Affirmative Healthcare for Trans Youth

Good afternoon. We are talking about if your child is transgender, they probably are. We have an amazing panel for you to discuss gender affirmative healthcare. Before I introduce all of the panel today, we have participants joining via Zoom and via Facebook. Zoom is anonymous, and you can submit questions live there not the chat portion, but on the Q&A portion. You can also submit comments on Facebook down below. Those will be shown to us. If you have a personal question, then those will not be answered today, but you can email doctor@gendergp.com for any questions of a personal nature. And also, if you have any technical issues, don’t worry, because this is being recorded, and so it will be up live on the website and also on Facebook. All questions are anonymous. With that said, I would like to introduce the lovely panel. Over to you, Helen.

Thank you very much. My name is Helen Webberley. I am a UK-trained doctor, and I have more recently taken a special interest in the care of gender-related issues, both adults and young people. I went with some of my colleagues to Los Angeles in January to the trans youth care conference that these guys put on, and I was blown away by their gender affirmative model. It was just so refreshing that they were not starting from a position of whether we should believe that trans children exist, or what we should do with them; but actually, we do believe they exist, and how do we best help them and support them, both medically and socially. So when I heard these guys were coming over to the UK, we set this up. And I am really, really excited to welcome our three USA members.

Good afternoon. My name is Dr. Johanna Olson-Kennedy. I am a US-trained, board-certified pediatrician and adolescent medicine specialist. I have been doing care for trans and gender-diverse youth for the past 13 years. Very excited to be here. I am the medical director of the Center for Trans Youth Health and Development at Children’s Hospital Los Angeles. We have about 1400 young people actively in our program right now between the ages of 3 and 25.

Hello, my name is Aiden Olson-Kennedy.  I am a licensed clinical social worker practicing in Los Angeles, California. I am also the executive director of the Los Angeles Gender Center. I have multiple roles. One of my roles is providing affirming mental health care to trans and gender non-conforming youth, young adults, and adults and their families. I have a particular interest in supporting parents. I am also a trans man myself, and so I am very much aware and thoughtful of what the experience of gender dysphoria is, as somebody who lives it. And I think about delivering my services through that format.

I am Lizzie Jordan. I’m CEO of Think2Speak, based in the east midlands in the UK. Oh, sorry – and we also have Darlene joining us by the wonders of technology!

Hi, I’m Darlene Tando. I am actually streaming live from San Diego, California, where I have my private practice as a licensed clinical social worker. I’ve been working with gender-expansive and transgender youth and adults since 2006. I would say about 95% of my practice is now working with youth and adults and their families.

Thank you very much. So now we move on to the first set of questions, which is around how the UK can move towards providing a more proactive approach to trans-youth, in line with the best practice happening in the rest of the world. So first I’d like to go to you, Johanna, to get your thoughts on that.

Okay so I’ve learned – I’ve been in the UK for the past couple of days – and what I’ve learned is a lot more about the system that young people travel through as they get their services here. And what is different about the United States is first of all, because we’re so big, and there are many ways that people practice this work, in our center at Los Angeles, the way that it works is that young people are initially brought into our services through our social workers who do a lot in the United States. Our social workers do more than work in the child protective system. They actually provide clinical services, mental healthcare, but they also do an incredible job of coordinating care and figuring out where people are going to be best served. So young people will come in with their families, or not with their families if they are at the age of majority or older, and our intake coordinators will have conversations with them and help to kind of guide people into the spaces that they need to be. So young people who are coming to get information about medical services will get scheduled with a medical provider, either a medical doctor or nurse practitioner. Young people who are coming in seeking mental health services will get directed or referred to those services. Sometimes people just want to have consultations with either doctors or mental health providers, all kinds of things. Sometimes people just need advocacy, so it’s much more of a process of triaging where people want to go. The important thing is, especially for youth care, is that young people get triaged into medical services if that’s what they need. And they need to have that done relatively quickly because the procedure of blocking the changes of puberty is a time-dependent procedure. Having people wait a long time precludes them from that opportunity of developing unwanted or undesirable secondary sex characteristics. So it’s really important from a temporal perspective because people have done a lot of waiting before they even call or start to access the services.

Great, and Aydin so then what would you look up for? If we’re going to best practice here in the UK what would you like to see?

I think this, sort of what Helen had said at the very beginning is, if you’re able to start at the place of trusting and believing that people know their gender, then I think that saves a lot of time at the front ends where the assessments and “Are you sure you want to keep regretting?” some of those beginning questions that actually young people themselves have already gone through and already done all of that work long before they’ve even presented to care, will allow people to access care which would then have a high likelihood of decreasing some of the mental health struggles that they may have experienced. It sometimes inadvertently precludes them from care. And so if you can get an ideal situation or circumstance where everyone would be able to know their gender, and then there wouldn’t be a process in which someone outside of that young person would either feel responsible or take on the responsibility of certifying some of the (unclear 07:36-07:41)

Because Helen here in the UK at the moment – the child sees the therapist who then decides whether they will receive medical treatment what kind of gateway. Do you think there’s a better route? If so, what is it?

Yesterday, on Friday, in Bristol, Jo put up one of her slides which showed the different places that somebody could go to when they first access. So when you go into the middle, and then someone there will help you get to the right place that you need to go. So do you need to go to the doctor first? Is it essential that we get puberty blockers really quickly for this young person because puberty is progressing and it’s hurting? Or is it that they really are questioning their gender and their families are really worried about it and not sure? Do they need some talking about, you know, and what’s the best place? Or is it that everything is settled and happy and we don’t need any medical intervention yet, everyone is on board, but how do we cope with the school and with society? And Darlene, when I was over in Los Angeles with you guys, I loved what you were talking about. And I’d love it if you could tell our listeners this today. When you were saying that the mom was saying, “Look it’s okay for you to do that in the home, but…” and I wonder if you want to touch on that because that really resonated with me.

I think that parents are in this position of trying to protect their kids from being teased or being misunderstood, and so they try to keep them safe in the home; but the message that gets sent is that you are not okay being who you are out in the world and so you can only be who you are at home because it’s a safe place. And so I think the message that the kids internalize is that the world is an unsafe place. “I can’t be who I am out there. If I am I might be hurt, I might be rejected,” and so it comes from a place of fear and uncertainty, rather than the parents saying, “It’s okay who you are. Be who you are here. Be who you are out there. And we’ll be here to support you.”

So here in the UK, with kind of what happens (unclear 09:49-09:52) we share care agreements with GPs. Is there a better way?

Well, if we have a situation in the UK that – and Aydin talked a lot about this before – you’ve got a young person who in their bedroom on their phone, on their computer, with their peer group, or whatever it is, has done a lot of research. They haven’t just woken up one day and said, “I am trans.” They’ve done ever such amount of research before they ever get to being taken to the doctor or to the clinic. And so if in the UK we had a system where a trans person and their family came to a clinic, and at the clinic said, “How would you like me to help you today?” that would be amazing. So we have our waiting lists are too long for whatever reason, but those children and families have already been to their general practitioner. So the family doctor, those people who been to their family doctor and said, “My child is trans, we’re approaching puberty,” or “We’re halfway through puberty or our child is really hurting, can you help? And at the moment we got a situation where the doctors are too scared to help. There’s not enough education. There’s not enough empowerment. We’ve seen bad things that happen to doctors who do help transgender children and adults, so there’s very much a position of fear. So what we got is GPs relying on shared care agreements, so when you go to the specialist services you may get a shared care agreement and take it back to your doctor and say, “I’ve got this thing, can you now help me?” And then the GP might say yes, or they still might say no. So what I would really love to see a position of, is your doctor, whichever doctor you go to, can make some decisions about helping you medically, and that would be just amazing. And we have a blank canvas. We have no training in the UK. We have no specialist registrar in the UK, so we have a blank canvas that we can make. We could start this ball rolling. And with the influence that we’re learning from our US colleagues, I think this is a really exciting time for the future.

