do not want to make natal girls and women less safe. When you throw open the doors of bathrooms and changing rooms to any man who believes or feels he’s a woman – and, as I’ve said, gender confirmation certificates may now be granted without any need for surgery or hormones – then you open the door to any and all men who wish to come inside. That is the simple truth.

Firstly, before doing anything else, I want to correct one point, which is your claim that ‘gender confirmation certificates may now be granted without any need for surgery or hormones’. I think this might be technically correct, in that the current law in the UK doesn’t specify that a transgender person needs to have done anything physically about transitioning before applying for a GRC. It does, however, specify that a person can only apply if (among other restrictions) they have lived as the gender in question for two years and are over 18, and that sounds as though it would in practice be virtually impossible to do without physically transitioning. Also, from what I’ve read, getting a GRC is incredibly difficult under the current system; it certainly doesn’t sound as though, in practice, one would be issued to anyone who hadn’t already transitioned.

People are certainly campaigning to have GRCs issued much more easily (with good reason, from what I’ve read in the previous link), but, as far as I’ve been able to find out, the law hasn’t yet been changed. So, the law you have concerns about is actually a proposed law rather than one that’s currently in place. I know that doesn’t in itself affect your concerns, but thought it important to get the facts straight before starting to discuss them.

Anyway. The fear I assume you’re alluding to here – the one shared by many other people who have concerns about trans rights – is that making it easier to gain a gender recognition certificate will lead to male abusers fraudulently gaining gender confirmation certificates naming them to be female in order to enter bathrooms or changing rooms to… oh, well, you know the rest. And I get that that’s a prospect that many people find really concerning (especially, as you said, people with a history of abuse who can find it quite viscerally terrifying).

Here is what does not make sense and has never made sense to me about this scenario, though. Please tell me if you think I’m missing something, but…

Nobody has to show proof of gender to get into public toilets or changing rooms anyway.

(Warning: this discussion has the potential to be triggering to people who fear the thought of male abusers getting into women’s spaces.)

There is no-one standing outside women’s toilets making sure only people who are legally female get in. There usually is someone standing outside changing rooms, but that’s only to make sure people don’t steal the stock; I’ve never heard of anyone checking documentation on the people who go in. So, how does having or not having a gender recognition certificate make any practical difference to these things at all?

As far as I can find, it isn’t even illegal for men to enter women’s toilets. I mean, stop me if I’m wrong about that; I’m not a lawyer, I’m someone who spent five minutes doing an internet search. But I can’t see how it could, in practice, be made illegal for men to enter women’s toilets without causing masses of problems. There are cleaners who are male, there are severely disabled people who need help in toilets and have carers of the opposite gender, there are times when one set of toilets is out of order and the only option is to let people into the other set, there are people with medical conditions that mean they sometimes need a toilet so urgently they can’t take even a few seconds to run round a building looking for the one they’re supposed to be in. There are also thousands of transgender people who don’t have a gender confirmation certificate and thus, even if they’ve transitioned, are still legally recorded as whatever gender was assigned to them at birth. A blanket law stating that men can’t go into women’s toilets would affect people from all those groups… without actually doing much about the very group that we’re worried about here, since a sexual abuser is pretty much by definition not put off by the prospect of breaking the law.

Why is there all this worry that an abuser might go to the work of filling out a form and paying a fee (currently £140) to get access to a public toilet, when he can just walk straight in anyway?

I get that, for the people who are scared about this, that probably doesn’t help much. I get that fears aren’t logical and don’t just vanish as a result of being told that the thing in question isn’t actually harmful. I get that trying to put legal barriers in the way of people with male anatomy or male chromosomes getting into female spaces makes some women feel safer even if it isn’t doing one darned thing in practice to make them safer. I get that fears of things that don’t in practice actually increase your danger level are still fears and still horrible and still real and important emotions. I feel deep sympathy for any woman or girl who’s frightened by the thought of a person with a penis possibly being in a public toilet next to the one she’s in. I hope that anyone who does feel that way has help and support to deal with her fears, and if you have any ideas that might help you or other people affected by this fear feel safer without harming or risking another group of people, I would love to hear about them and see them implemented.

But ‘keep gender confirmation certificates difficult to obtain’ isn’t such an answer. The reason people are campaigning to make GRCs easier to obtain is because the current process is horrendous. (See also this article which I linked to above.) So, when you advocate keeping GRCs difficult to obtain, you are in fact supporting a system that causes massive problems for transgender people without having any actual benefit.

