When I am interviewed by the media, journalists often want to focus on the highly emotive subject of transgender youth and specifically their access to gender-affirming hormones and surgery.
I am often asked to discuss the following topics:
- How can someone so young be so sure?
- How can someone want to make such drastic changes to their bodies?
- What about all the people that change their mind?
- But there is no evidence that puberty blockers are safe.
- Gender affirming hormones are irreversible.
- Gender confirmation surgery is such a huge step to take, we must be careful.
- Isn’t it better for these teenagers to wait until they are older before they do this? What is the hurry?
- Surely we must really interrogate these young people, make sure they know their own mind?
- This is just a phase, a modern trend, look at the increase – isn’t this just fashionable?
- There is not enough medical evidence and research available.
I have answered these questions over and over again, and I will continue to do so for as long as it takes. I will share my knowledge and experience with anyone who wishes to listen. I feel I have a unique perspective because I am a medical professional, a critical thinker and a passionate advocate, which means I see the argument from both sides – that of the patient and the doctor.
I have learned all I know from those affected, hundreds of trans youth and their parents, and from the medical literature, which gives me the views, findings and perspectives of other doctors who understand the needs of trans people.
Here I will use this understanding to answer each of these frequently asked questions in turn:
‘How can someone so young be so sure?’
A question that is often asked of trans individuals is: ‘When did you first know?’ In my experience, the answer is always a variation of: ‘I always knew something wasn’t quite right.’ In some cases the individual knew what that something was, and in others it can take years for them to find the language to articulate the way they feel. Some individuals are able to summon up the courage to talk about their experience but the conversation doesn’t go well, others simply are not able to share their secret. However individuals choose to express their gender feelings, let us be clear on one thing: being transgender is not something that simply pops into someone’s head one morning ready for disclosure, it is a sense of something they can’t quite put their finger on which is always there and which often develops over time.
Looking back, parents often agree – they may not have realised it at the time, but looking at photos, school trips, school plays, weddings, parties funerals, shopping trips – the past now makes sense. The language may not have been there to describe it, maybe a fleeting thought that was dismissed, but it was there from an early age.
A simple analogy for me is that of a young toddler with what is known as a ‘Port Wine Stain’. This is the deep red birthmark that can appear anywhere on the body, including the face. When that baby is young, they won’t notice the ‘difference’, they won’t notice that they have one and mum doesn’t point it out. However, as that young child grows, they start to recognise their reflection in the mirror and they start to recognise the similarities – and differences – between themselves and other children. And they notice that they have this mark and others don’t. They notice the difference. And they notice that people may react to that ‘difference’ in many different ways, and that reaction is not always positive.
I have heard trans people describe it in a similar way. They started to realise that they were in some way different to the other kids that looked like them. That people perceived them differently to how they perceived themselves. That people’s reactions to the way they behaved which felt natural to them, were sometimes negative.
Now back to the question, how can someone so young be so sure? How – because this has been with them since they were born. They didn’t just decide this yesterday, they have known all their life. This knowledge is not a realisation that comes with age, the only thing that age gives you is the power and strength to speak up, to find the words to describe what ‘it’ is and what you need. By the time trans people are ready to ask for help, they are sure.
I once asked a young trans boy how he knew he was a boy? He looked me straight in the eye and said: “How do you know you are a girl?”.
‘How can someone want to make such drastic changes to their bodies.’
First let’s think about what ‘makes changes to people’s bodies’. Age certainly does, I don’t look anything like I did when I was a child. Puberty – big time – that changes a generic ‘child’ into what we recognise as a young man or woman. Medicines, surgery, tattoos, adornments – these can all make bodies change in their appearance.
Ask a young trans person who is approaching puberty what they fear most and their answer is loud and clear: puberty. They know that puberty is going to change their body, making it unrecognisable over the next decade. I wish I could share with you the desperation that they feel knowing that their bodies are about to change. Knowing that this WILL happen unless someone does something to stop it. They know that drastic changes that are about to happen, scary, irreversible, major body changes that will change their androgynous child self into a very stereotypical male or female adult.
Medicine gives them the chance to stop that from happening as well as enabling them to progress in the puberty that will make them have the body changes associated with the gender with which they identify, rather than their birth assigned sex.
A key question we could ask is: which feels more drastic? Allowing a trans teenager to go through the irreversible changes of the ‘wrong puberty’ which will one day need to be put right through invasive surgery; or allowing them to stop the wrong puberty from progressing and instead course correct so that they can experience the right puberty?
The consequences of preventing trans youth from accessing the medication which will stop the drastic changes brought about by puberty, are as important a consideration as the consequences of giving them access to the medicine which will enable them to transition. And yet this is so often overlooked.