Because sometimes we see with the puberty blockers and the fact that that’s been used for a long time now for precocious puberty, and GP doctors are okay with that sort of prescription approved and supervised. And yet people then claim there’s a lack of evidence when the argument comes about using the blocker for the trans kids. So what do we do about that? How do we do this education?

That’s very true, we’ve been using puberty blockers or shutting down the hypothalamic-pituitary-gonad access for many decades across the world. We use these medications for lots of different age groups. We use them in very young children who are 5, 6, and seven years old who go into puberty early. We don’t want them to go into puberty early, so we use these medications to shut that down. We also use these medications in older cohorts as well, for things like endometriosis or prostate cancer or any situation where we do not want the gonads to produce sex steroids for a variety of reasons because these sex steroids are having a pathological influence on that person and patients. I think if we reconstruct or think about the view of the damage that endogenous sex steroids do for people with gender dysphoria, we could reorganize the way that we think about this work. I think that puberty blockers have – they’re not really only puberty blockers, we call them that in this work, but really we’re talking about the inhibition the hypothalamic-pituitary-gonad signal. And if we understand that we’re using it for this purpose, and we reorganize and understand that there is an established safety profile for these medications, we can stop using a different lens when we think about this care in terms of gender and gender dysphoria. It would be very useful for us to not apply a different level of scrutiny to medical care that has to do with addressing and alleviating or mitigating gender dysphoria.

So Aydin, how then do you have that conversation when you know blockers are offered for Tanner stage 2+, then how would you approach that, of it being available, and that’s a definitive, and make the conversation normal? Or is it well, let’s see and wait how you feel? How does that look like for you?

Well, I got to tell you my initial response when you say wait and see, I have the best role response to that. It’s kind of acknowledged that wait and see, those words have largely been used to stall people, slow people down, or even what we call give youth time to figure out or be sure about their gender. A wait and see approach really is more about giving time for their parents to go through the process that they need to go through. I think that those things can happen concurrently. I think a young person can move forward in a way that is right and feels appropriate and congruent for them, and the parents can also be having their experience and their feelings while also moving forward. We don’t actually have to stop to have the expertise to know what we need to do is the right thing. So as a non-medical provider my conversation with youth and parents on blockers is a little bit different. I can certainly provide some basic information I know, but I think that what Helen was sort of referring to is that young people do a lot of what we call coming near. A lot of back channels, what’s going on, answering questions and exploring things. And by the time they want to access care their parents just know they’re coming to the process, like, “Wait, what does this mean? What is that what is the side effect?” and young people already know those things. And so, allowing medical providers, allowing them to access medical providers and parents to get the medical information. And as a mental health provider, my job is how do I create a container where the parents fear and uncertainty and love – I mean fundamentally the foundation is that parents love their children – and so sometimes what prevents parents from moving forward is love. And so if I can help acknowledge that and say, “Yeah, this must be scaring you,” and how we do it anyway. How do we say things in a way based on what we know to be true about blockers and their safety?

So when we’re looking at time in the sense that is we’ve got children starting to be offered blockers at younger ages, and many then bring their mum, two years, two years plus. And yes, it’s advised that two years is a kind of window. What’s the solution for the next steps?

I think that there’s a fundamental disconnect between making a recommendation to start puberty blockers in early puberty and then not add on gender affirming hormones until around 16. I think part of that is because the protocols and the recommendations are kind of catching up with the clinical work and there’s a little bit of a disconnect. So immediately when the Endocrine Society released these recommendations the first thought that I had was, “Wow, if I block someone at 9, they could be potentially only on blockers until they’re 16,” which actually can potentially provide danger or potential harm to their bone density. So I really do think that it is important for us to acknowledge that people aren’t supposed to start puberty at 16. Actually, in other medical situations for example, when people have precocious puberty, and they start puberty at the age 5 or 6 or 7, they go on blockers until they are 12. And then across the board, those blockers are taken away, and that person goes through puberty, and the reason that is, is because we have an understanding as a medical and scientific community that people go through puberty at around 12, that’s kind of a midpoint for puberty. Except if you’re trans, and then you have to wait until you are 16, which doesn’t make sense in the context of our understanding of development in adolescents. We understand this so that if you go through puberty at 6, you need to pause it until you’re 12 to give you time for a bunch of things, linear growth, and other things. It doesn’t make sense that we’re applying a different principle of development to trans kids. It doesn’t make sense for people to go through puberty at 16 for a variety of reasons. One, it means it exposes them to only being on blockers for a very long time. Two, when you go through puberty, the stakes are different when you’re 16, 17, and 18 years old. When you’re 11 or 12, and you’re going through puberty, and you have your hormonal surges, you slam the door and tell your parents you hate them, and they don’t understand you and they never will. But when you’re 16, 17 and 18, you have access to vehicles. You have access to other adult human bodies. You have access to drugs and alcohol and a lot of things that you don’t have access to at 11 and 12. And we don’t often think about the potential consequences of waiting until someone is much older to start their puberty process.

Cis-people often say why don’t you change the mind rather than the body? And that you can’t change one or the other to have a healthy life or body. What do you counter that with?

I think gender is just inherent within the mind and it’s not something that anyone can change. I think over the years probably a lot of trans people have tried to change their gender in their minds before coming out, kind of like what Aydin was saying along the process of coming in. There’s also a bit of external sources that have tried to change people’s genders for a long time, and conversion therapy is now illegal in a lot of states in the US. It doesn’t work. You cannot change someone’s gender. And so I think the argument sometimes is you have a healthy body why change it? Well, I think you have a healthy mind, too! There’s nothing about being transgender that is unhealthy, it’s just gender that exists within someone’s mind, and there is no need to change that, but if there is a feeling of a misalignment with someone’s body, that needs to change in order to recollect someone’s authentic gender.

Do you think a child or a young person should be challenged?

Well, I think if someone is challenging the intervention the child is seeking for alignment, they’re actually challenging the gender. And that can be really harmful. People know their gender. And if a kid is trying to seek understanding about their gender and someone is challenging that, that can be really distressing, and it’s probably they’ve already challenged it themselves like I said.

Darlene, do you mind if I ask you something, one of the comments we often hear in the UK is that in order to get a diagnosis – I have to say I hate that concept – but in order to get a diagnosis of gender dysphoria or being transgender, it implies that you have to have some distress. So if there isn’t any distress going on, then how can be gender dysphoric and how can you then qualify for intervention. I’d really like your thoughts on that distress.

