The judgment in Keira Bell's case will be given tomorrow

[MaudTheInvincible]

The judgment of the Tavistock's appeal of the case will be given at 2pm.

www.gov.uk/government/publications/royal-courts-of-justice-cause-list/royal-courts-of-justice-daily-cause-list

Brave Keira. You have done so much to protect children from ideologically driven healthcare around the world. Your integrity and courage is inspiring and rare in this ridiculous day and age. 💚🤍💜

@InvisibleDragon

Returning a bit to the ideas of capacity to consent and the Tavistock / GIDS process ... (This is loooong, sorry)

Butterfly I haven't read all of your most recent posts in detail, but what I hear is that your experience of puberty blockers and transition was a relatively smooth one that perhaps represents a best case scenario:

• you were ?mid-teens when you started on blockers
• your transition was MtF, so blockers stopped you experiencing the irreversible effects of testosterone, which was the original intention of the Dutch protocol
• you were part of a small initial cohort, so you were given a lot of information about the long term impact of early transition and had the time to ask questions and come to weigh up the different options and come to a decision that worked for you
• You were seen as relatively 'stable' compared to other clients by the clinicians you saw - so presumably you didn't have other serious mental health difficulties / a significant history of trauma or abuse (or were able to work through that alongside your gender identity issues); you had a supportive, accepting family background and are roughly neurotypical.

For you, that meant that you were able to make an informed decision about transition that you were comfortable with at the time, and that has worked out well for you in the long-term although you have had some (small) health problems as a result of transition.

I think in clinical terms you were able to show that you were Gillick competent - that you had the capacity to make that decision about your health at that time.

However, I think a lot of things have changed in the 20 years since then.

Firstly, the number of referrals GIDS deals with has increased enormously. The yearly referral rate was about 30x higher in 2019 than in 2010 (www.transgendertrend.com/surge-referral-rates-girls-tavistock-continues-rise/). The size of the GIDS team has not increased by nearly that much. That partly means longer waiting times, but it also means less time for clinicians to really work in depth with the young people they see to help them find the best option for them. Kiera Bell said that her assessment sessions were perfunctory; and there are reports of patients being referred for treatment after just a couple of sessions despite concern from other clinicians.

• It is clear from the original Bell hearing (www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-and-portman-nhs-trust-and-others/) and the recent CQC report on GIDS (www.cqc.org.uk/provider/RNK/inspection-summary#genderis) that their record keeping is appalling and they are basically not functioning as a service. When the CQC audited their records, they found that the majority did not contain capacity assessments - namely how they determined that the young people were able to consent to the treatment. In the Bell hearing, it was clear that GIDS staff did not have a clear process for assessing capacity to consent, and that some of the young people who testified for them clearly lacked the capacity to understand the decision they were making.

Whilst you may have had the capacity to consent to a treatment that was presented as highly experimental, it really doesn't seem that today's cohorts are afforded the same level of care. That's very concerning, particularly when it is clear that much younger children are now being put on blockers.

Secondly, a lot of the young people referred to GIDS today have very complex backgrounds. About 40% have diagnosed autism or score highly on autism screenings. Others have experienced sexual abuse and other childhood traumas that have affected their sense of self and their feelings of dysphoria. If you read the judgement from the Sonia Appleby tribunal (www.gov.uk/employment-tribunal-decisions/mrs-s-appleby-v-the-tavistock-and-portman-nhs-foundation-trust-2204772-2019), it is clear that GIDS discouraged and impeded their clinicians from getting support and making safeguarding referrals when they had concerns about a child's wellbeing. That's really bad. It's probably partly the result of being overwhelmed with work already (making safeguarding referrals is quite time consuming), but it shows that there is a general culture in which the needs of vulnerable children are not being recognised.