Surely the individual has the right to choose which path they wish to travel?
‘What about all the people that change their mind?’
Despite what we may be led to believe by the media, the truth is that very few trans individuals change their mind.
Being trans is not a new phenomenon and trans kids grow up to be trans adults. If hundreds and thousands of people who thought they were trans ‘grew out of it’ or ‘changed their mind’, where are they, why are they not flying the flag and waving the banner in their multitudes?
While I see the same few loud voices banging their drum time and again, wringing their hands over the very notion of trans youth, I also see the anguish of those many trans people wishing they’d had access to care at an earlier age, so they wouldn’t have had to endure the prejudices that someone who is identifiable as trans, often has to face.
When it comes to medicine we must always act with care and the necessary caution. This is why doctors go through years of training. We must then use our expertise and our ability to listen to what the patient is telling us they need, to come up with a treatment plan to keep them safe. We must take a holistic view when we see someone suffering, on what the best course of treatment is. In the case of trans youth who are still going through puberty this is the combination of puberty blockers and gender affirming hormones, as laid out in the guidelines issued by leading centres for excellence in the treatment of trans people around the world.
If we do nothing the suffering continues, as puberty marches on unheeded, causing those irreversible changes and long-lasting damage. Withholding care is not a neutral option. The notion of making everyone wait lest one should change their mind simply harms the majority.
‘But there is no evidence that puberty blockers are safe.’
We have used these medicines in children with precocious puberty for decades, we know they are safe. The argument which is often trotted out is that we do not know their effects in transgender youth. Let me be clear, if the medication is safe for a cis child, it is safe for a trans child. To suggest otherwise is nonsense and smacks of gatekeeping by any other name.
What we do know is that denying that young person access to something that will help them prevent the wrong puberty is not safe.
‘Gender affirming hormones are irreversible.’
This statement is 100% correct: gender affirming hormones are irreversible. At this point I would like to make something very clear; if you are trans, if you were born male but know with every inch of you that you are female – or vice versa, if your dysphoria is so strong that you would actually rather take hormones for the rest of your life which will impact your future fertility than continue in a body that feels so wrong, you WANT gender affirming hormones to be irreversible.
It is also worth noting that the process of altering your hormone profile is SLOW. You don’t take them for one day and all of a sudden turn into a six-foot, bearded man. You don’t take them for one day and develop 34DD breasts and a size 28 inch waist. Again, this notion is total nonsense. It takes time for them to take effect which gives that person extra time to reflect on how this fits with their life and their place in society.
The effects of the hormones which are being produced naturally by our bodies are irreversible and with them come irreversible changes. If we are going to get trans healthcare intervention right we have to stop seeing naturally produced hormones as RIGHT and anything else as WRONG.
‘Gender confirmation surgery is such a huge step to take, we must be careful.’
I totally agree, which is why it is my firm belief that we should be looking at prevention, rather than cure, wherever possible. If we gave puberty blockers and gender-affirming hormones in time, then we would not have to have top surgery, facial feminisation surgery, hair transplants, breast augmentation, nose reshaping etc – you get my drift.
Of course any operation is a major decision, and many young people have to make that decision in their lives. However, let’s treat this the same as with any other surgical intervention. Lay out the facts, take the patient’s wishes into consideration and come to a joint decision. Nobody wants to have an operation that has risks, but we have to jointly balance the risks and benefits of having the operation, and not having the operation.
‘Isn’t it better for these teenagers to wait until they are older before they do this? What is the hurry?’
For those who still aren’t convinced, this is often the next question. As I have outlined above – the “hurry” comes with pubertal progression and the development of secondary sex characteristics that will never go away.
One solution, a kind of “half-way house”, is to give trans youth the puberty blockers but hold off on hormones. That is what the NHS does in many cases. This may sound like a sensible solution but, in fact, it simply leaves the individual in limbo. Teenagers want to be ‘normal’, they need to fit in. ‘Puberty with peers’ means allowing trans kids to go through the right puberty at the same time as their peer group.
There is also an additional risk to those whose puberty is delayed. As was explained to me by Dr Johanna Olson-Kennedy, Medical Director at The Center for Trans Youth Health and Development at Children’s Hospital Los Angeles, cisgender teenagers are able to experiment with politics, society, sex and drugs, all at a time when they are still close to the family home. If you don’t allow a trans person to start puberty until they are 16 or 17 they don’t get to start that experimentation until their early twenties, by which time they are often away at college or University and distanced from the very environment that makes experimentation safer.
Waiting until they are older makes those who are scared for them feel better about the choice they are making, but does it help the trans teenager?
