On healthcare for young trans people; There is no magical moment at which a child becomes an adult. No single instant at which we may safely declare that a young person has exited adolescence, and is fully equipped to enter the world of mortgage stress, Saturday morning food shopping and running arguments about the thermostat says Max Morgan
Rather, it is a gradual, imperceptible process of physical, intellectual and emotional growth, a process that varies wildly from individual to individual, until they awake one morning to the bitter realisation that they’ll be lining the pockets of some bastard they hate for 40 hours a week until they’re too old to be considered useful.
It should also be noted that the physical, mental and emotional aspects of development often do not go hand in hand. There are many teenagers who may be physically underdeveloped by comparison to their peers, who are intelligent, politically engaged and emotionally mature. Indeed many, by the age of 16, are more sensible, thoughtful and rounded individuals than some in their early 20s (or even their early 40s, but that’s a whole other article).
As a society, therefore, we impose arbitrary limits on what constitutes an adult. We pick an age at which we think most young people are able to make important decisions for themselves, but even these numbers vary quite significantly from country to country, state to state and region to region.
Taking marriage as an example, in Scotland, a person may consent to this at the age of 16. In England and Wales, it is 18. In some US states, there are no limits at all on the age at which a person may marry, which seems like a thing those who spend their lives insisting they’re ‘protecting children’ ought to be utterly fucking enraged about.
But even before our children reach the age at which we say, “That’s it, you’re on your own,” we entrust them to make decisions that might impact their whole lives. At 14 or 15, they are asked to decide which exams they will sit, which will obviously affect the future exams they are able to sit, the university courses they are able to access, and in turn, the employment opportunities open to them when their education is completed.
At various ages prior to that, they may consent to take part in rugby or martial arts or some other dangerous sport, in which a moment of inattention or bad luck could inflict life-changing injuries. At 17, we will put them in sole charge of several tonnes of fast-moving metal that could end their own life or someone else’s. And spanning right across this ill-defined grey area between childhood and adulthood is the ability to consent to a range of medical treatments.
Gillick competence, a long-standing legal principle in the UK, allows for a child under the age of 16 to receive medical treatment or advice without their parents’ consent, or even knowledge, provided they are considered ‘Gillick competent’ by medical professionals. This principle is accepted and widely applied, mostly successfully, and largely without wider societal protest.
And yet, where healthcare for young trans people is concerned, there are many, from social media trolls to authors of antisemitic children’s books, all the way through to elected politicians, who are willing to abandon this principle in favour of applying a different set of standards to young people whose assigned sex at birth does not match their gender identity. I’m sure I don’t need to point out that choosing to apply a legal and medical principle to all except a particular demographic is Bigotry 101, but for the purposes of clarity, I will do so.
Those who oppose any kind of any kind of gender-affirming healthcare for young trans people will say things like, “Children shouldn’t be making life-changing decisions!” but as I’ve already demonstrated, they do. All the fucking time. A 13-year-old child, for example, may consent to taking contraceptives like “the pill”, side effects of which include headaches, nausea, breast tenderness and an increased risk of life-threatening blood clots, heart attacks and several types of cancer.
A young person who becomes pregnant before the age of 16 may consent to an abortion, an enormously difficult and emotional decision for anyone, but especially a child. They may also decide to carry the foetus to term, which will have some of the most life-changing impacts it is possible to imagine. But we accept – entirely correctly – that if they are aware of the implications of their decision, their wishes should be respected, because it is their body and their choice.
The majority of young trans people, I would contest, are more emotionally mature than their peers. They’ve usually been forced to grow up quicker as a result of the torrents of abuse they face, both in person and via the press and media, simply for being who they are. As such, they are keenly aware of the implications of healthcare for young trans people. They’re aware, not only of the treatment options available to them (or the treatment options that would be available to them if trans healthcare in this country was remotely fit for purpose), but of the side effects, longer term health implications and the potentially harrowing alternatives to not receiving treatment.