There is also a thread throughout the Appleby judgement about children in homophobic environments who may be same-sex attracted identifying as trans, in some cases in a way that seemed parent driven. It's clear that clinicians were concerned about these types of referrals, but that they were shut down by senior staff as "transphobic". That's also really concerning. This and the lack of consideration about trauma, abuse and non-neurotypical clients, especially coupled with the quite cursory assessment process, suggests that there are children and young people being put on this pathway of blockers and transition for whom other pathways could be more suitable. That's not to say that transition is inherently bad. Just that it comes with a heavy medical burden (infertility, loss of sexual sensation/function, lifelong medication, risky operations, reduced bone density, increased cancer and osteoporosis risk), especially if natal puberty is halted very early. So it is very important that other psychological issues are well managed so that a young person is in the best possible place to make a decision about transitioning; that other alternatives to childhood transition are considered, and that any safeguarding concerns about reasons for wanting transition are properly investigated. Based on all the evidence from GIDS, I am not convinced that any of that happens at all, making me very concerned about the harmful and potentially unnecessary treatments being given to children and adolescents.

Thirdly, the demographics of GIDS referrals has changed hugely. The Dutch protocol (blockers followed by hormones) was designed for young people who had experienced (parent documented) gender dysphoria from childhood and tbh who were mostly transitioning MtF. That was the bread and butter of GIDS 20 years ago. Today a lot of the referrals are for people who want to transition FtM and who only started presenting as trans at the onset of puberty. They are being put on the sam pathway but it's a much poorer fit. Blockers that stop masculinisation at puberty are good at helping trans girls to pass better as adult trans women; but blocking the growth spurt at puberty blocks trans boys from even reaching the adult height they would have attained without blockers. Trans boys, because they still remain biologically female, are also at much greater risk of serious osteoporosis in adulthood if they miss out on the bone density increase of their natal puberty.

It's also worth considering that the concept of being trans is much more prominent than it was 20 years ago. (Note - this paragraph is more speculative. I'm basing my argument on ideas from Ethan Watter's book 'Crazy like us' about how people in different times and different cultures have different ways of expressing psychological suffering.) That means that it's very possible that young people are more likely to express distress through the lens of gender dysphoria. Whereas 20 years ago someone might have developed anorexia or used self-harm, similar feelings of distress and alienation may be interpreted by young people today as evidence of being trans, with transition viewed as a concrete solution to their unhappiness. Those young people may interpret steps along a path to transition as proof that their suffering is genuine, valid and understood by others. That's not to say that there can't be more young people for whom transition is genuinely an appropriate pathway, but we need to be very careful to fully explore a young person's understanding of transition (in a way that, as above, I don't think GIDS is doing) before starting them on a pathway to an early medical transition.

Finally, there have never been any proper randomised controlled trials of puberty blockers for trans children. 20 years ago this was a very new idea, so proof of concept trials with no control group are a reasonable first step. However, today we still have no high quality data to say (beyond anecdotes) that puberty blockers have any clinical benefit. Data that we do have (see the NICE review of evidence here www.evidence.nhs.uk/document?id=2334888&returnUrl=search%3fq%3dtransgender%26s%3dDate ) suggests that there might be a small improvement in depression when teens are given blockers, but that there is no significant effect on anxiety, anger, dysphoria or other quality of life measures. At this point, we are beyond asking whether a child can consent to the treatment; we need to ask why the treatment is being offered at all, given that it functions no better than an antidepressant and comes with a much longer list of severe side effects.

At this point, I honestly don't think GIDS is fit for purpose. I am uncomfortable with blockers being prescribed outside of a clinical trial with a control arm (placebo, treatment as usual, waitlist, take your pick ...). I would also want to see wholesale restructuring of their service and preferably much tighter integration with other mental health services before I had any confidence that they were able to practice safely and meet the healthcare needs of the children they support.

@InvisibleDragon - thanks for your thoughts! I'm not technically neurotypical (mild high functioning ADHD, seems to be a very common comorbidity in trans women; apparent to me in childhood but not all that impactful; never seemed worth pursuing until later as I had bigger issues, and the prevailing of the time got very weird about other MH diagnoses simultaneously with the GIC gatekeeping dance) but the rest of the assessment seems broadly correct. I suppose the only ones who could tell you would be Drs Bernadette Wren, Russel Viner and Caroline Brain!

