In the past two months, the UK has seen three key issues that directly threaten the safety of trans people, especially trans young people. However, one of these issues has received little to no attention whatsoever. Perhaps this is because it is not a popular time to criticize the NHS, who are fighting so hard during the coronavirus pandemic. While this is of course deeply appreciated, trans young people’s access to support are under threat and these issues must be pointed out.

The first key transphobic issue occurred on 22 April when the Minister for Women and Equalities, Liz Truss MP, made several statements that suggest her intention of changing the rights of trans young people. Click here to read Mermaids’ response to Liz Truss MP’s problematic statements, and take action by writing to your local MP. 

Second, perhaps the most famous author in the world, JK Rowling, became vocal in her transphobic views through tweets, a blog post, etc. While the views of an author may not seem dangerous, the Harry Potter author is incredibly well-respected and admired, giving her words a great deal of power and influence. It is important to be aware of what she says and to resist any harm she might cause. However, rather than provide her sites with more views, here are links to two thorough critiques of what she said: 

https://twitter.com/Carter_AndrewJ/status/1270787941275762689?s=20 

https://www.facebook.com/permalink.php?story_fbid=2560000527649349&id=100009182802430 

Both of the above have received some critical attention (though more is needed), but another key issue facing trans people in the UK, especially trans young people, are the changes that were made on 28 May 2020 to the NHS’ website pertaining to gender dysphoria. (To see the original wording, click here).

The new wording on the NHS’s website is biased. It focuses on the negatives, and suggests that hormone blockers and cross-sex hormone treatments are dangerous. The wording here seems to be designed to scare people, avoiding any positives in order to discourage parents from supporting their trans children, something that could have serious consequences for trans young people’s emotional health and wellbeing. 

Let’s be clear from the beginning: no one is forcing children into sex changing surgeries. This does not happen, and this fear is based in a long history of casting LGBTQ+ people as dangerous perverts. Instead, after an already too long and difficult process, trans young people may access hormone blockers (or GnRHa), which pause the development of puberty, save the trans young person from irreversible changes to their bodies, and drastically improve their emotional health and wellbeing. It is trans young people’s access to this treatment that is currently under threat. 

Let’s go through this threat point by point. 

Some young people with lasting signs of gender dysphoria and who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist) to see if they can take hormone blockers as they reach puberty. This is in addition to psychological support.

This opening statement is worryingly vague and suggests a dangerous new direction for young people’s transitioning processes. 

‘Lasting signs of gender dysphoria’ suggests two problems: 1) What will be counted as evidence for ‘lasting signs’? Will this have to conform to outdated gender norms? 2) How long does a young person need to demonstrate that they are experiencing ‘gender dysphoria’? Will it still be two years, or will this be made even longer? It is important to question how this time may be used to delay the process of supporting trans young people. 

The wording of ‘meet strict criteria may be referred’ is also concerningly vague, and suggests that the already difficult process of getting support is about to be made even more inaccessible, and that a referral is not guaranteed. 

Finally, ‘This is in addition to psychological support’ is especially worrying. While young people are already receiving support through CAMHS, the wording here is concerningly vague. What kind of psychological support? Will this be different than what is already being offered? What is the purpose of this support? It is important to question whether making psychological support a necessity (rather than an available option when needed) will pathologize young people and treat being trans as a psychological disorder, when the WHO’s ICD-11 makes clear that it is not. 

This opening statement suggests that the NHS’ position is that they do not believe that young people are smart enough or competent enough to understand their own identities or make their own decisions about their bodies and futures. While the HRC say that ‘gender-affirmative approaches follow the child’s lead’ (pg. 16), the NHS shows a clear bias against young people by enforcing a difficult process of getting adult approval in order to get the support they need. 

However, this is not just about young people, but is about trans young people especially. Take, for example, the NHS’s guidelines for early puberty (https://www.nhs.uk/conditions/early-or-delayed-puberty/). Here, ‘using medication to reduce hormone levels and pause sexual development for a few years’ is a perfectly acceptable form of medical treatment for cisgender children experiencing ‘emotional or physical problems’ related to their changing bodies. This is a double standard that prioritizes the needs of cisgender children over trans children.

 

These hormone blockers (gonadotrophin-releasing hormone analogues) pause the physical changes of puberty, such as breast development or facial hair.
Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.
Although the Gender Identity Development Service (GIDS) advises this is a physically reversible treatment if stopped, it is not known what the psychological effects may be.

While these three statements are not necessarily untrue, they again focus on a negative bias. They also do not mention the many positive psychological effects that have already been studied. According to Simona Giordano & Søren Holm in their paper ‘Is puberty delaying treatment ‘experimental treatment’?’ published in the International Journal of Transgender Health in April 2020:

The published literature provides insight into the likely benefits of GnRHa. In summary, they reduce the patient’s dysphoria (Cohen-Kettenis & Pfafflin, 2003, p. 171; Kreukels & Cohen-Kettenis, 2011, p. 467), reduce the invasiveness of future surgery (for example, mastectomy in trans men; treatment for facial and body hair, thyroid chondroplasty to improve appearance and cricothyroid approximation to raise the pitch of the voice in trans women) (Cohen-Kettenis & Pfafflin, 2003, p. 171); GnRHa is correlated with improved psychosocial adaptation (Cohen-Kettenis & Pfafflin, 2003, p. 171; Kreukels & Cohen-Kettenis, 2011, p. 467) and reduced suicidal ideation and attempts. Hembree noted increased suicidal ideation where blockers were not given (Hembree, 2011; see further, Imbimbo et al., 2009; Kreukels & Cohen-Kettenis, 2011; Murad et al., 2010; Spack, 2008). (pg.118).