I think Aydin and I gave a talk on this topic. I think for a long time we’ve looked through the lens of distress, so there has been a lot of long of waiting to intervene until someone is in a lot of distress. I really would like to see that model changing so that we start from a place of, “Tell me who you are, and we’ll believe you. And then tell us what interventions you need because of that.” So I think with the waiting for this distress in order to make the diagnosis – which I don’t like either – is really harmful to a lot of youth. I think gender dysphoria can be a part of the journey, but it doesn’t have to be this very concrete cluster of symptoms that include a lot of distress in order for someone to intervene. It’s more about how do we get you to feel more aligned or more authentic.

And distress looks different each time. Distress looks different for so many different people like one of these things Darlene and I talk about is that people’s temperament also impacts how they experience distress, but then also how they display or talk about or manifest distress and sometimes in the way we look at trans youth and youth with gender dysphoria is that we have looked at and define distress to be this very narrow set of symptoms and experiences. I think that really could’ve cut out a lot of ways that all of us. Even the four of us here, could have distress while experiencing, we would talk about it, and it would show up, and it would be tangible in a variety of different ways. So we’ve also created this very singular reduced narrative of what it means to be trans, but also what it means to have gender dysphoria, and I think we’re doing it a disservice when we do that.

I want to add one more thing also. I think in medicine one of the fundamental tenants is prevention. We’ve worked very hard; let’s use the example of diabetes. We don’t wait for someone to be in DKA before we think about or move forward with treatment for diabetes. It’s similar across a lot of entities in medicine. It’s why we practice and do screening. We don’t wait for someone to be really sick before we intervene. It’s not a healthy model, and we understand that the cost of practicing a model like that is differentially greater than if we apply prevention models.

So when we look at that, people often go to desistance and people changing their minds. I mean it’s often a reason for not doing anything and that kind of medical pause or whatever pause, but is there a reason to delay treatment for young people? Sometimes people say it’s a bit of experimentation – one of the questions that came through.

Do you mind if I start on that one? I think the fear of de-transitioning or re-transitioning, which is what these guys taught me when I went over there – the fear is huge. It is extremely scary for the parents, the aunties, the school, the nurse, the doctor. God, imagine giving a treatment to a young person and then that young person said I’m stopping that treatment and I’m going to have a go at my birth gender. I would be terrified. That would come down on my head because I made the wrong diagnosis or I intervened too early, and that fear is enormous. But the problem is, who is going to be harmed of my fear? The person that’s going to be harmed is the transgender community, all of the children and young people who didn’t get care because the doctor is too scared, or because mum is too scared, or because school was too scared. And that fear is causing a lot of difficulties.

Do we talk by numbers, what sort of numbers or statistics you guys think?

We don’t have figures I guess maybe people are too scared to produce that figure. I know Jo is not scared. She talks proudly about the children who de-transitioned for a while or forever or whatever because that’s what they wanted to do with exploring their gender. But we don’t have figures. I’m guessing people are too scared to say those figures. But what I understand is that when I look at our trans adults, I’m not seeing swathes of big numbers of trans adults going, “I was a child who thought I was transgender all of my childhood and then when I grew up I realized I wasn’t.” We don’t see those people. So there are not hundreds and hundreds of people who de-transitioned, desisted re-transition, whatever is because we don’t see them coming forward and that gives me great hope, but I know Jo speaks well on this.

I think it’s valuable just to remember that there are going to be people who are going to re-transition, and we don’t necessarily have to be afraid of that. I think that we need to honor people’s capacity to adjust and move forward, and move sideways, and move backward, and all of that is really important. And I think when I consider the cost-benefit ratio of this situation of people re-transitioning or moving to a different place in their life, I think the numbers are first of all very small. But I can tell you that I went back through our list of people that I’ve taken care of over my career which is probably about a 1000 people. Of course, it is very difficult, because we don’t keep people in care forever because we’re a youth clinic where people will graduate out when they’re 25 years old, but also are mobile, and that’s what we want them to do. Young adults should be moving around. They should be establishing their life and care. I’m extremely fortunate that a lot of people continued to stay in contact with me. The numbers are very low probably 15 to 20 people out of a 1000 or 1500 who have in the context of my care either stopped taking hormones, never started taking hormones. I think one of the mistakes that we make is we assume that assessment is a one-time thing that happens before someone starts to care. But the truth is, like everything in medicine, assessment is an ongoing process. Every time somebody comes back to visit you for their medical follow up, you’re having a process of assessment with them. As a medical provider you find out if it’s working for you, is it not working for you, whether we need to change. People email or people come through the portal, and they ask these questions. It’s ongoing. It’s not one thing that you green light and then you forget your hormones, see in 10 years. That’s not how this works. It’s not how anything in medicine works. We are also not understanding that every time a person either takes a pill or puts a needle in their body they’re doing their own process of assessment. Is this what I want to do, do I want to move forward with this? Is it working for me? And so we undervalue the work that is happening on a consistent basis over time for people. And so if we really break down what the fear is, and I think the fear is very real. We don’t like being wrong, whatever that means, and we certainly want to have that certainty moving forward, but we don’t have that certainty about anything in life. We start people, for example, on psychotropic medications and we don’t know if those are going to help people. We don’t know if they’re going to make people less anxious or less happy, we just know that it has worked for a lot of people. Just like blockers and hormones, they work for a lot of people, and so we go forward with that assumption. If it’s not working we stop, or we increase the dose, or we try a different medication. This happens all the time in medicine. We just apply a different level of scrutiny to gender work.

The benefit of being married to you is that we have all those amusing wonderful things, but I was like, I just did my injection this morning, and I was like oh I can use that I can say that. This morning I made a decision, and then you were like, and I was oh she took it right from underneath me there. But I think, I’ve had people who have transitioned and have come back and said, “I need to do something different.” The reason why we don’t use the desist or the detransition language is that we can’t actually detransition. That’s not a thing. And possibly that’s what’s scaring people. People can retransition, people can continue to a new or different direction, but you can’t move back! And I think that’s what feels scary to people. Like you can’t undo. If I stopped taking testosterone, there are certain pieces of my physical body that will certainly change, and there are other pieces that certainly would not change. For those of us who are transitioning, that’s the point. Like the things that are not going to change are actually the things that we want to happen. And when I’ve had clients who said, “I need to do something different,” I have yet to meet the person, and I’m open to them existing – I have yet to meet the person either in my clinic, or on social media and online spaces, that has said “I regret it.” What I heard over and over, is that there was no way that I get to where I am right now, which is a deeper, and more diverse and robust understanding of my gender had I not been able to travel on the road to get here. And we create a false paradigm around what regret implies that if we don’t do something we’re going to prevent regret, and that’s not how that works. You had to have access to something. Certainty is also a false paradigm. Many of us had done things in our lives that we felt pretty certain about, and then we arrive, and we’re like oops! Whether that’s marriages or careers, or moves, you know there’s a whole of them here right? And that’s true. That gets to be true to trans people as well. Then we don’t have to be scared of people making a different decision and moving in a different direction. If we talk openly about it, we can sort of remove the fear so people can feel safe to explore themselves.

Darlene, some mums often say that, when they present to medical care, they say well my child was trans, so trans all the way through, and then around about puberty or around about this age all of a sudden they put it all in the bin and said I’m not doing this, and then they did makeup, and they did long hair and everything like that. So how can that child truly be trans if when they’re a teenager, a rational thinking teenager, they bin it all and say, “I’m going to go back with my birth gender.” Can you help with mums and dads that worry about that?

Well if I understand your question correctly, you’re talking about the kid who kind of overperforms their birth gender around like middle school, early teenagehood?

