A History of Affirmation

  • Post author:
  • Reading time:43 mins read

A huge thank you to SunMum, a Bayswater Parent who has researched and recorded this history of the affirmative approach to treating gender confusion in young people emerged in the latter half of the 20th century.

How did the affirmative approach to gender dysphoria take root and why is it dangerous?

This article traces the changing response of parents and professionals to gender non-conforming or to gender dysphoric children and young people in the US and the UK since the 1960s. It shows that the ‘affirmation approach’ which evolved around 2006 in the US and spread to the UK was driven as much by parents and support groups who enlisted media support as by medical evidence. This article traces the US story first before moving to discuss UK provision because the US model of private medical provision differs from the NHS and offers a more comfortable environment for gender medical care. The history is also different in relation to boys and to teenage girls: the affirmation approach to gender identity evolved as a response to little boys who are extremely feminine and was later adapted to cater for the rising number of teenage girls who believe they are boys. Since 2012 there has been an exponential growth in gender dysphoria amongst young people in developed countries.(Butler et al., 2018) The numbers of parents who have joined the Bayswater Support Group since 2019 are one indication of this change.

One explanation is that we are witnessing a ‘culture-based syndrome’ – a new way of understanding and expressing distress that is a product of a particular culture at a particular time.(Hacking, Ian, 1998; Showalter, Elaine, 1997) Another theory is that trans children have always existed. (Gill-Peterson, Julian, 2018) All that was lacking, goes the argument, was the language to express this experience and the medical interventions to allow children and young people to express their true selves. A Gendered Intelligence Instagram post from 2020 denies that gender dysphoria has a history with the claim that ‘we’ve always been here, authentically divine’.

From the Instagram account of Gendered Intelligence

Bayswater parents may wonder if this is true.

Affirmation in the US

i. 1960s and the alteration of intersex bodies.

Until the 1960s, ‘gender’ was a word which belonged to linguistics, used to describe the feminine and masculine by changed word endings. The extraordinary rise in cultural interest in gender can be traced to the mid 1950s when psychiatrist John Money was working with intersex children. Advances in endocrinology and surgery allowed doctors to intervene to alter the bodies of those born with disorders or differences of sexual development. (Intersex activists have subsequently campaigned to stop these early medical interventions in children’s bodies.) These new technologies brought with them a need for terms to describe a subjective sense of the self as a sexed being that was not derived from the evidence of the body.(Hausman, Bernice L., 1995, pp. 72–79) In 1955 Money coined the terms ‘gender role’ and ‘gender expression’ as he struggled with the new task of assigning sex at birth in relation to intersex infants. Psychoanalyst Robert Stoller added the term ‘gender identity’ in 1964 to describe:

a complex system of beliefs about oneself: a sense of one’s masculinity and femininity. It implies nothing about the origins of that sense (e.g., whether the person is male or female). It has, then, psychological connotations only: one’s subjective state. (Green, 1992)

But this was also a homophobic period and medical decisions were constrained by social attitudes. In 1965, when John Money named and opened the world’s first ‘Gender Identity Clinic’ at Johns Hopkins university, Time Magazine published an article called ‘Psychiatry: Homosexuals Can Be Cured’. Although Money was a sexual liberal, his overriding consideration when treating intersex patients was to achieve a heterosexual outcome. If it seemed likely that an intersex patient might be ‘psychologically a homosexual female’, Money and colleagues chose medical interventions to make her male. By doing so, as Money put it, ‘the perversion socially ceases to exist.’ (Hausman, Bernice L., 1995, p. 99) A heterosexual outcome was more important to Money than the preservation of fertility.

ii. The problem of the “sissy boy”

In the early 1970s, John Money’s student and co-author, Richard Green, embarked on a prospective study of what he described as ‘sissy boys’. These were boys who

liked to dress in girls’ or women’s clothes. They preferred Barbie dolls to trucks. Their playmates were girls. When they played “mommydaddy” games, they were mommy. And they avoided rough-and-tumble play and sports, the usual reasons for the epithet “sissy.” 

The results, published in 1987 as The “Sissy Boy Syndrome” and the Development of Homosexuality, showed that feminine boys were ‘far more likely to mature into homosexual or bisexual men than are most boys.’ (Green, Richard, 1987)

Richard Green

For explicitly Christian psychologists such as George Rekers, this was a reason to intervene: in Growing Up Straight: What Every Family Should Know About Homosexuality and Shaping Your Child’s Sexual Identity (both 1982), Rekers explored behaviour modification techniques to try to change gender expression in feminine boys and so to prevent the development of adult homosexuality. (There was media interest in 2010 when Rekers was found to have employed a male prostitute as companion for a two-week holiday in Europe).

iii. 1980: Gender Identity Disorder of Childhood.

But social attitudes were changing and in 1973, homosexuality was removed from the US psychiatric bible, the Diagnostic and Statistical Manual of psychiatric disorders (known as the DSM). Although adult homosexuality was no longer a disorder, a new diagnosis of ‘gender identity disorder of childhood and adolescence’ (GIDC) was introduced in 1980. Some saw this as an attempt to treat pre-homosexual behaviour in children before it could develop – a means of pathologizing the childhood form of a behaviour that was no longer considered to be a disorder in adults. This allegation was rejected by Kenneth Zucker, who had drafted the diagnosis and whose Toronto clinic had from the 1970s encouraged children to become comfortable in their natal bodies and to adopt forms of gender expression that allowed them to function socially.(Zucker & Spitzer, Robert L., 2005) Zucker’s clinic was relaxed about adult sexual orientation.

