Forget the moral panic—early treatment for trans children could be life-saving

I am a trans man. In 1975, I failed the clinical assessment for cross-sex hormone therapy, and was told I would never be treated. In the 1960s, 54 per cent of family doctors claimed they would prefer a patient commit suicide rather than provide them with gender reassignment treatments. Thankfully, my GP was different and I got the treatment I needed. Aged 19, as I started life as Stephen, I knew how lucky I was, having managed to avoid being sectioned and given aversion therapy. Being trans was bloody hard work.

Today, clinicians increasingly challenge Emma Hartley’s assumption that there is an absolutely clear distinction between the biology of sex and the social constructs of gender. Some sex dimorphic nuclei and other physical brain features, along with genetic indicators, have been found to differ in trans people, meaning biological elements may well feature in the trans or non-binary person’s experience of gender.

The UK has nine regional Adult Gender Identity Clinics, but still only the Tavistock serves trans and non-binary identified children and adolescents (T/NB children). With limited resources the clinic is having to respond to a worldwide exponential growth in the numbers of  T/NB children seeking gender affirmation treatments. The growth is a consequence of multi-channel television and the internet, which have made quality information on gender reassignment accessible to all, empowering many to recognise what is behind their feelings.

Accusations of an institutional rush to prescribe pubertal postponement treatment (PPT) are wrong. In 1995, the head of the Tavistock, Domenic Di Cegli, refused to accept any child under 18 as old enough to consent to pubertal postponement. In 2000, a colleague and I published a paper explaining that this was an incorrect interpretation of clinical and legal rules. Rather than exploring whether the child was competent, doctors were rushing to judge a child as being too young. In law, though, even if a child is not competent, their parents can consent.

Things have changed since then but the Tavistock staff are still careful, considered and cautious. Most complaints from those using the services are about the length of time to get an initial appointment, and then the length of the assessment process before PPT will be considered.

PPT has been shown to be a beneficial pathway. The Amsterdam clinic has been providing PPT for 25 years, and has found that T/NB children who have supportive environments at home and school are better able to determine whether or not they wish to take PPT, and later, whether to progress to gender reassignment. A recent analysis of data from the 2015 US Transgender Survey, involving 20,619 T/NB people between the ages of 18 and 36, found that access to PPT immediately reduced a young T/NB person’s risk of suicide and developing mental health problems, which continued to decline as they grew into adulthood.

The significant growth seen in the number of those assigned as girls at birth seeking help has many reasons. Those of us who have worked with the community as long as I have—45 years—are not surprised by the numbers. Though some T/NB (male to female) girls like to wear feminine clothes, boys’ clothing feels neutral. T/NB (female to male) boys also prefer neutral “boy” clothing. They seek help at a much younger age so as to escape the societal expectations that come with the excessive feminisation of clothing and culture, which they hate.

There is some correlation between anorexia and being a T/NB (female to male) boy, but it is not causal. Rather, not eating is one way of avoiding that excess feminisation—of not having to wear a bra and stopping their periods. If a child states that they are, or should have been, a boy (not just that they wish they were a boy), then they will resume eating immediately on receiving PPT or, if 17 or older, cross-sex hormones. Adult trans men are not anorexic.

For the last 30 years, a strong co-morbidity has been noted between being trans and being on the autism spectrum. In the past, the obsessional nature that sits with being on the spectrum was probably essential to obtaining gender reassignment treatment. That may change as gatekeeping to puberty blockers or cross-sex hormones become less judgmental. But being on the spectrum does not mean it is causal: more likely it will be linked through a broad range of physical and social aspects of the person. Those of us who are both trans and on the spectrum have mostly managed to live full lives.

Clearly some lesbian women feel that trans culture is “taking away” the best of their masculine women. I suggest that they consider the deep unhappiness that lies behind those women who seek help with their gender identity. Those of us who have been through gender reassignment do not lightly recommend this extraordinarily arduous path. Lesbian women should not assume that just because we are men that we have left behind all of the “female” aspects of ourselves. Increasingly many of us accept the depths of our complexity. But, either way, that debate is a red herring, and nothing to do with treating the distress experienced by gender incongruent children and adolescents.

Read Emma Hartley's feature on why so many teenagers are seeking to transition from female to male