Yes, the ones actually that looked or displayed trans-ness all the way through their young lives. Then there was a point where I think you called it trying out their first gender for the very last time? And we see that a lot and I’m interested in helping mums and dads out there whose kids tried out their first gender again if you know what I mean.

Okay usually I don’t see that pattern actually where the child is asserting their selves as trans, and then they kind of try their birth gender really hard. The way I see it usually is part of the coming in process. So they may be aware that something is not quite aligned, but then during middle school that’s something they overperform their birth gender. they receive a lot of good feedback from their parents, and then they try to say, “Well maybe I can really do this, maybe I could be happy this way.” And usually, it doesn’t fulfill anything within them. And so what happens is that later when the parents look back to that, they go, “But what about when you wore that beautiful dress, or when you were in this sport that you really enjoyed,” and they feel like that was their authentic gender because “I saw how happy you were, how could that now not be your authentic gender?” And so I think that’s just part of, like Aydin and Jo talk about the coming in process, where we try to understand, and also that struggle of knowing, “I’m not sure if people are going to accept me if I come out as trans or if I really assert myself like this, so let me see if I can just be happy with my birth sex.” And that’s where we talk about it’s not possible to change one’s gender in one’s mind. You can perform things in a different way that may feel okay in a moment, but then authentically it doesn’t fit.

So we’ve had a question that says “I’m really worried and upset about my child saying they’re trapped. How can I help my child when I haven’t come to terms with it myself?” Darlene, what would be your top tips?

I think that it’s really important for the parent that they can be going through a lot of pain at the time as they’re affirming their child and at the same time as helping their child access any interventions. Because what’s going on for the kid is really intense dysphoria. When Aydin and I talk about distress, we talk about it as chronic stress, so it’s almost like a trauma. And so this isn’t something that can just kind of wait till the parent gets on board, and then when they intervene the trauma will all go away, or the dysphoria will all go away. It’s leaving an imprint on the child that this is happening during their childhood. This is happening during their adolescence. And so if they’re really at this intense dysphoria during that time, it leaves a mark for a long, long time. And so for a parent, to be able to say, “I’m going through intense pain that my kid is too, so I need to do something that might be uncomfortable for me to decrease my child’s dysphoria, and then I can also at the same time I can seek care for myself and seek the support of other parents who have been through this, or talk to other adults about my feelings, certainly not the child.”

So Helen, here in the UK we’ve got about an 18-month list from the time a family has chosen to access doctors for example, how can a parent support their child during that time?

It gives me another example of a lesson that I learned in the USA. If you had a child who had been run over and had a broken leg, and that was really hurting their child, and then you had to wait 18 months to have that broken leg fixed. We would feel that what you’re talking about there is completely bizarre, but this is true. The children that are waiting to be seen are hurting. Severely hurting. They’re hurting inside, and they’re showing the world their pain in many ways, and that can be tantrums or tears or frustration or anger. We see it on their bodies. We see what immense pain is doing to their bodies. And I’ve seen scars, I’ve seen overdoses, I’ve seen nooses around necks. These children are really shouting loudly that, “I’m hurting.” So how do we get rid of that 18-month waiting list, because it’s causing a lot of harm? And that child has been to lots of doctors and lots of caregivers while waiting for the Tavistock, and each one of those has been able to say, “I can’t help you.” Now how many of us are actually accountable for saying, “No I can’t help you?” Because I actually read down in the medical books, Jo gave the example of diabetes, it’s written down in the medical books, and you learn about it. If you have a child who is presenting with diabetes and you as a doctor wouldn’t help them until they went to a medical specialist clinic, and in that time something bad happened to that child, you as a doctor would be accountable. So how is it okay that all these doctors and nurses are saying “No, I can’t help you, because I don’t know enough about it, or I’m not qualified, or I’m not allowed to help you,” and the damage is happening to that young person while they’re waiting. We need to be accountable for that, anybody who’s been in contact with that child needs to be accountable for that child. I was listening to a BBC podcast on female genital mutilation, and what they were saying is that every single person that saw that child who had that procedure done had noted it but had not done anything about it. All of those people need to be accountable for not taking any action on that young person when they saw that something bad was happening. So we got too small a specialist service, we got too long a waiting list, and we got a big cohort of medical providers who could help but are currently, for whatever reasons, not helping. And that is what I feel. My background is family doctor general practitioner, and my background says to me we are the best people to help because we understand young people, we understand families, we understand children from naught to 16, and then adults from 16 to 70 and old people from 70 to death. So we need to be helping more in primary care.

We’re receiving parts of dysphoria and depression on school life, on work life, for children and young people. What does a better way of supporting that for someone’s whole life really look like, Johanna?

I think understanding that gender dysphoria seeps into every part of somebody’s life is really critical. I think when you have a scenario – and this is not exclusive to the UK – there are a lot of places in which the care scenario looks like it’s organized around the comfort the people around the individual. We need to reorganize our care that’s focused on the individual that’s coming in for care, rather than on everyone else feeling more comfortable. I think one of the fundamental issues is that there is an assertion that you can do something on the front end to prevent someone from re-transitioning or regretting their decision. But that has never been identified, and while the people who are against trans care will posit that there is not enough data, I will come back and say that there is not enough data to support the idea that something can happen on the front end that will keep the small number of people from regretting or from re-transitioning in a later time. There’s never been that. There’s never been anything that has posited if you do this on the front end, you will only put people through to care who are not going to regret, or who are not going to re-transition. There’s never been that. So part of this again is modeling our care with the young person at the center and really having an ongoing dialogue with what that person needs and really trying to meet those needs. And helping young people understand what is within the limitations, what is possible from medical intervention, but also what isn’t possible from medical intervention. It’s helping people understand what gender dysphoria looks like, how to identify it, and then assisting people in navigating it and helping them understand that medical intervention is not going to eradicate gender dysphoria. That is a lifelong thing.

Make sure you post your questions on Facebook or your Q&A on Zoom. We’ll come to them in the end when we’ve got some few minutes.