It’s even worse than that, though. In the USA, this myth about trans rights increasing the risk of sexual abuse is one that is being deliberately and actively weaponised by powerful hate groups with anti-trans ideologies. Warning here for descriptions of very serious assaults at some of the following links… because this climate of whipped-up fears drastically increases the risk of assault on trans people generally, and it also increases the risk of public bathroom use for any woman who can potentially be mistaken for a man, whether this is because she actually is trans, because she’s gender non-conforming, or because she just happens to look androgynous. Trans people have to live in fear of something as simple and everyday as using public bathrooms, because for them it is actually dangerous to do so.

I don’t think the UK is as bad from that point of view – we don’t have the Religious Right to the same degree as they have on that side of the Atlantic – but trans people here still suffer transphobia and anti-trans bigotry and even violent assaults, and the fears you’ve described here are a big part of what drives this. I believe you completely when you say that this is not what you want, that you want everyone including trans people to be safe and protected and free from harm. But good intentions don’t mitigate the effects of supporting harmful policies; the policy you’ve just supported above (not to mention the transphobic activists whose pages you read) are, in practice, contributing to the climate that causes these assaults.

So, when I disagree with you, when I stand up against the beliefs you’re supporting, it is not because I dismiss your fears. It is not because I don’t sympathise or want to help. It is because your fears and my sympathy should not be used to support actions that, while doing nothing to change the risk of the abuse you fear, will increase the abuse risk for transgender people and the level of other problems they face. It’s not OK for them to be the collateral damage of your attempts to ease your fears.

J. K. Rowling, if you do ever read this, thank you for all the joy your books have given to me and to my daughter over the years.

Be well,

Sarah

 

(I will hereby stress once again that all comments – from whichever side of the issue – should be polite and respectful. Yes, this means you. Think of how you would wish someone to talk about an issue that’s extremely sensitive to you, and use that same level of respect. Thank you.)

Since I didn’t have time to write something myself, here’s a round-up of posts on the subject from FTB-ers:

In Happy International Day of Trans Visibility! Abe Drayton from Oceanoxia has put together a collection of links on the subject.

In With Head Held High, Rhiannon from Intransitive points out the importance of greater visibility for marginalised groups, so that members of those groups aren’t left self-blaming and alone. From this post, I also found the Tumblr Assigned Male, which uses some rather nice cartoons to explain transgender issues.

In I made a video for the Trans Day of Visibility, PZ Myers at Pharyngula posts… well, a video he made, obviously. It’s called ‘The Fallacy of Biological Sex’, and seems to mention something about myths about athletes, which looks interesting.

In The Invisible Queer, Great American Satan at the blog of the same name muses a little on being genderqueer.

Best wishes for rights and societal acceptance to people everywhere, and may transgender people everywhere get to enjoy the comforts that so many cisgender people take for granted.

Siobhan, a blogger on this site, has posted an article on one Dr Les of Calgary, titled Calgary Physician Calls Transgender People “Demented, Distorted”. She quotes, with links, multiple examples of frighteningly transphobic comments Dr Les has made on his blog or Twitter account.

In the post at the first link Shiv gives, for example, Dr Les dismisses gender identity as a belief that’s ‘soft-headed’, ‘blithering idiocy’, and ‘dangerous bunk’. He also describes the AAP guidelines on care for transgender youth as recommending that transgender children be ‘ushered post-haste down the injurious road to sex reassignment’, which is, quite frankly, a bare-faced lie. (And a very dangerous lie for transgender children whose parents make the mistake of trusting Dr Les to be honest with them on this point and don’t check the guidelines out for themselves to see that this doesn’t remotely represent the advice they give. This dishonest scaremongering could put people off seeking the help their children need.)

This is really bad behaviour from someone who, as a doctor, has a responsibility to show the public a better side. It’s horrifying that he feels it appropriate not only to hold these kinds of bigoted, simplistic beliefs without finding out more, but also to express them in such insulting terms.

You can read more in Shiv’s article; she’s read more of his work than I’d be able to stomach.

Quick background: This is a follow-on from the post I wrote in response to SkepDoc Harriet Hall’s sadly misleading post Gender Dysphoria in Children. In my reply, I challenged the myth that children with gender dysphoria are being pushed or rushed into transitioning at very young ages. In fact, international medical guidelines on the subject are clear that medical treatment for children with gender dysphoria should not be started prior to puberty (for more on recommended management of younger children with gender dysphoria, see Part One).

