6 
Think of the Children
Even people who support trans adults and our medical needs can balk at the idea of the existence of trans children, let alone the fact that they may need medical care. I understand that. If what I knew about the subject came from general reporting, and not personal knowledge, I might be worried, too. There are the attention-grabbing headlines, of course: the ones about “sex changes” for toddlers, and “transgender hormones” for preteens. There’s the incredible increase in the number of young people and their families seeking referrals to gender-identity clinics, and dubious theories as to why that might be. Everyone can remember at least one time when they were young and headstrong and thought they would want something new for ever, only to get bored with it in a week or two. Opponents of trans people capitalize on those memories. It is right that we should be worried about young people, but there is also a danger that those worries could actually be making life harder for the very children in question.
First, some facts: what do we mean when we say trans children, and what do we mean when we talk about treatment?
Crucially, when talking about young people, the term “gender non-conforming” is used, rather than trans. The reasons are twofold: to try to describe without pathologizing or locking into a specific category, and because the children being referred to gender specialists, who are being described, express a broad range of behaviors and reported beliefs about their own selves. A gender non-conforming child could be a child challenging traditional ideas of gender expression: a little boy who is adamant that he wants to wear dresses and be a princess. A gender non-conforming child could also be a child insisting that their gender is different from the one they were assigned at birth: a child who insists that he is a boy, despite being told by everyone else that he’s actually a girl. Or, of course, a gender non-conforming child could be a mixture of these things: a child who knows that they are neither a boy nor a girl, who refuses the sex they were assigned at birth and a host of gendered expectations. Some children and adolescents are clear in naming themselves trans. Others are not: they agree that they are the sex they were assigned at birth, but not to the gendered expectations of what that sex should mean. The main reason this category is so large is because of the various motivations parents have for bringing their children to medical attention. Some parents are concerned that their children are not developing along normative gendered lines, and want that child to be encouraged to change their behavior to better fit societal mores. Other parents seek out a gender specialist because that child is in pain from their bodily dysphoria, and from being classed as the wrong gender. I note these differences here, because they make a big difference to later arguments over some of the most controversial research in the area.
When we talk about treatment what we’re mostly talking about is the emotional and practical guidance families need to help them to support their children, and the counseling and group therapy that may be required to help a child who feels depressed, isolated, and in need of reassurance and care. There are additional options for teenagers and young adults, but emotional support is at the heart of caring for gender non-conforming youth.
A representative of the TransYouth Project at the University of Washington explains:
Our experience is that everyone gets nervous when 5-year-olds are mentioned in the same sentence or paragraph as hormones and surgery—and for good reason. Once again, though, care is needed in interpretation. First, and most critically, the only intervention that is being made with prepubescent transgender children is a social, reversible, non-medical one—allowing a child to change pronouns, hairstyles, clothes, and a first name in everyday life. No one in mainstream medicine (or elsewhere, to our knowledge) is performing surgery on or providing hormones to prepubescent transgender children.
There’s a line I’ve heard from multiple trans people about the double bind of age and the acceptable trans narrative: to get access to treatment as an adult, you have to have known you were trans since early childhood. But if you say that you’re trans in early childhood, you’re told that you’re too young to know.
When we ask trans adults when they first knew that they were trans, the majority will say that they knew as children. They may not have had the words, but they recognized that there was something about them that made them markedly different. Natacha Kennedy of Goldsmiths, University of London, is one of the leading researchers into the experience of gender non-conforming youth, particularly in educational contexts, and into the childhood experiences of trans adults. Her 2012 study, “Transgender Children: More Than a Theoretical Challenge,” cuts deep for me; reading the experiences gathered there was an exercise in old pain. Kennedy found that, while a majority of trans adults become aware of their transness at a young age, an average of eight years old, they were also aware that that knowledge was shameful and needed to be hidden away from their friends and families. Not knowing how to understand their own feelings, many first believed that God had made a mistake, before coming to understand that they must be the ones who are wrong, mistaken. The average time span between realization and verbalization—learning any words other than insults and abuse with which to name the trans experience—was seven and a half years. Before they found that language, the huge majority of respondents felt like they were the only ones in the whole world to feel as they did.
My childhood was atypical in a number of aspects, and I know that the ways in which my parents did gender was one of the main ones. I am so very grateful for that. It’s a standard question to ask: “When did you know?” People ask it of me, and they ask it of my parents. And I think I like my mother’s answer the best: “We were learning as we went along.” But, for far too long, I still felt the shame of being different: a failure, a freak, and alone.