I think that gender dysphoria is a life-long experience and that while intervention is really helpful and can remove very specific pieces of gender dysphoria, the miserable gender dysphoria that people experience around their bodies or voices or hair or a variety of different things that are treatable with medical intervention. We absolutely should be doing those things so we can clear those out. But the reality is there’s no amount of medical intervention that’s going to make me not trans. And so I think it’s important we also talk about just being trans, just the incongruence that will always be there will produce distress and discomfort in a variety of levels of severity throughout life. So if your approach is like we’re going to cure gender dysphoria, I think people will continue to be quite disappointed whether it’s the person experiencing it themselves or the provider. There is something about if you don’t have gender dysphoria if you never experienced gender dysphoria you can’t even begin to understand what that is like. It’s seeping into schools, it’s seeping into young people’s ability to be with their families, and maybe their church or religious communities. And I think if you hide even five minutes of the experience when somebody has a high level, no known intervention, not treated gender dysphoria. It is actually remarkable to me as somebody who has and continues to experience gender dysphoria that they are even functioning, even alive and breathing. And so when somebody gets to that place where it’s so unbearable, as a mental health provider I cannot even understand what I would talk about with somebody for 6 or 9 months about their gender. Like I actually cannot conceptualize what those conversations would look like other than extremely redundant. But during that time I actually can’t continue, I actually can’t function because the noise is too much. I try to do an example where people experience as a trans person. If I had untreated gender dysphoria, you would be chatting at me saying people are listening to your voice and think that you’re a girl. But no one would see you, only I would hear you. And then you’d be coming at me like, “Oh, people see you have female chest, so you need to adjust your shirt, you need to adjust your binders.” So I bring all of these anxiety symptoms, but no one can see her say that, and you’re over there chatting at me. So trans youth, we’re caught at this race where there is a tremendous amount of noise. And that noise is not kind. That noise is really abusive. They’re mean voices. They’re anxiety-producing voices. And so if people could begin to understand that level of noise and reverberation of intense chaos, and then we see young people who are cutting themselves and doing different things. We would actually be able to look at that and say that’s a reasonable solution to this young person experiencing something that is completely unreasonable. And so when I talk to parents – and I really love the work I do with parents it’s some of my favorite work – I can position myself as a trans person who is experiencing and has experienced these things to create the communication pathways that the young people cannot do. Young people, particularly in those early stages of disclosure in an intervention, they do not have the ability to communicate what’s actually happening to their parents because of the relationship, there is tension between the young person and their parents, that’s inappropriate sort of tension exists. But also they don’t have the perspective and the experience. You know a lot of what I’ve come to understand around gender dysphoria and my own gender is like looking through a rear view mirror. I have to be able to say like, “Oh I remember when this was happening.” Now I get this is what was actually going on, but in it, I was just feeling it. And I didn’t know how to put words to it in a way that seem to make people understand or get something they’re used to something different.

So then we see a lot of children and young people getting their education from social media and from YouTube and learning, and then parents always seem on the back foot of that. So when we look at that, I mean is that necessarily a bad thing? What does that look like? How should that look like?

Youth getting their information online? I think that it is great. Do I think that there are places where it’s like unnerving and sort of unpredictable? Most certainly, but we have talked about here today is access being a real issue and a real problem. So if people cannot get access to spaces where they can talk about what’s going on, but also just gather language and knowledge and information and connect to other people who have similar experience, we’re not going to provide that for people in an appropriate, timely manner that is supportive and affirming then where else are they supposed to count that? It’s like if we’re not going to provide it in real time and face to face time, then they’re going to find it somewhere else. Go ahead.

But Darlene, people say about social contagion and the internet fueling that in social media, and you know, these vulnerable kids, what is that we’re really doing?

It’s important to understand gender itself is not contagious, right, so being transgender is noncontagious, being cisgender is not contagious either. So I think that what parents see happening is that kids are finding language to describe their experience and realizing that other people have had similar experiences. And so they can find a community online, they can find a language online, even if they meet someone in person at school who triggers some understanding in them. The other kid did not make them trans. The other kid brought being trans to their conscious awareness. And I use the example of being on vacation and sightseeing all day and being really hungry, but you’re not really aware of it until you walk by a restaurant that smells amazing or you read a menu that looks delicious, and you think, “Oh my goodness I’m starving.” The menu or the smell didn’t make you hungry, it didn’t deprive you of food, but it brought it into your conscious awareness, and so we have to have catalysts sometimes to bring these things into conscious awareness. But it’s not a contagion thing.

Great work of putting it there. So how can we work in a more positive way, and sort of body positivity for judging young people? How can parents help with that?

You know I think parents really want kids to feel more positively about their bodies and I think some parents can remember a time maybe during teenagehood where they didn’t feel comfortable with their body. And they give a lot of good advice about that, but it’s not the same as dysphoria. Trying to help a dysphoric kid feel more positive about their body is probably going to be an exercise in exhaustion because it’s not something that can happen for the kid. The kid has to come to terms with coping how to feel about having a body that does not align with their gender, but I don’t really feel or can speak better to this that it’s really about feeling more positive about one’s body. It’s really about coping with the dysphoria and then also trying to access interventions that can possibly help align one’s body.

We have a situation that I hear UK parents say, that if your child is not displaying enough distress, then it doesn’t really mean that they want this enough. And then if they get to be at the other end of spectrum that they’re so distressed that they’re not in school, and they’re not engaging in society but they’re hiding themselves in their bedroom not going to school every day then they’re not allowed to access care because you have to be in life to be able to access care. And these kids are not in life. They’re in their bedroom hiding. And I’ve seen children who hide in many ways, they hide in their bedroom, and they may turn their computer on, not the webcam, they would have an avatar which shows who they are and how they want to be, and they would hide their voice. And many children won’t speak, because of what you were saying, Aydin, that this voice doesn’t sound right. So they’re hiding in many ways, and actually, they’re saying is that if they did speak, they would say, “Could I just try this intervention and see if it will help?” But no one will give it to them. And the narrative when you do give it to them, mum says, “They’re out of their bedroom, they’ve come out of their bedroom, they’re speaking again, they’re going to the streets, they’re playing with their friends again, what have you done?” And what we’ve done is we’ve affirmed their gender. And we’ve given them what they were just saying please can I try this? Where do you see that?

Yeah I think we discount the elation that people experience when they’re affirmed. And while we focus so much on people who are still, continue to startle even though they had interventions which are a small number of people, we don’t pay as much attention to the elation that people experience when they are affirmed. And in fact, in my practice, that’s been used to deny care. Like people who socially transition their child feel much better, and they see that as evidence that their child just wants to fit in. And so there is just no correct pathway if you are not supportive of this care, there is nothing that a young person can do that will convince that. The thing that I have also seen is the rear view mirror perspective of parents who said, “Oh, after I witnessed this elation, after I witnessed the fact that my young person can now cope and move to school and have friends and get in relationships and partnerships, it’s unimaginable to me to remember back to before my child was in that space.” And we don’t often talk about those stories as much because they don’t make really good afterschool specials. And so I think it’s valuable for us to think about those, you know, so many times where people have experienced, even if it’s not elation, it’s more comfort, and that is really important. Fundamentally, if we want to change the experience, we need to abandon out cisgender-normative environment, because the fact of the matter is there always going to be significantly less percentage of people who are trans than who are not. And if we can open up and understand that those pathways of trans experience are human pathways of development, and we introduce that idea to people very early on in their education, we will have less of an issue with trans people trying to navigate through cisgender normative environment that is often hostile at worse, but at best misunderstanding of those developmental pathways. There is an inaccurate fear that if we introduce the idea of trans developmental pathways to people that they will become trans. That’s not real. That’s not how that is. And so, like Darlene was saying, it’s not about contagion, it’s about being alerted to or having a catalyst understand. This is a fundamental problem in how people believe or the timeline should be for when people talk about being trans. That because we don’t have pathways that are defined or that people have exposure to, some people can put together their gender puzzle when they’re little, and some people it’s 13, and some people it’s 30, and some people it’s 60. And that has to do with the environment that someone’s in.

So if we look at specifically across those hormones, when do we think they should be available, Helen?