For trans young people who do not receive support, the statistics are incredibly worrying. According to Stonewall: 84% of trans young people have deliberately harmed themselves, and 92% have suicidal ideations (with 45% having attempted suicide.) These numbers are shocking, and much more work is needed to support trans young people’s emotional health and wellbeing now rather than worrying about hypothetical problems that may occur later, despite scholarly evidence suggesting otherwise. 

It’s also not known whether hormone blockers affect the development of the teenage brain or children’s bones. Side effects may also include hot flushes, fatigue and mood alterations.

Simona Giordano & Søren Holm also comment on this issue. To begin, they explain that it is incredibly difficult to predict how any drug may affect a patient, and that all drugs have side effects: 

we are rarely in a position where we can predict an individual’s response to a particular drug with absolute certainty. Most drugs have side effects, and most have some rare but serious ones, but our inability to predict whether this particular patient will experience a serious side effect does not make the prescription ‘experimental’. If it did all prescription, even of Aspirin would be experimental. What drives clinical decisions is the risk/benefit ratio using a probabilistic calculation, which includes elements such an assessment of the risks of the condition if left untreated, the expected benefits of the intervention, the expected risks, the potential more remote risks, their likelihood. (pg. 116)

While they agree that GnRHa may have a negative impact on the formation of bone mass, they conclude that: 

even large, well conducted follow-up studies may not be able to provide definitive answers to questions about the biological, psychological and social long term effects of GnRHa treatment seen in isolation. Even if long term follow up shows a particular set of effects of the ‘whole package’ of interventions, it will be close to impossible to disentangle the specific effects of GnRHa treatment. This is the case even for seemingly hard biological outcomes like peak bone mineral density. This may be influenced by GnRHa treatment, but also by dose and duration of cross sex hormone treatment, by surgery and reconvalescence, by level of physical activity etcetera. This means that it is unlikely that in this area of care we can achieve the sort of evidence-base that can lead to whole-ranging clinical guidance applicable to all patients in all contexts (pg. 118).

Essentially, while it is good for people to know the side effects of what they are putting in their bodies, the NHS’ concerns here should not determine their decision making around whether/ how easily young people should be able to access GnRHa.

From the age of 16, teenagers who’ve been on hormone blockers for at least 12 months may be given cross-sex hormones, also known as gender-affirming hormones.
These hormones cause some irreversible changes, such as:
– breast development (caused by taking oestrogen)
– breaking or deepening of the voice (caused by taking testosterone)
Long-term cross-sex hormone treatment may cause temporary or even permanent infertility.
However, as cross-sex hormones affect people differently, they should not be considered a reliable form of contraception.

First, breast development can be reversed with surgery, and while speech therapy cannot reverse the effects of a voice breaking, it can certainly make an impact. What is key here is who the priority is in this wording. The wording suggests a fear for cisgender young people undergoing irreversible changes and the harms that this may cause them, but there is no mention here of the changes that puberty causes in transgender children and the need for surgery to help them. Furthermore, it fails to highlight the purpose of GnRHa, and how gender-affirming hormones are not offered to young people and are only made available to a person after a difficult process to make sure this is the right decision for them. This wording functions to scare people away from gender-affirming hormones, again failing to note the importance of this process for trans people. As Simona Giordano & Søren Holm explain:

most likely GnRHa will only be given to those who most likely will choose to continue to transition, but should the patient change their mind, then no permanent changes will have been effected (whereas, should an untreated person transition, permanent changes of pubertal development will only be partially reversible surgically).

Thus, without GnRHa, trans people will need to undergo surgery that could otherwise be avoided. Irreversible changes will occur with or without medical interventions, and thus it is important to ask: how are trans people made a priority in these descriptions and in the policies they may promote? 

Finally, when it comes to infertility: this is not the case for all trans people, and for those that it does apply, contemporary reproductive technologies can (and often do) assist with this. It is a myth that trans people cannot have children, a myth that may be based in a history of trying to control women’s bodies for reproductive purposes. It is in this way of thinking that transphobia can harm cis women as well. 

There is some uncertainty about the risks of long-term cross-sex hormone treatment.
The NHS in England is currently reviewing the evidence on the use of cross-sex hormones by the Gender Identity Development Service.

There is indeed some uncertainty about the risks of long-term cross-sex hormone treatments. There is also much certainty about the important positive benefits of long-term cross-sex hormone treatments. The fact that this description fails to highlight these benefits demonstrates a clear bias against trans people and supporting their care. As the NHS in England reviews evidence and makes new policy decisions, it is imperative that they approach these decisions with trans people’s wellbeing as their top priority. 

If you are worried about changes being made in the NHS that may harm trans young people, then it is important to raise awareness about this issue and be vocal about your support for improving access to support for trans young people.

 

Sources: 

https://www.tandfonline.com/doi/pdf/10.1080/26895269.2020.1747768?needAccess=true

https://www.stonewall.org.uk/system/files/the_school_report_2017.pdf

https://assets2.hrc.org/files/documents/SupportingCaringforTransChildren.pdf?_ga=2.35503077.519674698.1591474056-208760301.1591474056

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