At home I was never made to feel as though there was something wrong about my behavior, or that there was any gendered difference between the expectations placed upon my brother and myself: that we would be kind, and honest, and try our best. So I was allowed to dress up in my father’s clothes, and dress up in my mother’s, and my brother and I pooled a collection of variously gendered toys with which to create elaborate set pieces and storylines. I very much liked shiny, glittery things and pretty dresses, and also being the biggest, strongest kid in the playground who could beat everyone at arm wrestling. When my father went away on business my brother and I would practice shaving our faces with his razors, foam, and cologne. When my father was feeling particularly generous, we would practice face painting on him. I never had the impression that there were things boys should do and things girls should do at home, and when I heard that kind of attitude at school I was outraged. Joan of Arc was my hero, and I had an active fantasy life in which I was transformed into a stern and androgynous warrior with elaborate armor, and a white steed.
It was puberty that let me know that I was trans. First the dysphoria and then, crucially, the lack of any knowledge of people like me, and the societal approbation for all the ways in which I wasn’t “normal.” Between the onset of puberty, at the age of eight, and the point at which I had the beginnings of language about myself, at fifteen, I veered between denial, self-hatred, and terror. It’s a tribute to my family that, alongside all those negatives, I also knew that I was loved, and still believed in their belief in me. It’s a typical and an atypical trans narrative, and it’s for those reasons that I share it. Because many of us did and do know young, and many of us suffer alone, unable to reach out. But also because what we can receive from those around us—unconditional love, unwavering belief—can carry us through to a better future.
By listening to, and believing, the young people who say that they are trans, we have the chance to end that pattern of isolation and self-loathing, to make the experience of being unconditionally loved the norm, rather than the exception. Removing stigma and sharing knowledge is not the same as forcing a label or category onto a young person. And if there are gender clinics willing to help families, and society, toward a place of openness, wisdom, and care then we should all be grateful.
AS TO WHY there are more openly trans young people now than there ever were before, the answer would seem to be obvious. There is constant talk about how society has shifted in terms of trans acceptance, knowledge about trans issues, visibility of trans people. This media moment is a symptom of something much deeper, and more profound: the year-on-year work undertaken by activists working in the fields of health care, legal change, community support, education, and outreach. Slowly, we are (at least in some fields) gaining wider support, a more legitimate voice in a broader culture. In her work, Natacha Kennedy describes the importance of “key words”: words and phrases which allow a young person to recognize themselves and find others like them, unlocking knowledge of trans existence. Is it any wonder that, in a world where trans people are more widely seen and believed, children who may be trans will have earlier access to the words that help them describe themselves?
These cultural shifts do not impact on trans people alone. After all, trans children do not appear out of thin air. A change in parental attitudes would cause a significant change in the recording of numbers of trans youth. Trans people have, historically, been highly likely to experience family rejection and physical and emotional abuse from parents. Homelessness is a serious problem for trans teenagers, and stories of violence are common. What if this shift in numbers is simply this generation of parents doing better by their trans children?
As ever, though, this change can’t happen fast enough. While conversion therapy is fading out of practice in the treatment of trans adults, it’s all too often the first port of call for families looking to have their child “fixed” of their transgressive behavior.
The death of American teenager Leelah Alcorn at the very end of 2014 sent shock waves across social media, following the publication of her suicide note on Tumblr. A trans girl with unsupportive parents, Leelah had been forced into conversion therapy to try to change a fundamental aspect of who she was. Her initial plans to wait it out and transition when she was free of her parents’ control couldn’t withstand the constant pressure to be other than she was. Before taking her own life, she wrote: “My death needs to mean something. My death needs to be counted in the number of transgender people who commit suicide this year. Fix society. Please.”
Leelah Alcorn is one of many. Every trans person I know will have their own stories of suicides in our communities. Many of us will have personal stories to tell of times when death seemed like the only option. Living in a transphobic world is hard on any adult. For an adolescent with no wider support network, subject to constant cruelty at school and at home, the pain can often be unbearable. Conversion therapy can be, is, the final straw.
There are parents like Leelah Alcorn’s who cannot stand to see their child live a truth that runs contrary to their religious or cultural beliefs. They choose conversion therapy in the hope of salvation. Other parents will be driven by a desire to avoid the shame of having a trans child, or by ideological views about gender just as strong as religious fervor.