It's clear that some of the kids who come to GIDS aren't yet gillick competent, especially at a very young age, and are yet in an extremely high state of distress and desperate for treatment. Trying to be axiomatic about what is an exceptionally sensitive and personal set of circumstances for each person is clearly an approach that is doomed to failure.

Do you agree that, even if you consider it unfit for purpose currently, the service itself -that is, careful, cautious and measured evaluation of childhood gender dysphoria- is clearly necessary, now more than ever? The evidence that GIDS is struggling is surely a solid case for greater resourcing, greater support and wider discussion of the difficulties involved.

I side-eye with intense suspicion any calls to dismantle or restructure it without a clear plan of what that actually looks like in practice, because, well, I know how devious the reactionary forces in our world have become, I know well their strategies for hijacking well-meaning changes like this, and how good they are at hiding behind benign-sounding language and using trojan horse cases to erode funding, support and protections while cynically preying on the understandable fears of people who just want the best for their kids.

@Fitt

I feel dreadfully sorry for Jazz, who appears to be caught up in a path planned for her but not necessarily BY her

Butt's starting post here was all about how great it was that Bell v Tavistick was "out of the way" so that 10 year olds can go ahead unimpeded.

A day later Butt is describing it as being a path a ten year old has been caught up in.

I advise you to re-read what I said rather than what you assumed I said.

the service itself -that is, careful, cautious and measured evaluation of childhood gender dysphoria

www.bbc.com/news/health-51806962

Clinicians reported worries that some patients were referred onto a gender transitioning pathway too quickly.

However, the review heard from several staff that one member of the GIDS leadership, Sarah Davidson, would sometimes refer children for treatment after only one or two appointments.

"Absolutely it should never happen because this is a pathway that will lead to huge, huge changes for this young person, potentially, infertility," one GIDS clinician said.

Such a quick referral, staff claim, could risk putting young people on potentially life-changing medicines who may have been struggling with issues such as their mental health and sexuality.

InvisibleDragon went to great lengths with a fantastic post to emphasise how the service you knew Butterfly is not the service there now and you have completely ignored it. The service itself does not provide the cautious and measured evaluation it should.

Do you agree that, even if you consider it unfit for purpose currently, the service itself -that is, careful, cautious and measured evaluation of childhood gender dysphoria- is clearly necessary, now more than ever?

What is gender dysphoria in children? This is how the DSM-5 defines it:

The DSM-5 defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
3. A strong preference for cross-gender roles in make-believe play or fantasy play
4. A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
5. A strong preference for playmates of the other gender
6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the physical sex characteristics that match one’s experienced gender

www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

I don't see anything there which indicates that children should become lifelong medical patients. 2-6 are all about stereotypes, so any child with these 'symptoms' should be seen as perfectly normal.

1, 7 and 8 are more concerning. Why would a child think they are the opposite sex? A child who is disturbed by their own sexual organs may have been abused. These symptoms all need investigation, but the idea that the most appropriate form of treatment is to become a medical patient for life and require extensive surgery is ludicrous.

The question for me is why are perfectly normal children becoming lifelong medical patients just because they don't conform to stereotypes?

@NotBadConsidering

the service itself -that is, careful, cautious and measured evaluation of childhood gender dysphoria

www.bbc.com/news/health-51806962

Clinicians reported worries that some patients were referred onto a gender transitioning pathway too quickly.

However, the review heard from several staff that one member of the GIDS leadership, Sarah Davidson, would sometimes refer children for treatment after only one or two appointments.

"Absolutely it should never happen because this is a pathway that will lead to huge, huge changes for this young person, potentially, infertility," one GIDS clinician said.

Such a quick referral, staff claim, could risk putting young people on potentially life-changing medicines who may have been struggling with issues such as their mental health and sexuality.

InvisibleDragon went to great lengths with a fantastic post to emphasise how the service you knew Butterfly is not the service there now and you have completely ignored it. The service itself does not provide the cautious and measured evaluation it should.