I’m writing Part Two because I realised there is a fairly obvious follow-up question that readers might have; while that’s all well and good, why are children starting medical treatment for gender dysphoria during puberty? After all, at this stage they’re still children. Surely, runs this line of argument, it would be better for them to wait until adulthood before any decision is made about medical therapy with its possible (or definite) long-term consequences? It’s an argument that sounds superficially logical and has convinced many people.

Unfortunately, there is a huge problem with it: Children’s bodies are not going to wait. When the decision arises as to whether a pubertal child with gender dysphoria should start medical treatment or not, the alternative to treatment is not going to be that everything remains comfortably in status quo for several more years while the child grows up. The alternative is going to be that the child goes through the significant biological changes that come with puberty.

For a child with persistent gender dysphoria, this is a very big problem. If you read Part One of this, you might remember the Steensma et al research study that looked at the differences between ‘desisters’ and ‘persisters’ with gender dysphoria, and found that the onset of pubertal changes had been a key point for the children they surveyed; while those changes improved the desisters’ feelings of gender dysphoria, they worsened the gender dysphoria symptoms for the persisters. A lot. Children who already felt uncomfortable and out of place with having a body whose gender didn’t match theirs were faced with that body developing much more specific features of that gender… and they found this quite a horrific sensation.

It was terrible, I constantly wanted to know whether I was already in puberty or not. I knew about the puberty blocking treatment and I wanted to be in time. I really did not want to have breasts, I felt like, if they would grow, I would remove them myself. I absolutely did not want them!

I noticed the Adam’s apple of my brother, and an uneasy feeling stole upon me. If I would get an Adam’s apple like his, I did not want to live.

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

As soon as puberty started, I could no longer be myself. A boy does not have breasts. As a child it didn’t matter that much, boys and girls don’t differ except that boys have a penis, and girls don’t. But the way I was changing was very wrong. I couldn’t hide it anymore.

At the time my breasts started to grow, I wanted to hide them. I always tried to wear loose shirts. I felt so insecure that I didn’t want other people to see me. So I frequently skipped school and they suspended me. Then I became even more withdrawn.

Before puberty started, I felt physically a boy, but when my breasts started growing, I felt more like a mutant.

(quotes from young people with persistent gender dysphoria in Steensma et al., ‘Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study‘, Clin Child Psychol Psychiatry 2011; 16(4): 499 – 516)

(With regard to the suicidal impulses expressed by some of these patients; yes, this is a very real risk. Several studies have shown a very high rate of suicide attempts among transgender people, and many of these work. Transitioning, and general acceptance and support from others, have both been shown to decrease this risk significantly.)

Imagine, for a minute, that you read or hear a story about doctors at a gender identity clinic forcing a child to go through puberty in the gender that isn’t theirs, against that child’s wishes, even though the child was distressed about it to the point of suicidal unhappiness. We’d all be appalled at the thought. Well… that’s what children with gender dysphoria of this severity go through when made to experience puberty without medical treatment. Their body doesn’t match their gender identity; when they  go through puberty, they’re having to deal with their body becoming more and more obviously that of a gender that isn’t theirs.

As though that wasn’t bad enough, forcing children to endure the wrong puberty has long-term consequences as well; that child is now going forward into adulthood with physical changes that are much harder to reverse. If that child is a transgender girl (a child with the physical body of a boy, but with the internal gender identity of a girl), then she’s had to develop facial hair, stronger facial features, and a deep masculine-sounding voice. She’s going to be stuck with the choice between either having a lot of difficult (and expensive) procedures to reverse these, or spending her life looking and sounding noticeably male even once she starts taking hormone treatment to transition (with all the considerable social stigma and unpleasantness that this will cause her). If that child is a transgender boy who wants to transition physically, his eventual transition will have to include surgery to remove the breasts that could have been prevented from growing in the first place.

There are times in life when doing nothing is a decision. It might be a default decision rather than an active one, but it’s still a decision and it still has consequences. When a persistently transgender child has started puberty, is becoming frantic with the changes, is becoming ever more certain about their decision to transition, is faced with puberty still proceeding apace… then that’s one of those times. In such a situation, doing nothing – withholding medical treatment, insisting that the child has to endure all these changes for years more before being allowed to start treatment for them – is outright harmful to that child.