There are many parents who do not care whether a child is trans or not, but who push for conversion therapy because any behavior which challenges gender norms is an embarrassment, or a threat, to be “fixed.”
And then there are interested observers, outsiders, who, lacking personal experience, support conversion therapy because they believe the widely touted claim that the majority of gender non-conforming youth will never transition, will change their minds of their own accord, and turn out to be, more or less, “normal.”
In this framing, adult trans people are claiming that these young people are also trans to further a political cause or promote an ideology, with no respect for what it is that these kids actually need. UK journalist Julie Bindel has described treatment for trans young people as a form of child abuse. This attitude reminds me of nothing so much as the scaremongering over the myth that gay men, bisexual people, and lesbians recruit children to the “gay lifestyle” because we are sinister, predatory, and, supposedly, can’t have kids of our own.
If that were actually the case, it would be an outrage—but it’s simply not true. It’s an enticing message, playing as it does on preexisting prejudices, but try to find some supporting evidence and you’ll come up cold. American advocate Brynn Tannehill explains:
The most cited study (Steensma) which alleges an 84 percent desistance rate, did not actually differentiate between children with consistent, persistent and insistent gender dysphoria, kids who socially transitioned, and kids who just acted more masculine or feminine than their birth sex and culture allowed for. In other words, it treated gender non-conformance the same as gender dysphoria. Worse, the study could not locate 45.3 percent of the children for follow up, and made the assumption that all of them were desisters. Indeed, other studies used to support this also suffered from similar methodological flaws. As a result, the 84 percent desistance figure is meaningless, since both the numerator and denominator are unknown, because you have no idea how many of the kids ended up transitioning (numerator), and no idea how many of them were actually gender dysphoric to begin with (denominator). When Dr. Steensma went back in 2013 and looked at the intensity of dysphoria these children felt as a factor in persistence, it turned out that it was actually a very good predictor of which children would transition. In other words, the children who actually met the clinical guidelines for gender dysphoria as children generally ended up as transgender adults. Further research has shown that children who meet the clinical guidelines for gender dysphoria are as consistent in their gender identity as the general population.
I consider reparative treatments—which, being based on the combined efforts of caregivers and doctors and/or therapists to try to change a child’s gendered behavior, in my view seeking to shame them into conformity, and to restructure love and support as something conditionally granted in exchange for compliance and denial of self—to be not just harmful for trans youth, not just harmful for all gender non-conforming children and teenagers, but a gross betrayal of the Hippocratic injunction to do no harm. That’s not a medical treatment—that’s brainwashing and emotional abuse.
The alternative to this is what is known as gender-affirming therapy. Texas-based clinical psychologist Dr. Colt Keo-Meier explains:
The gender affirmative model supports identity exploration and development without an a priori goal of any particular gender identity or expression. Practitioners of the gender affirmative model do not push children in any direction, rather, they listen to children and, with the help of parents, translate what the child is communicating about their gender identity and expression. They work toward improving gender health, where a child is able to live in the gender that feels most authentic to the child and can express gender without fear of rejection.
We can support children without pathologizing them, and can allow them to express themselves without external pressure to fit into one category or another. We could show parents how to provide that support, and allowance for exploration, at home. We can organize youth groups and support circles, where children and parents can meet others in similar situations, can reach out and not feel quite so alone.
And for those who need them—and remember that not all trans people need hormones or surgery—we can make sure that age-appropriate hormonal and surgical options are available. This is the particular point that causes so much outrage, so much anger. As ever, the reality is far less frightening than the headline spin. The hormone treatments known as puberty blockers have been in use for a long time, long before they were prescribed to some trans teenagers. The whole point of puberty blockers is that they are reversible; they were developed to treat children who enter puberty at a very young age, to allow them the time to wait and grow and start developing at the same age as their peers at eleven or twelve years old, as opposed to four or five. For trans children who have expressed a deep and persistent need to physically transition, puberty blockers are a godsend: a chance to take the time to explore their options, to settle on what they need, and an opportunity to avoid the psychological and physical agony of experiencing the wrong puberty. When these teenagers are older, around the age of sixteen—the same age at which they could join the army, get married, or create a child—then they can, with close supervision, begin hormone therapy. When they reach the age of eighteen they, like any other adult, can choose to pursue surgery. I cannot see what is controversial about this. It is a careful, conservative approach to supporting those, and only those, who actively seek out medical transition. And, from the research we have, it seems to be working incredibly well.