It was an extremely eloquent and well written post that was enjoyable to read, and I was largely agreeing with it. Not all of it, but the majority of the content. I also appreciated the reference to the blocker study.

I saw and read extensively the various articles about GIDS that appeared last year, alongside the documentation surrounding the Kiera Bell case. Thanks for the link though.

I think this sentence may be the source of confusion:
"Do you agree that, even if you consider it unfit for purpose currently, the service itself -that is, careful, cautious and measured evaluation of childhood gender dysphoria- is clearly necessary, now more than ever? The evidence that GIDS is struggling is surely a solid case for greater resourcing, greater support and wider discussion of the difficulties involved."

I thought the meaning was quite clear, but evidently not, so please allow me the indulgence of rephrasing:

I think it's clear from demand there needs to be a Gender Identity Development Service that performs careful, cautious and measured evaluation of childhood gender dysphoria.

I've mentioned this before, but out of interest I read some old versions of the DSM. What I find striking is the big difference in how trans children were conceptualised back then compared to now. In the 1980s, after a couple of very large long term studies it was settled that the best approach for children unhappy in their sex was to 'wait and see', and to provide appropriate mental health support and counselling. The other model, that of forcing children into stereotypical gender roles was correctly denounced - it was unhelpful and just caused suffering to children for no reason.

What is fascinating to me is that in the 1980s gender dysphoria in children was very much a male child phenomenon - there simply weren't enough female children with the condition to even study it! And these little boys overwhelmingly grew up to be straight, bisexual or gay adults - practically none of them persisted in their gender dysphoria and went on to become trans adults. In fact, in The DSM 3 outright states that there is no such thing as the 'trans child' and that trans adults who claimed to be dysphoric as children were likely engaging in wish fulfilment or confabulation. There was simply no evidence of the trans child to trans adult pathway. Childhood gender dysphoria was a separate condition from adult gender dysphoria!

So in the 1980s and early 1990s, parents were told that their dysphoric child needed nurture and care and would in all likelihood grow out of it and become a gender nonconforming or gay adult. There was no medicalisation. No urgent need to block puberty or socially transition these children.And these kids went on to live happy lives - there is no record that there were swathes of unexplained suicides of kids desperately unhappy to be 'trapped' in the wrong body. So my question is...how on earth did we get from there, to where we are today? In the space of a couple of decades childhood dysphoria has become this urgent mental health crisis that needs life long medical intervention or else the child WILL kill himself (or herself, as is more common now.) Where was this urgent mental health crisis in the 70s and 80s?

So the reason I'm sceptical of GIDS is simply because in the space of a few years childhood gender dysphoria has entirely transformed as a condition. It used to have nothing to do with adult dysphoria. Now we are told that trans children become trans adults. It used to be exceptionally rare. Now it is so common the clinic has 3 year+ waiting lists. It used to be a condition which mainly affected boys. Now it mainly affects girls. It used to be accepted that medicalisation was not necessary and that trans children would grow up to be normal, most likely gay adults. Now medicalisation is THE gold standard treatment and is regarded to be urgent and life saving. Seeing how this condition has transformed beyond all recognition in the space of a few years , I'm very reluctant to say that the medicalisation model is the best route.

It used to be a condition which mainly affected boys. Now it mainly affects girls

And the 4400% increase in girls presenting to gender clinics isn’t matched by the same increase in adult women. I’ve heard people dismiss concerns about the number of girls presenting by arguing that the numbers were always this high, but reduction of the stigma has enabled girls who identify as boys come forward.

So - where is the 4400% increase in transmen presenting to adult gender services? If this isn’t a craze or a trend or social contagion why aren’t hoards of women clamouring for testosterone and “top surgery” to become their true selves in their 40s?

Butterfly
Do you agree that, even if you consider it unfit for purpose currently, the service itself -that is, careful, cautious and measured evaluation of childhood gender dysphoria- is clearly necessary, now more than ever? The evidence that GIDS is struggling is surely a solid case for greater resourcing, greater support and wider discussion of the difficulties involved.