They’re also acutely, painfully aware that transitioning will lead to an avalanche of hatred, suspicion, infantilisation and, tragically, as we’ve been heartbreakingly reminded this week, a risk of being murdered for who they are. This is not a decision, in the overwhelming majority of cases, they are taking lightly, or because of some ‘fad’ or ‘social contagion’. It is a thing they do because not doing so – even in this climate of outright hostility towards them – would be so much more damaging.
Before I go any further, it is necessary to point out that, in this country, healthcare for young trans people under the age of 18 NEVER involves surgery. It doesn’t happen. Ever. It is a lie propagated by transphobic bigots who spend way too much time thinking about ‘healthy teenage breasts’. Such surgical interventions may be ‘requested’ at an earlier age in various parts of the UK (though never before the age of 16), but with waiting lists currently running into several years for a first appointment at a Gender Identity Clinic, and the NHS’s steadfast refusal to reduce those times, in practice, it won’t usually happen until a person is well into their 20s.
A young person may request hormone treatment from the age of 16, but again, it is vanishingly rare for them to receive such treatment given the punitive waiting times.
The only healthcare for young trans people available under the age of 16 (again notwithstanding the inordinately long waiting lists) is puberty delaying medication. This type of medication has been used for decades to delay the onset of adolescence in children with precocious puberty. A principal reason they’re prescribed for this condition is because a too-early onset of puberty can be extremely distressing for the child affected, and it would be an act of unconscionable cruelty to needlessly inflict that upon a young person when it can be avoided. Unless they’re trans, of course.
In trans children, this medication works in exactly the same way, to delay the onset of puberty until the child is ready to consent to further interventions. Or sometimes, though much more rarely, until they decide they no longer wish to transition, at which point they can discontinue treatment and go through puberty normally. The treatment is effective, reversible, in most cases safe, and has been shown to markedly improve mental wellbeing.
That’s not to say it’s without side effects – virtually no pharmaceutical intervention is. Some of the more serious side effects may include reduced bone density and, depending on certain other factors, potential impacts on future fertility. These possible complications are not to be taken lightly, but as far as I’ve seen, no one is doing that (though if they are, that’s a separate matter). It is important that these issues are discussed at length with the young person involved – just as it is important for a girl requesting a prescription for the contraceptive pill to be aware of her elevated risk of cervical cancer – and that their progress is continually monitored by endocrinologists and other medical professionals.
Those who oppose this vital healthcare for young trans people will instead advocate for what they call ‘watchful waiting’. They assert that we should monitor the young person through puberty, and wait until they reach adulthood to offer any kind of gender-affirming care. But this is not the neutral act they make it out to be. Yes, puberty blockers have side-effects, but do you know what else has side effects? Puberty.
Forcing a young person to experience puberty that is utterly incongruous to their gender identity is an act of extended physical and emotional torture, inflicting psychological harm from which many will never recover. If you doubt this, imagine you have a cis daughter (or maybe you don’t have to imagine). Now imagine she started growing facial hair, and getting a deep voice, a strong jawline and broad shoulders.
Imagine, if you can, the immeasurable distress she would feel as her body morphs into something that does not match who she knows herself to be. Imagine the daily anguish as she descends into depression, withdrawal and maybe even self-harm. And imagine there was a way you could take away this pain, a relatively simple intervention that, while not without some risk, would alleviate her suffering. Wouldn’t you move heaven and earth to bring her this relief?
This is the grim reality for so many young trans people, who not only have to cope with this indescribable level of emotional and physical pain, but with a society that ridicules, abuses and rejects them. No one – not a single person – is arguing that puberty blockers should be handed out on a whim, but we are arguing that circumstances exist where they are the only intervention that doesn’t constitute an act of wilful cruelty against an innocent young person.
And if you think the intentions of those who oppose this kind of healthcare for young trans people are in any way pure, ask them how they feel about social transition. For the uninitiated, social transition can include measures like changing names, pronouns, clothing and hair to more accurately reflect a person’s gender identity. It involves no surgery, hormones or medical interventions of any kind. In all but a statistically insignificant minority of cases, those who oppose puberty blockers will also oppose this simple act of affirming a person’s gender.