Well, if you look at everyday teenagers, what are the gender they are? They don’t get to choose when their puberty starts. Puberty starts for them when their body brings it in. We have this artificial thing that if you’re trans and you don’t want the puberty that your body is going to give you naturally, it’s going to be stopped. And then your doctor has the key to giving you your puberty at the time where your doctor feels is right for you. Johanna talks very proudly about a 12-year-old that she felt was right to bring into puberty, and she talked about that 12-year-old is now 23 and thriving and loving it. I have to shamefully say that I have a 12-year-old that I induced puberty in, and what has happened to me is that it has let to me being suspended from the medical register. So we’ve got two doctors who gave gender affirming hormones to 2 children at the right time, and both kids are doing really well, but one approach has led to difficulty, and one approach has led to the excitement. Going back to the question when is it right to give a child, allow a child to start puberty, who is better to tell you that than the child, the family, and their peers? And what I hear children say is – what I hated is – what they’re telling me is they say, “It’s awful because everyone else in my class is going through puberty, and I’m not. I’m the one that still looks like a 13-year-old little girl, when all of the other guys in the football team are growing muscles, their voices breaking, growing hair on their chin, and it’s not fair why don’t you help me? I can’t wait till I’m 16 to start puberty.” And when we were in Los Angeles, they had a panel of 4 trans youth, really brave sitting up there taking questions from a scary audience. They were amazing. They had all started puberty. They were at a younger age than what would be allowed at the UK. They had all actually had surgery already. The trans boys had. And we said to them if someone said to you that you’re not allowed to start puberty until you were 16, what would you do? And there was almost like a stunning silence, and then they were like, “I don’t think I’d be here.” And that’s how bad it felt to them, looking in their rear view mirror. If you wouldn’t let them start puberty until 16, they felt it would’ve been so bad they couldn’t cope and couldn’t go on, and that’s awful. So when should kids start puberty when you have to induce rather than when your body switches it on? When the child is ready, and when the child’s environment is ready. And who’s going to tell you that? The child.

T is really important too because not all trans young people want to start puberty at twelve. Some want to wait they’re not certain yet. They want to think about something. They’re on a blocker. They have that capacity to have a little bit of time to think about those things. There have been people who’ve said. You know a handful of people I’m not sure yet, I want to wait. There are other people who say well I’m going to be taking hormones for the rest of my life, so maybe I’ll buy myself a year or 2 on the front end, and all of these are very reasonable. Some people have said, “I want to start. I want to start. I want to start!” And they start and then say, “Oh wait, I want to stop for a minute I’m not sure I’m ready yet.” People have done all of those things, and all of those are okay, but you know what those require? Ongoing conversations and ongoing assessments at their visits with myself or their therapist, all those things are important I think establishing one singular protocol for this care is very problematic as every individual has their own pace of development and their own thought and feelings about it.

In the states, there are process forms available for non-binary people.

Yes. We’re endorsing non-binary identities. We have conversations about how they want to wear those genders, how they want to wear that particular iteration of their gender, and what hormones can and can’t do around that. There are some people who really specifically want to be non-gendered at all when people see them, and then some people may say while my gender identity is non-binary, but I want to present that in a more feminine or a more masculine way and that conversation is obviously an evolving one over time. It may change over time. Gender expression is incredibly fluid for all humans including cisgender people. And so having these conversations about what elements of your physical body do you want to impact or might want to change. I’ve had non-binary folk assigned female at birth who take testosterone for a year, and they know they’re going to take it for a year, and they stop after their voice goes down or you know some other element of their physicality changes and they’re feeling comfortable in that presentation. A lot of non-binary young people assigned female at birth really only want chest surgery. And that is a critical piece for them in order to express their gender in a way that feels most authentic for them and sometimes those young people are precluded from that because testosterone is sometimes used as a requirement for them to get chest surgery. That is unfortunate because the way that the current WPATH guidelines outline this for adults is that testosterone or hormone therapy is not a requirement, but in the youth section, it is, so that is very confusing for providers. But certainly, gender-affirming hormones are available for people who have non-binary gender identities.

So we’ve got a question coming to us about the absurd link between trans people and those on the autistic spectrum. So the question is how should we best treat children who say they are trans and are also on the spectrum?

Okay well, I mean who put them on the spectrum? I want to ask in the first place. I think it’s again down to that label and that diagnosis. You know, how do we diagnose somebody as being on the autistic spectrum? And one way that somebody who might be showing signs of being on the autistic spectrum is through social difficulty. And so children who will have social difficulty might be labeled as being autistic. I know very much so that trans youth can find it very difficult to interact because that body doesn’t fit socially, their thoughts aren’t matching, that voice doesn’t fit. And so they often have social difficulties. And so the young person saying, “I’ve got trouble with my gender.” And the professionals are saying, “I think you’re autistic,” and that’s maybe really difficult to unwrap. And I think it’s listening to that child. Yes, there will be children on the autistic spectrum who are also on the transgender spectrum. And they both need addressing in their own right. But again down to these labels and this diagnosis. And that’s really problematic for me. I don’t know what you guys think about that. Anything to add, Darlene?

I have to say I do have a lot of clients who are on the spectrum, and I think that their relationship with their gender or how they express their gender can vary. A lot of times we’ll see adolescents not really caring that much about performing gender in a way that pleases everyone else when they’re on the spectrum. And so parents get a little bit distressed by this because they don’t understand why their child is not necessarily performing gender the same way. And that can create some difficulty in understanding the child or the youth’s authentic gender. And so I think it’s important to know that not everyone expresses gender the same way, not everyone cares if everyone else is reading you right, because if that’s not your number one concern of being authentically connected to another person, that changes the presentation and the relationship to gender.

I think it’s also valuable and it’ll be exciting to write about this, but there are people whose symptoms of autism go away when they are affirmed in their gender. And that’s not to say that there aren’t people who are both on the autism spectrum and have gender dysphoria or are trans, have a gender different than the one assigned to them at birth. And so I think that as we learn about that, I find it interesting that most people who have this diagnosis of something happening with their gender and also being on the spectrum, have a diagnosis of the high functioning autism spectrum. And I think that’s valuable to think about. And I agree with what my colleagues have said about this. I think that for people who have autism features or are on the autism spectrum, they need those things addressed so that they can function to the best of their ability. And if they have things happening around their gender those needs be addressed so that they can function to the best of their ability. I don’t think we need to draw a linear line between autism and gender dysphoria. I don’t think we need to go through a certain pathway. I think that you’re allowed to have autism and also be trans.

I have a couple of questions about surgery. So the first one is what will be your suggested pathway for a young female to male person who wants to preserve their fertility, but also wants to get blockers at Tanner stage 2, if you plan to start menses? Johanna, you want to get that one?