Of course, it’s also preferable for children not to be making a final decision about transition at that point. After all, we’re talking here about children who are in the early stages of puberty, hence in their early teens at most and in many cases younger than that. Whatever myths you might have heard about gender identity clinics, the professionals there are in fact fully aware that children might change their mind, and are not in any sort of hurry to rush a young child into anything irreversible or even difficult to reverse. So, when a child with persistent gender dysphoria is finding that the early changes of puberty are making the symptoms worse and not better, this presents a dilemma.

Here, therefore, is the management that the WPATH (the international) guidelines advise in such a situation:

When, and only when, a child has persistent and intense symptoms of gender identity issues that are getting worse rather than better with puberty, and other issues in the child’s life have been looked for and dealt with so that this isn’t a case of, say, a child making a poor decision due to severe depression or anxiety, and the child wishes to start treatment after a full discussion of the pros and cons with child and family… then doctors will start a type of treatment known as a puberty blocker. This does not cause any physical gender changes; as the name suggests, it blocks the hormones that cause pubertal changes, thus allowing doctors to hit the ‘pause’ button on the child’s puberty and give them a few extra years to make a decision about gender transition. During this time, the child should be under the care of a paediatric endocrinologist who monitors their response to the puberty blocker and is on the lookout for any side-effects.

If the child’s gender dysphoria persists, and remains at such a level that they wish to physically transition, the next step is hormonal transitioning; taking either testosterone or oestrogen, as the case might be, to bring about the bodily changes of the gender with which the child identifies. (At this point, most people do go on to transition – after all, by this stage you’re down to a subset of transgender children with severe and persistent problems – but it isn’t inevitable. Children who decide against transitioning can simply stop the puberty blockers and allow puberty to proceed normally.) While this is, of course, the point at which changes do start becoming irreversible, that still doesn’t happen straight away. This isn’t like waking up from surgery; the hormonally-induced body changes need to be there for some weeks before they gradually become irreversible, whereas if someone finds that the changes towards a different body are distressing then that reaction is going to be present from an early stage. So, even at this point, we’re still talking about having some leeway to stop things; you haven’t committed irreversibly to gender transition from the moment you swallow your first pill.

The decision about whether or not to transition hormonally is generally taken and implemented around the age of 16, though that’s not an absolute. Again, this is a compromise; the desirability of giving children as much time as feasible to make this decision has to be weighed against the distress of being in a wrong-gender body plus the psychosocial and sometimes physical ramifications of postponing puberty.

As for genital surgery, the guidelines advise that this should be postponed until adulthood. (They also advise waiting until the person has lived as the gender in question for at least twelve months.) It is worth noting here, by the way, that surgery is by no means an inevitable step of transitioning; it’s the one step that everyone who doesn’t know much about transgender treatment will focus on, but in fact many transgender people find that transitioning with the use of hormones is enough for them and that, once the rest of their body matches their inner gender identity, they can deal with having a wrong-gender set of genitals. Either way, it is recommended that this step not be taken prior to adulthood.

Now, hopefully it should be clear by now that the reason for this protocol is that so far it’s the best compromise that exists between the potential risks of treatment and the known risks of not treating an adolescent with severe gender dysphoria who is distressed by pubertal changes. Whatever myths you might have heard, no-one is recommending this because they are oblivious to the potential side-effects of medication or because they think that prescribing for a child is an ideal and sought-after situation. It isn’t. The ideal situation would be for everyone to be born into a body that matches their own inner gender, so that transgender problems wouldn’t exist. For that matter, the ideal situation would be for no child ever to have a condition serious enough to need medication; I don’t know of anyone who wouldn’t be delighted with that situation.

But that, of course, isn’t the situation we’ve got. We have the real world. Some children have serious, or potentially serious, medical conditions which do require treatment; not because medicating children is ideal, but because the consequences of not prescribing for a child with a serious problem can be worse. One such problem is severe gender dysphoria. We can leave children in such a situation to suffer the consequences of an untreated condition – knowing there is a high risk that those consequences will have a serious and significant impact on the child – or we can offer them treatment. It’s hard to believe that any of us would choose the former option were it any other medical condition involved. Why should we do so for children with gender dysphoria?