‘Surely we must really interrogate these young people, make sure they know their own mind?’
Trans youth do not wake up one morning and decide they are trans. They have spent years thinking it through, agonising over it, working it out. By the time they get to the doctor they are sure and in most cases they have brought their families along on their journey.
As medical professionals, instead of asking if they are sure, we should be asking how we can help. We should be asking what they need, if they have support at home, do they need any extra help? We should be asking if we can talk to those who make up their support network, we should be expanding the conversation, not shutting it down.
‘This is just a phase, a modern trend, look at the increase – this is just ‘fashionable’
As I stated earlier, being transgender is not a new phenomenon. It is simply the case that we now have the language which has always been lacking, for individuals to be able to step out of the shadows and share their truth. It is also true to say that the prejudice is slowly but surely being called out and the bullies are being silenced.
Rather than gender variance being fashionable, I would argue that the ‘modern trend’ is inclusivity. Understanding that diversity exists and is just a wonderful part of human nature. Thank goodness we are not all the same, every one of us is different. It isn’t fashionable to be trans, what is fashionable is to have a heated debate on the subject.
We have seen an increase in those being brave enough to come forward for help. An increase in those having access to the education and vocabulary that describes what they feel. An increase in services willing to help them, rather than lock them away.
‘There is not enough medical evidence and research available.’
This is factually incorrect and a product of the misinformation spread by those who would seek to prevent trans people from accessing the care they need.
There is an abundance of literature available. Many amazing Clinical Guidelines which have thoroughly reviewed every research paper, every clinical protocol, every case report and every finding. They have considered the evidence and conclusions have been drawn by the leading experts in the field. These are even carefully graded so the reader can score the level of evidence that backs the guidance.
On the flip side, there are also publications which only choose to cite those articles that fit with their anti-trans narrative.
The evidence for affirmative care for trans people is easy to find, I have read it all. I have combined it with my own experience of talking to trans people of all ages. My conclusion is simple: gender-affirming care gives a young person the chance to live their life without being identified as trans if they do not wish to be. It helps prevent anxiety, self-harm, depression and suicide.
So let’s take a look at this evidence:
- Study: Blocking puberty in transgender teens linked to lower likelihood of suicidal thoughts Melissa Jenco, News Content Editor January 23, 2020
‘The American Association of Paediatrics, The Endocrine Society and the World Professional Association of Transgender Health support providing transgender adolescents with gender-affirming care. This includes gonadotropin-releasing hormone analogs that temporarily block puberty by stopping the production of testosterone and oestrogen.’
Excellent, a simple statement – easy to follow and full of hope for our trans youth. What about some evidence of harm if we do not intervene, does that exist?
- Suicidality Disparities Between Transgender and Cisgender Adolescents Brian C. Thoma et al. Pediatrics November 2019
‘The authors studied 2020 young people aged 14-18, of whom 1148 were transgender, and asked them about their thoughts of suicide and self-harm. The outcome was that transgender adolescents had a higher incidence of all suicidality outcomes than cisgender adolescents.’
It is of vital importance that we remember, when looking at these statistics, that we are not talking about the incidence of smoking, or tattoos, we are talking about deaths in young people.
Suicide is life-changing, it is drastic, it is irreversible and it is happening to trans youth.
So what about the outcomes in later life? How do trans individuals fare as they get older? Is there any evidence for that?
- Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation – Jack L. Turban et al. Pediatrics February 2020,
‘The authors studied 20619 transgender adults aged between 18 and 36 and asked them about the use of puberty blockers during adolescence and measured mental health outcomes and suicidality. 16.9% of those asked said that they had wanted puberty suppression, but only 2.5% had been given it. There was a statistically significant increase in the odds of lifetime suicidality in those who did not have blockers. This shows that the effects of being denied access to puberty blockers has the potential to have a lifelong effect on the mental health and risk of suicide in trans adults.’
This evidence begs us to ask some hard questions: Why there is such a difference between the rates of suicidality outcomes between cisgender and transgender adolescents? Is it simply because they are transgender that their mental health suffers as a result? Or is it the experiences they face because they are transgender?
In my experience and from what I have read in the research – it is the latter – and as such it is entirely avoidable and an urgent priority to be fixed.
- We know that some young people are transgender.
- We know that some trans youth kill themselves and we know that it is not simply because they are trans.
- We know that there are clear treatment protocols which are proven to significantly improve life outcomes in this patient cohort.
It is time for change, time to accept gender-affirming care and its benefits. Time to believe what today’s trans adults tell us, because they used to be trans kids.
Everyone of us has a part to play in this. Trans youth need belief, understanding, support and action. Is that too much to ask?
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