Yes, I do think there is a need for a service that works with children and adolescents with gender dysphoria. The Cass Review has alluded to something like a much less centralised, local service and I think this is broadly a good idea.

(Preface: I'm not a senior person in the NHS or anything so what follows is just the opinion of a random person on the internet, but anyway ...)

One of the issues GIDS (the London clinic plus a satellite centre in Leeds) has is that it is basically the single point of access to treatment for childhood gender dysphoria for all of England and Wales (Scotland has a separate clinic called Sandyford). So they take referrals from everywhere. That worked well when they got a out 50 referrals per year but is totally unworkable now that there are thousands.

In particular, NHS patient notes aren't centralised, so if a patient has a local GP and is under a little cal CAMHS team, I suspect that any notes made by those teams won't fully accessible by the GIDS team and vice versa. There's also a silo effect: GIDS only does gender stuff; local CAMHS deals with any other mental health stuff. This isn't very helpful for the patients, as gender dysphoria and other mental health issues can be very intertwined, so working out the best course of action for an individual child means looking at everything together as well as each individual thread.

I'd like to see individual NHS trusts setting up their own gender services, preferably as a part of a wider CAMHS service. That way, children with dysphoria will be assessed by clinicians who have expertise with a wide range of different mental health presentations and can work holistically with the child (and their family) to reduce distress and to diagnose and treat other mental health difficulties alongside the gender dysphoria. A local service also makes it much easier to make safeguarding referrals if needed, as clinicians only need to be familiar with one local authority system. However, I wouldn't want local services to just replicate the GIDS process - which is why I think they should be part of a larger CAMHS service - so that there is wider oversight and better support.

I'd also like to see a proper clinical trial of public blockers with a control arm and follow up through adult services. Hopefully some other country is already in the process of doing this, because these drugs have been being prescribed without an appropriate evidence base for far too long.

Oh ffs, so many typos.

@InvisibleDragon

Oh ffs, so many typos.

Bloody good post though.

I'd also like to see a proper clinical trial of public blockers with a control arm and follow up through adult services

Something has gone awry when the main treatment for distressed, trans identifying children is medical therapy. What would a control arm look like? Mental health services are stretched everywhere and for many of these children psychology/psychiatry responses are very much that things will improve with hormone treatment, except there’s no evidence that they actually do.

As mentioned upthread, gender clinics have lost sight of how children without gender identity issues also have complicated mental health and behavioural presentations. They also self harm, run away, perform badly at school, demonstrate suicidal ideation and have anxiety and low mood.

The medical approach to these complicated girls has become very simplistic and a control arm of decent psychology is inaccessible to many (expense and access).

The ethics of a study are significantly more complicated now too. Remember originally they had to apply to a different ethics board after being originally rejected. Now, there exists their own study that concluded there was no improvement in psychological functioning. So how can they get ethics approval for a study that tries this again when an uncontrolled study didn’t even show benefits?

The mindset needs to shift completely, from treating puberty as something children can opt out of to something that needs to happen, with the distress it may cause supported in a way that is best evidence-based. The study should be therapy X vs therapy Y in children who are going through a normal and fully required state of physical development.

Very interesting post @WeeBisom thank you.
Are the old versions of the DSM available on line or do you happen to have copies?

It does seem that the medicalisation model has been very much consumer led aided and abetted by big pharma, the internet and other medically non qualified parties.

InvisibleDragon I think you are right about decentralising gender services

It used to be a very niche thing that local services never saw and therefore it made sense to just refer to a tertiary centre but that's no longer the case. Also it got us out of engaging with difficult issues. We are just supposed to check they don't have another diagnosis then refer on to the specialists as 'we are not commissioned' for GID. I also had no relevant training although I think that might have changed now.