A few weeks ago, the British Medical Journal carried two educational articles about management of gender dysphoria in the non-specialist setting (one written by a gender dysphoria specialist with input from patients, and one a collection of advice from transgender people). Transgender people can have some significant problems with healthcare both for their gender dysphoria care and for their general care, so, although this only affects a small minority of the population, this is an issue it’s important for me as a GP to be aware of.

I have a separate site where I keep the notes I make on any medical articles or educational modules I read, in order to refer back to them later. This time, however, I thought I might post them here; after all, transgender health care is an important topic to many people here. Here are the points covered by the articles:

• When someone comes to you expressing problems with gender identity (‘you’, here, meaning GPs, not the general population), offer them referral to gender identity services ASAP. Waiting lists are horrendous, so, if a patient does want to explore the possibility of transitioning, the sooner they get on the waiting list to do so the better. As a GP, I’m very schooled in the approach of “let’s wait a bit and see how this goes with time”, and for a large proportion of the patients I see that is perfectly appropriate, but gender dysphoria is one of the situations where it isn’t. The gender identity services themselves will be the ones who can offer expert assessment and help patients reach an informed decision regarding transitioning. (As one of the patients in the second article pointed out, gender identity treatment has one of the highest satisfaction rates of any branch of medicine. Puts the desistance myth into perspective, doesn’t it?)
• Take the trouble to find out what name and pronouns your patient wants to use, and use them. That, frankly, is just basic courtesy. However, be aware that, for safety reasons, a patient may need letters to be addressed to their old name for the time being (if they’re living with family members who are against the transition and unsupportive or even threatening over it). Use their new name and pronouns when discussing them with other healthcare personnel; it’s a way of respecting their gender even when they’re not there.
• Transgender people who haven’t yet accessed proper treatment may be self-medicating with hormones purchased online. Ask about this and advise that it does carry risks and that ideally it should be stopped until the person is seen by the gender identity clinic. Of course, given the waiting lists, there’s a gulf here between ‘ideally’ and ‘bearably’. If a person can’t face stopping medication for the time it’ll take to get seen, advise them to let us know of side effects and to let healthcare practitioners they see know about the medication.*
• Suggest informal on-line support groups while a patient is waiting to be seen. Tranzwiki.net was the example given.
• Some surgical treatment can take place locally, such as hysterectomy/oophorectomy; however, do bear in mind that a person who has become visibly male may feel very awkward about attending a gynaecological clinic. One possibility suggested was that a patient in this situation could get a woman to accompany him to the clinic, if possible, so that he wouldn’t stand out as a solitary male in a sea of female patients.
• Screening can raise unexpected problems. For one thing, gender-based automated systems in the NHS are not set up to deal with patients who’ve changed gender, and so they may not be called automatically for screening they should actually have (aortic aneurysm screening for MTF, cervical screening for FTM who still have a cervix in situ). Remember that the form that goes with the sample will need to clarify what’s going on so that the lab doesn’t simply assume that the cervical smear sample labelled as coming from Mr Fred Jones, M, to be a mistake. For another thing, the screening tools for things like risk of cardiovascular events or fractures include gender as one of the factors used to calculate risk, and the data on transgender people in this context simply doesn’t exist. It’s necessary to do some common-sense estimating and explain the uncertainties to the person in question.
• On the topic of screening, the article also stated that AMAB women do not need routine mammography as, in the absence of progesterone, their risk of breast cancer is too low for it to be needed.
• Conversely, an AFAB male who still has breasts should be advised to have mammography if in that age group, but may find it distressing to discuss the matter. The article ‘I am your transgender patient’ suggested that talking about ‘chest’ rather than ‘breasts’ might be easier for some men in this situation.
• There isn’t any single rule or guideline for how transgender people feel about their gender, their identity, or their gender-specific body parts. They might be very distressed by some, quite comfortable with others. It’ll vary from person to person. This is one of the (many) situations in medical practice where you have to be sensitive to the person’s cues and willing to find out their wishes and to follow their lead.

 

*This, of course, raises the question of whether GPs in that situation should prescribe hormones themselves rather than leave the patient with the risks of buying hormones on-line. This wasn’t covered by the article. WPATH guidelines do touch on the possibility of ‘bridging’ prescriptions, but it’s a complicated issue that carries the risk of major medicolegal problems for the GP if they prescribe outside their area of expertise, and there are very good reasons why GPs would typically be unwilling to do this. This is beyond the scope of this particular article, which is why I haven’t gone into it further here.