I think the question about fertility comes up a lot. It comes up a lot from parents and a lot from professionals. I’m always blown away by the amount of thoughtfulness that young people have already put into this conversation and this conundrum because people who have not gone through their third or fourth stage of puberty are not going to have fully developed follicles that they can use for fertility preservation. So what does that mean? That means as medicine stands right now if somebody is on blockers, and they progress onto gender affirming testosterone treatment later, and they continue on that through their lifetime, they’re not going to have fully developed follicles and they will not contribute biologically to their own children. There are not because blockers have been used in youth gender for a short-ish amount of time. There are not yet cases that have been published of people who were on blockers, went onto gender affirming hormones, and then years down the line decided to try and go through their female puberty. We don’t really have an understanding of that. I can tell you that there is – I have a young person in my practice who went onto blockers in early puberty, then went on to testosterone for about a year, and then came off of both of those things and went entirely through their female puberty. It happened at a later time than their body would have taken them through it. This was incredibly dysphoria-producing for this young person who ended up going back on testosterone and having chest surgery. So what is uncertain is whether people’s ovaries are hibernating and that if they made a decision later on to stop hormones, that they could go through female puberty. I’m not guessing that’s going to be something that a lot of people choose to do at a later time. But I think it’s a mistake when we say that fertility is eradicated. I think that fertility is placed on hold. It’s not the presence of blockers or testosterone that causes eggs not to mature. It’s the absence of a hormone milieu that favors estrogen. And so we have a lot yet to learn about this. The safest way to advise patients is, “You are not going to have the capacity to contribute to children biologically.” It’s another reason that blockers can be really helpful because someone can go on blockers while they’re thinking about the outer world are considering that and whether or not the fertility piece is important to them. I do want to say though that we have to be very clear about a question that’s on the table for that young person, because for us as adults – and oftentimes providers are cis-gender adults – the question that we’re positing is, “You know what about this future thing that you may or may not embark on?” That’s so important to humanity, which is fertility for that young person. The question we’re asking them is, do you want to go through your endogenous puberty? I’ve never had somebody say, “Yes, I want to go through my endogenous puberty even though the idea of it is horrifying and terrifying for me so that I might be able to at some point later in my life have children.” I’ve never had anyone choose that. I have had people say I need to stay on blockers a little bit longer so that I can make sure I fully understand that.

I think though that we sometimes don’t add into this conversation is it as trans people who transition understand we’re giving things up. That it is an exchange, we give things up with the understanding or the hope that what we get is going to be worth whatever it is that we’re sacrificing. And that there are tons of people who would love to genetically contribute to their children who, because of just typical sort of normal biological sort of medical circumstances, cannot. And that is sad, that is absolutely sad. And as trans people we should also be given the right to say, “I don’t get that, and I feel sad about that, and I am angry about that and I’m grief-stricken about that,” and be allowed to sort of go through that process, but not to use that potential process or experience of sadness about what we don’t get as a reason to not give us what we need. I transitioned at 31, you know, and there are many times in my life since I transitioned where I feel deep sadness about not genetically contributing to children. And I’m OK. It’s like my sadness around fertility will never cause me physical harm or threaten my life. Not being given the opportunity to transition or being delayed 18 months – which is just like unbearable – to me that absolutely not only could have but would have injured me in a way that I don’t know I could have come back from.

So I’m going to get to top surgery for trans boys. When would you like to see that?

When they need it.

I would like to see top surgery not needed. And I think if we get trans youth care rights for the majority and stop puberty happening –  if we haven’t got there in time, we haven’t got there in time. But if you’ve got a young person who’s saying, “Please stop my puberty because it’s going to make me grow a chest when I don’t want one,” and we haven’t done that and they’ve grown a chest that they didn’t want, and then they say, “You made me grow this, and now you’re saying that you can’t take it off for me.” I feel their anger, but I feel that if we get trans youth care rights, we won’t have trans women with broken voices, Adam’s apple, or angular jaws. And we won’t have trans men needing surgery, and that is what I’m hoping that I’m going to be live to be old enough to see trans care being done right.

We’ve got a question that says, “What are your thoughts about the impact of trans girls taking blockers at Tanner stage 2 on their ability to have successful bottom surgery, given that there’ll be less physical skin work with? How do you balance the benefits of blockers with their impacts on successful surgery in the future?”

You see, once again we’re going to have cis-surgeons and cisgendered physicians discussing what the best time for that trans girl to be allowed to have hormones because if we block her puberty too young, she’s not going to have enough penile growth to give a decent vagina. And if we do it too late, she’s going to have some masculine features. We need to be asking the young person and balancing that with the young person again. At the same time, we need to be creating medical techniques that allow that surgery to happen.

I think that there is an assumption that if you get blocked in early puberty, then there’s no way to create vaginal depth that is typical that people would seek out, but that’s just not true. There’s a lot of ways to do it in the United States – and I know other places there are many ways that people work with people who are blocked early. There are there places where tissue is harvested from. It’s testicular tissue or abdominal tissue. Now we have peritoneal tissue or the lining of the peritoneal cavity that’s being used. So there are actually a lot of ways that we can do this. There is a more interesting –, and fundamentally it speaks of this issue of giving up things, right? So I think for trans women to transition after they’ve gone through puberty, they have a clearer sense or clearer options around whether or not to have genital surgery. And I think this is interesting, right? So for people who get blocked, it’s a different decision because they don’t have adult genitals, so they are making a different decision around their genitals. And that’s a question that we should be talking about and talking with both adult trans women, but also young trans girls about. That’s a more relevant question and can we get enough tissue and would you like to take a chance on your voice dropping in order to have enough tissue to make what we consider to be a viable vaginal canal? The questions are different than the ones we would posit. And it’s frustrating to me that there is a lot of attention on these things that people are seeing as impacting the quality of life for trans people, like fertility and vaginal depth, when really these are being used as barriers to care.

So we’ve got about fifteen minutes left, so I’m going to jump into some of the questions that have come through and joined the live stream. So one of them is, “What do you see the role of mental health professionals in the care of trans and gender diverse children without existing mental health issues?” Darlene?

You know, I talk a lot about this, as far as dysphoria. People look at what is the treatment for dysphoria, and a lot of times these kids are sent to therapy to talk about their dysphoria, which is really interesting because the dysphoria is created from that misalignment that could be addressed, not cured, but that may be alleviated a little bit by medical interventions. And so kids instead are sent to a therapist to talk about – sort of like the kid who got run over that Helen was saying – go talk about what it felt like to be run over rather than getting some medical care for your injuries. And so I think it can be a supportive role, and it can certainly help the youth talk about transition and coming out and what that process is like, and building coping skills for dealing with dysphoria. But it really has to happen at the same time as they’re able to access the medical interventions that they want and that they need. And that said, I also think if a kid doesn’t feel like they need therapy, they should not have to be in it, because you only get something out of therapy if you are invested in it. Not if someone else is telling you that you need it. And so I think that medical care is really important. And I think having you know 18 to 20 month waiting period for that would be just so difficult, for both the youth and the provider, to sit there with that dysphoria but not be able to go anywhere with the kid really needs.

I think that that therapy plays a significant role in supporting youth, supporting families, supporting schools, supporting sort of all components. The first sort of year, year and a half to two years after the medical transition has begun, is the time in which probably people need the most support. It’s not the month and The years leading up to starting the medical transition. I think every human should be in therapy, quite honestly. But I think for trans youth, I think the parents and families who are going through these are really significant changes. There are really some very steep learning curves involved for an entire family and the young person who is transitioning and I think a therapeutic space to talk about those things like the frustrations and the fears and I don’t know what to do in, and the kind of that feeling of like I feel like I’m in chaos right now. We’re talking about – we’re going to use the model here in the UK – that if you’re 16, and you are now in the beginning stages of puberty at 16 or 17, but you’re not pure concordance, like there are some things that you need to be able to have a space to talk about around what that actually means in relation to dating, in relation to employment, in relation to pursuing college or secondary education. There are real concrete practical things about life that trans folks are navigating, negotiating. And the more you are delayed in your own process when you’re trying to access these things, the more challenging it is. Again, I think that you know, I agree a hundred percent with Darlene, that if somebody doesn’t want to be in therapy – as a therapist I know that you can sort of attest to this – as a therapist when you’re sitting in a room with somebody who absolutely does not want to be there, it is the longest 50 minutes that anyone can have. And so you can put a kid in a room, but you can’t actually make them have an experience. And I think that while young people should be given the opportunity to have affirming therapy, I think it’s that the people who need therapy the most leading up to a medical transition and probably right after medical transition are parents. Parents are largely not supported in this process. Provide the intervention to the young person, provide every young person, and the parents are often just sort of floating around trying desperately to make meaning of their feelings and their fears and their frustrations and their anger. I actually think that we should reorganize our efforts to better and more effectively bring parents in. Supported parents are better at supporting their children.