For my as a psychiatrist (not a CAMH one) I am very uncomfortable with gender dysphoria. I just don't agree with the underlying assumptions about gender but you are not allowed to be gender critical in today's psychiatry because we are so afraid of another scandal like when homosexuality was classified as a mental illness. It's hard to do anything except affirm for fear of being labelled a bigoted conversion therapist and yet these poor kids are obviously in need of therapy and not hormones as far as I can see.

The long waits with people then self medicating with cross sex hormones and being 'affirmed' by everyone around them into thinking this is what they need are a real scandal. They need early access to therapy from a local service to address underlying issues and only then consider hormones if still needed. The drive to say this is a normal variant and not a mental
illness means it's hard to mandate that people get therapy because so many people believe it's not an illness and we are being asked to sign up to disavowing 'conversion therapy'

Surely in decades to come we will wake up and look back on this as a shameful scandal as we did with hysteria and homosexuality. Psychiatry is very open to being hijacked by cultural values throughout history and used to control 'deviancy' in society you would have thought we would have learnt by now.

Now, there exists their own study that concluded there was no improvement in psychological functioning

That’s not the public’s perception though. Hormonal manipulation is sold as literally life saving. Parents who have made it as far as a gender clinic will believe this and it will have been reinforced by doctors and psychologists along the way. The parents who will consent to a therapy only arm are likely those who are not fully on board the “my child will kill themselves if they go through puberty” narrative. This will act as a confounder in itself.

So many valuable informed posts - thank you WeeBisom and InvisibleDragon for your recent posts.
One thing that struck me from Keira's initial case was the exposure of the levels of pressure from vested interest groups like Mermaids. I assume that it was these influences that generated the dangerous view that the need to safeguard children can be ignored. The compensation paid to Sonia Appleby is stark evidence that this came from the (captured) top of the service.

Thanks, WeeBisom and InvisibleDragon for very well informed and thoughtful posts.

Children and YP need vastly improved mental health services, this gets clearer and more urgent by the day. What worries me wrt dysphoric children is that we appear to be pursuing a course of action that is not supported by evidence or research.

@ArabellaScott

Thanks, WeeBisom and InvisibleDragon for very well informed and thoughtful posts.

Children and YP need vastly improved mental health services, this gets clearer and more urgent by the day. What worries me wrt dysphoric children is that we appear to be pursuing a course of action that is not supported by evidence or research.

And has long term irreversible effects. It wouldn’t be so bad if the treatments didn’t do the harm they did with poor evidence. But we are going to be seeing the consequences of this for decades to come.

On how to ethically do a better trial on blockers, I'm not totally sure. This is partly why I hope there's a trial happening outside the UK, so that data is already being collected.

I also think the two options in the UK need to be blockers as part of a proper trial or no blockers. Continuing to prescribe blockers with no good evidence for efficacy should not be an option. That sounds really harsh (denying access to lifesaving treatment) but, in the absence of good clinical evidence of benefit, it's actually about preventing harm.

Something similar happened with a new drug for Duchenne Muscular dystrophy about 10 years ago: There was a big fanfare about how promising it was and parents were clamouring to get their child access to this wonder drug outside of clinical trials. It then failed it's clinical trials spectacularly and major problems were found with the initial research (not fraud, just mistakes -www.science.org/content/blog-post/ptc-s-latest-ataluren-woes ) . It just didn't work, but people had been desperate to have it and had attributed improved functioning to it.

I'm worried that something similar is happening with blockers - at least for the current cohort of patients. So on the one hand, I want there to be a proper trial that really tests whether they are beneficial once and for all; but on the other I'm asking at what point does the lack of evidence so far make it unethical to keep doing more trials? That's one of the reasons why I'm so angry with the way GIDS has been running: they have had years (and funding) to do this properly and they made a total mess of it. They had an opportunity to really show that what they were doing was effective, but messed it up. That's really failing the patients they are supposed to be helping.

If there was another trial in the UK, one thing that studies do sometimes is a "waiting list" control arm - so some people enrolled on the trial get the treatment immediately, while others get it after a delay. I think something like this could work to get some idea at least of short-term effects.

This is partly why I hope there's a trial happening outside the UK, so that data is already being collected.