The most important research to date (there is now a fair amount, all positive) appeared in 2014, a longitudinal study of fifty-five young adults in the Netherlands who had been diagnosed with gender dysphoria and treated under the gender-affirmative model, with the use of puberty blockers beginning around the age of fourteen. Participants went on to pursue surgery, at an average age of twenty-one. At the time of the study, these young people “were no longer experiencing mental health consequences related to gender dysphoria, their quality of life and happiness levels were on par with their non-transgender peers, and none expressed any regret about delaying puberty or transitioning.” A 2015 study from the Rady Children’s Hospital in San Diego found much the same thing. Of the forty-two young people who had sought treatment, including puberty blockers for young teenagers and hormone therapy for older teenagers, none had expressed regret or wanted to stop treatment. Significant improvements to mental health were found across the board.
The research is ongoing; the US National Institutes of Health commenced the largest-ever study of trans youth at the beginning of 2016, which will take at least another six years to complete. We don’t have all the answers yet; as with any evolving aspect of human nature, it is unlikely that we will ever hold all the answers. But we know enough now, after decades of trial and error, personal evidence, and dedicated study, to understand how harmful conversion therapy is, how pointless, compared with the alternatives on offer. If the well-being of our young people is truly our greatest concern, we should follow the research, and not our own fears and prejudices.
STILL, DESPITE THE data, there will be those who believe that this is all too risky, that it’s unacceptable to allow children to pursue any path that they might later come to regret, even if the actual risk of regret seems negligible. From my perspective, this seems to display a deliberate blindness to the wide number of risks we already allow children to take, that we encourage them to take.
There was a moment of risk-taking in my own childhood that I would not have taken if I had known what would follow. But because it was considered a normal level and category of risk there were no warnings, and nobody tried to dissuade my parents from allowing me what I wanted.
I broke my right wrist at the age of eleven, falling off a horse. It was a very bad break, and I was already firmly committed to pursuing a career as a professional pianist; it had been an overwhelming ambition throughout my childhood, and my teachers were both confident in and encouraging of this ambition. I had started riding because that’s what the popular kids did at my school, and I wanted to fit in, to make the children who hated me accept me as one of their own. The children’s ward I ended up in, preparing for and recovering from emergency surgery, had several other patients who had been injured by horses: one young girl, the same age as me, had had her pelvis crushed after the pony she was riding had reared up and fallen on her—she would never be able to bear children. The doctor who treated me told my parents that horse riding was more risky than riding a motorbike, and that he would ban it if he could.
I needed two further operations on my wrist, a handful of invasive procedures under local anesthetic, and years of intensive rehabilitation. Throughout those years, I kept training, kept playing, up until the point where I could no longer move my fingers. I was accepted into one of the most prestigious music courses at a British university—I spent the first two years in a haze of pain medication, depression, and despair. Eventually, after a great deal of uncertainty, time off for treatments, and more time off to recover from those treatments, I regained the limited use of my right hand. It wasn’t enough. Popular wisdom at the time held that trans people on hormone replacement therapy would in all likelihood lose their singing voices completely; my voice was the only instrument left to me. I retrained as a classical singer, at the cost of treating my dysphoria completely. I learned to work around my chronic pain to the point of being able to play simple piano accompaniments, and to work around my dysphoria with non-hormonal treatments and a wonderful support network. Losing both of those dreams at once was, and is, a constant struggle.
Maybe you think that these two examples—of musical vocation, and transition—are incompatible. I do not think that they are. My sense of myself as a musician—the constant internal music playing, the need to express it, the joy of sitting down at the keys and playing without thinking, without being anything but the physical embodiment of something far greater and more beautiful than I could ever hope to be—this is who I am at the core. It is so much more important to my sense of self than my sense of gender, my sexed body, and those things are pretty foundational.
The hypocrisy in telling young people who are genuinely desperate for treatment that it’s too risky for them to have it—even after they have jumped through so many safeguarding hoops—while sanctioning, encouraging, other kinds of risk distresses me. It has everything to do with cultural norms, and nothing to do with keeping children safe while still allowing them their autonomy. We have to move forward from the idea that it is somehow a shame, a failure, for a child to grow up to be trans. We have to start approaching this subject with young people’s best interests at heart, not our own concerns and judgments about how we would want our children to conform. Being trans is not a fate anyone needs saving from. But everyone, every child, needs to be loved for who they truly are, without conditions.