Just as they will oppose provisions in the GRR Bill for 16-year-olds to alter their birth certificate to reflect a gender different to the one assigned at birth.
Again, this administrative measure requires no medical intervention, and may be reversed at a later stage if they change their mind. Had this law been in place in England, Brianna Ghey, the 16-year-old trans girl murdered in Warrington recently after years of transphobic bullying, would at least have had the shred of dignity that will now be denied to her in death. Instead, her death certificate will record that she was a boy, the final abusive act of a society determined to strip trans people of every last vestige of our humanity.
A petition has been started to grant expedited posthumous legal gender recognition for trans people.
Needless to say we fully support this!#DignityForBrianna https://t.co/okyUtNv3uL
— www.TransLucent.Org.UK (@TransLucent_Org) February 16, 2023
If any person opposes these simple, non-medical approaches to affording trans people some basic dignity, it is 100% safe to assume that their reasons for opposing medical care for trans youth are not borne out of anything even approaching altruism.
Of course, there is a longer term consequence to denying healthcare for young trans people, and for those who oppose it, it is an entirely intended consequence. If they force a young trans person through an incongruous puberty, it often makes them much easier to ‘clock’ in later life. It makes them easier to mock for not ‘passing’ to a level they have deemed acceptable. It makes them easier to fear-monger about because they don’t look the way our hostile society has decided they should look.
Denying this basic care is a deliberate act, designed to double to the abuse and humiliation trans people face, carefully crafted to ensure they will never know a minute’s peace at any stage of their lives.
Opponents will also point to those who go through some measure of gender transition (to whatever degree) and later choose to reverse that: so-called ‘detransitioners’. These people, they assert, are undeniable proof that we should withhold gender-affirming care for as long as possible, with some even arguing that no such care should be available until the age of 25 or 26, when the brain is ‘fully developed’.
Once again, I’m almost certainly stating the obvious here, but it is preposterous and inhumane to suggest that, for virtually every other purpose, a ‘competent’ person is able to give informed medical consent from as young as 13, that every other person in the country is fully and completely an adult by the age of 18, but that trans people must wait until they are halfway through their twenties to be able to even begin to live as the person they know themselves to be.
It is also worth noting that, of those who do end up detransitioning, a large percentage will do so not because they aren’t transgender, but because of any number of other factors including lack of funding, rejection from family, and feelings of being unsafe in the current trans-hostile environment. The actual regret rates for gender-affirming interventions are comparatively minuscule (by most estimates between 1 and 2% of the overall number, not just those who detransition), and significantly lower than virtually any other treatment you might care to name, including abortion, breast augmentation and various types of cancer treatment.
Those who do choose to detransition, for whatever reason, deserve to be treated with all due respect and dignity, but they should not be used as a means of denying care to the huge majority who report enormous, life-saving benefits.
Healthcare for young trans people, like any other measure that can impact a child’s development or sexual health, is a complex area of medicine that should be approached with care, understanding and love. But for too long, discussions around it have been plagued by lies, fear-mongering and dehumanising terms like ‘mutilation’ and ‘sterilisation’. The suggestion that young people are being ‘rushed into’ medical interventions, given the aforementioned years-long waiting lists, are as ridiculous as they are dishonest.
Those who advocate for healthcare for young trans people are not ‘groomers’ or ‘predators’, they’re invariably people who have suffered the alternative and don’t want to see that torture inflicted on anyone else. They’re parents who have to watch their children grow ever more distressed and isolated, laying awake at night worrying about what they’ll do to themselves if they don’t receive help. They’re medical professionals who have seen, first hand, the transformative impact gender-affirmative medicine can have on a previously depressed, withdrawn and anxious young person.
The time is long overdue to approach healthcare for young trans people with the same level of openness, honesty and compassion as any other. We need to accept that young people have widely differing rates of emotional maturity, meaning that any kind of blanket approach is inherently flawed. We need to start believing that a child who is old enough to consent to contraception, abortion or child birth, is old enough to delay the onset of a potentially traumatic puberty until they reach the stage at which other treatments are appropriate.