There is, but it doesn’t look very good. And the author is trans, which is a conflict of interest in my view.

pubmed.ncbi.nlm.nih.gov/31290407/

I am (cautiously) optimistic that all the publicity about the untested experimental nature of these treatments for children will begin to have an impact. Along with the prospect of court cases and damages against medics who wilfully ignore the complex issues of establishing informed consent for teenagers giving up their fertility and future good health - surely this must make them stop and reconsider?
The recent outrageous evidence in the Webberley case is also very in terms of the lack of records, assessment and diagnosis along with interference from adults with an agenda. Hopefully the GMC are not totally in thrall to the lobby groups and retain some sense of what's ethical and safe for children?
And I have heard from reliable sources that when Hilary Cass says this group of children must get the best possible support and expertise throughout their care, she doesn't mean the interference from self interested adults but is speaking about the quality of medical services.

Now the sunlight has exposed the lack of ethical treatment of children, things will start to change? Hopefully......

I think the main issue is that children, once they hit 12, 13, 14 are encouraged and surrounded by their ‘medicalisation’ and that normal anxiety, normal growing pains, normal identity questioning is rebranded as ‘extreme mental well-being issues”.

Most young teenagers do not need mental health services. Mental health services are not that great either, creaking with years of under funding. Most of what improve mental health for those who do not have a serious disorder (and most children do not) is not therapy or drugs, or radical change - it is the very practical and mundane - eat well, sleep well, exercise, be kind, be aware of social media rabbit holes (and don’t go down them!), explore, have structure, be a good friend…

There is a wealth of evidence of the very real and tangible effects that eating well and exercising, having stability have on mental health and wellbeing.

The kids we always miss on this are those from very chaotic and unstable homes, where abuse of some form is taking place. They absolutely need to be prioritised for intervention, but again it is stability, security that will most impact, not a 6 week course of CBT.

The rush to identifying (as anything) is a negative mental wellbeing risk for most children and young people. Ironically it is the negative mental wellbeing that can result from the charged, extreme and intense focusing in from adults around the child that contributes to mental harm - and this harm is then cited as the reason they need to transition!

@MrsOvertonsWindow Also… I don’t know when the change came about to rush rush kids into transitioning. With the accompanying hysterical they will be damaged forever if they don’t.

I worked with many TW over 20 years ago and most were middle aged. Most had spent many years dressing as a woman, perhaps part-time. And even they had to go through quite a rigorous psychological assessment, and often had to live completely as the gender they wanted for at least a year, in order to even begin to be considered for any medical transitioning. I can’t speak for TWs of course, but everyone I spoke to seemed OK with this, as the drugs and eventually for some surgery, were irreversible. It was a way of ensuring that no psychological damage was done through a rushed decision.

None of those TWs said they were mental damaged by waiting to transition. Which for many of them were 10+ years of thinking about, waiting for.

What suddenly changed that now children who haven’t even begun to grow into themselves, their bodies and their minds, are rushed to medicalisation?

[quote NotBadConsidering]This is partly why I hope there's a trial happening outside the UK, so that data is already being collected.

There is, but it doesn’t look very good. And the author is trans, which is a conflict of interest in my view.

pubmed.ncbi.nlm.nih.gov/31290407/[/quote]
That list of authors is like a who's who of gender evangelists.

Joanna Olson-Kennedy - who thinks it's no big deal for 13-year-old girls to have mastectomies.

Diane Ehrensaft - who thinks that babies can show they're trans by pulling bows out of their hair or unpopping their onesies to make a 'dress'.

Norman Spack - who was 'salivating' when he first heard about the idea of blocking puberty in children.

I accessed the old versions of the DSM via my university library. I don’t think they are available for free online. I spoke to a friend who used to work at the Tavistock and her theory of what happened is just that the medical model became more attractive because it was a lot cheaper and easier. The tavi is actually supposed to be a psychotherapy Center but comparatively little therapy actually takes place. My worry is that transitioning children isn’t actually addressing the underlying mental health issues at all.