We’ve got a question from Daryn about puberty blockers as implants. “I’ve been told that these are currently not available in the UK. My son really struggles with the three monthly injections. It’s painful. We have to take a day off from school and work to get it, and the effects go up and down between the beginning and the end of the three months. Could we travel to the states to get the implant, or is there a way to get it in the UK?”

Well, Jo at the beginning talked about the other things that we use, the GnRH agonists. So we use them for endometriosis, we use them for prostate cancer, we use them for precocious puberty. In the UK, we do have implants. The problem that we have is that these medicines are not licensed for use in transgender people. So doctors again have that fear. But the same injections that we have in the UK are for puberty blocking, are available as implants, and they are available as nasal sprays. So there are medical options. What you have to do is find a doctor who isn’t too scared to give you that option.

Oh, there is a nasal spray? That’s a huge learning curve right there.

I think this is a really interesting space to understand that in the United States, the FDA has approved nothing for gender dysphoria. Nothing. So not gender affirming hormones, not blockers. There are two particular kinds of blocker implants, and neither one of them was approved for gender dysphoria. And so if you’re going to do gender affirming hormones or blocker care for trans youth, All of it is not FDA approved. The interesting thing about this is that in the US, the two blocker implants have quite a substantial cost difference and so, you’ve got to make decisions about that. And again there is a certain level of just going out there and saying I know this is important and we’re going to use it.

Could somebody travel to the US and the UK? Is that a thing?

They do, yes, they do. I feel as a UK trained doctor who is very proud of my National Health Service, why do people have to pay to go a long way over to your country, for not just the treatments that the assessments and what have you that go with it and the aftercare? Because obviously, you said it’s not just a one-off visit. When actually what you prescribe in the USA, our doctors here on the NHS can prescribe (unclear 1:19:36).

So we’ve got a question that says, “How can we start to move towards a new standard of care amongst GPs in the UK? (unclear 1:19:46) How do we change that model?”

I wish we could change this overnight. There are two key things that I think we need. We need education. We need to empower a GP in this country to be able to feel able to help transgender people of all ages. And we also need parents. I’m going to look directly at all the parents now who haven’t felt that they’ve got the care that they need. If you don’t feel you’re getting the care that you need, you need to speak up about it. And I do know that lots of parents have spoken up about it and have been pushed back because when you complain nobody wants a complaint and often it’s push back. But we need to keep pushing. We need to keep fighting for the care that we think that our children and our adolescents and adults deserve and need in the UK. If you went to your doctor and said,  “I have a bad elbow,” and your doctor said, “I’m sorry, I don’t know anything about elbows,” you would be like, “Well, didn’t you go to medical school? Don’t you think you should go look it up?” And that is exactly the same for transgender care. No, they didn’t get taught it at medical school, not yet. But we need to bring in that education. But doctors are clever people. We went through tests to get to a certain level. There are books. There are things written. We can go and educate ourselves about transgender care. And at the end of Johanna’s course – again I’m going to go back to it because it was just life-changing for me – she said, “Thank you very much to all the trans people who taught me so much.” So we get an education from books and from manuals or journals or what have you. We also get our education from listening to you guys out there, so speak, share your stories, educate. And if things aren’t going right for you in health care, then we need to stand up and say, “You didn’t do that right. I want you to try that again.”

We don’t want to get change through that. And that’s unfortunately what happens a lot, that you know you have to have a lot of really bad things happen before things change. And we don’t have to follow that model here in the UK. But we also don’t have to follow that model in the US either. And there’s too much damage that has been done to the community by the medical system in both of these countries; by the mental health system, by the medical system, by the folks who are making decisions at the highest levels. It’s this is an important ground up change that has to happen.

So quick question, Jo and Aydin, are you working on any research at the moment? And if so, where and when will the results be published?

Yes, we are definitely working on research. I’m participating as one site in a four-site large grant that’s federally funded about the impact of blockers and the impact of gender affirming hormones on a variety of things, on mental health parameters such as anxiety, depression, suicidality, drug use, high risk sexual behaviors, which is kind of typical and not that different on what’s what’s going on. But we’re also looking at life satisfaction. We’re looking at gender minority stress. We’re looking at parents’ support. There’s a whole many many things in addition to the physiologic safety profile and the rate of change. There are so many things that we don’t have information about that’s written down, and it’s really kind of a collection of clinical experience, but it’s really important that these things be written down. We have a cohort of over 400 young people in that study right now, all of whom are undergoing medical interventions to address or mitigate gender dysphoria. We’re going to have our first series of papers looking at baseline information but also about how the protocol is started, the measures that we use, the challenges of those measures, and those will all be coming out this summer.

Are you guys coming back to the UK any time soon?

We would love to. We would love to bring Darlene with us. You know, the three of us do a 14-hour training that Helen has referred to a couple of times. And we talk about medical care. We talk about mental health care. We talk about the social piece of being trans and transitioning. And I think that what our hope and goal are, is that at the end of those 14 hours, people feel empowered to lean into their discomfort and their uncertainty and do it anyway. As humans, we have all sorts of places where we’re like, “I am not sure, but I understand that doing nothing is an inappropriate response.” And so we can empower people to say, “I’m nervous, and here I am stepping anyway.” That’s a really important piece, and I think that’s actually how change does happen.

I think what it taught me is that in the UK when I talk to parents, parents firefighting the whole time; that they are so worried about how to get this child the care. They haven’t got the space to do the parenting stuff, Darlene, that you talk about so well as how to support your happy trans kid through life, because it’s going to be challenging, instead of that firefighting thing that we’re doing over here with our unhappy trans children. And of course, you could come back here to the UK and teach our parents how to help our happy, supported trans kids – it would be amazing.

Johanna, you’ve got one last sentence to frame the conversation around what we’d like to see for trans kids in the UK.

I think that we need to apply the same standard to gender across the board. We don’t ask cisgender people to provide certainty about their gender. And we really shouldn’t do that for trans youth either. I think we need to not burden young people with certainty such that they do not have room for their own uncertainty. And I think that is a critical piece – is take out some of the fear, take out some of the gender essentialism that gender equals genitals or gender equals chromosomes. And if we can differentiate those things, we’ll have a much clearer idea of how to help young people be successful and thriving in their lives which they all deserve.

Thank you. Thank you so much for joining us today, and for sending in all the amazing questions. I appreciate it. Lots of them we still haven’t got round to. But if you keep an eye on the Gender GP website, there will be blog articles going up in the next few weeks answering lots of those questions. And this will be available online to watch on a later date. Also, a massive thank you to all the supportive mums. It is Mother’s Day here in the UK, all the supportive mums we’ve got across the country. And to our panel, thank you so much for spending your time with me this afternoon, and for answering amazing questions about having to give. And to Darlene.

Thank you for having me.