In 1998, the mother of a gay son called Catherine Tuerk formed a support group in Washington for parents of gender variant boys which aimed to ‘fully affirm and celebrate the child.’ (Tuerk, 2011) This was the first appearance of affirmation. But at this stage most parents believed that their gender nonconforming boys would become gay not transsexual.

Catherine Tuerk

Tuerk ‘thought that expression of feminine interests was part of the normal childhood development of many gay men.’ But she ‘was also sensitive to the social environment of homophobia and heterosexism, and the prevalent belief that allowing a boy to openly express his femininity would stigmatize him.’ Children were helped to understand ‘the harsh realities of societal intolerance’ and were discouraged from cross dressing in public. Parents found ‘safe places for the full expression of gender variant behavior, primarily in the home.’(Tuerk, 2011) Tuerk felt there was a difference between ‘the theatrical fun of gay boys playing dress-up and the stressful attempts of transsexual boys, who believed they were girls, presenting as their correct gender.’ Those who would later want to transition, she argued, concealed this desire beneath childhood gender conformity.

iv. 2006: The birth of ‘affirmative support’

By 2006 it seemed as if gender nonconformity was on the way to being accepted and researcher Karl Bryant detected:

the beginnings of a cultural shift in the mental health professions vis-à-vis the meanings attached to childhood gender variance. It is this cultural shift that holds the most promise for generating new models of affirmative support for gender-variant children.(Bryant, 2006)

By ‘affirmative support’, Bryant meant the new tolerance for the femininity of boys who might grow up to be gay.

But a different cultural shift that Bryant had not detected was already under way. In 2006, according to Catherine Tuerk

a trend began as more parents within the listserv felt their sons were transsexual girls rather than gay boys. This trend was initiated and supported by the intense interest in stories in the media of children beginning gender transition at early ages.(Tuerk, 2011)

(It’s interesting that Tuerk uses the word ‘trend’ here). What was changing was not the behaviour manifested by children but the way this was interpreted by parents.

See Tom be Jane by Julia Reishel
The Village Voice

We can see an example of this new approach in an article from May 2006 by journalist Julia Reischel which appeared in Village Voice. The article, which makes fascinating reading now, described the ‘Anderson’ family: a five-year-old boy called ‘Nicole’ and mother ‘Lauren’.(Reischel, 2006) Catherine Tuerk explains that this was the first pseudonymous account of the child who would gain fame under a different pseudonym as Jazz Jennings.(Tuerk, 2011, p. 772) Lauren, the mother, had noticed that “As a young toddler, he wouldn’t let me snap her onesies together because she wanted to wear a ‘dwess’ like his sister.” (Reischel points out that the mother shifts pronouns mid-sentence). At the time, Lauren thought that her three-year-old son’s insistence that he was a girl was ‘just a phase.’ But her paediatrician took it seriously and so Lauren turned to ‘her college copy of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and discovered “Gender Identity Disorder.”’

Lauren is typical of the new trend in her belief that her feminine son was transgender, not gay. Reischel points out that this was a minority view at the time:

Some therapists insist that such children should be discouraged from living as the opposite sex because, they have found, the large majority of such children grow out of it. Studies show that many end up as gay adults. But a growing coalition of therapists, scientists, and activists disagree and refer to such children—even those as young as three years old—as transgendered, insisting that the child’s new identification shouldn’t be discouraged.(Reischel, 2006)

Reischel reports Kenneth Zucker’s concern that the family might ‘have been swayed by an activist transsexual agenda and are ignoring the possibility that Nicole might simply be a troubled child.’(Reischel, 2006) In 2004, when her child was just three, Lauren consulted a psychologist who told her (after a one hour consultation) that: “Nicholas is a transsexual who wants to be a woman.” To help Lauren with this news, the psychologist introduced the family to a male-to-female transsexual who had transitioned after fathering three children.

In 2006, when Nicole was five, the family contacted Mark Angelo Cummings, a female to male transsexual who was on television to plug his new memoir, The Mirror makes no Sense. Cummings decided that Nicole ‘should become a poster child for childhood transsexuality and should be protected at all costs from scientists like Zucker, whom he compares to Hitler’. Nicole would be ‘a central part of his mission.’

We know how things turned out: under the name of Jazz, Nicole did become ‘a poster child for childhood transsexuality.’ Her puberty was blocked and she underwent three operations for genital surgery before she was 18. In 2015, activists achieved their aim of having Kenneth Zucker (who had drafted the most recent DSM gender dysphoria diagnosis) fired from his clinic at the Toronto Centre for Addiction and Mental Health [CAMH]for failing to follow the ‘gender-affirmative approach’.(Singal, Jesse, 2016) Kenneth Zucker was later cleared of the charges and received substantial compensation. CAMH apologized ‘without reservation to Dr. Zucker for the flaws in the process that led to errors in the report not being discovered and has entered into a settlement with Dr. Zucker that includes a financial payment to him.’(Canadian Broadcasting Corporation, 2018) And in 2019, a (temporarily) detransitioned Mark Angelo Cummings appeared on YouTube as Maritza Cummings to argue against the medical transition of children. (Boyce, Benjamin, 2019)

v. The Advent of Puberty Blockers

Reischel’s 2006 article also mentions a new medical approach to childhood gender dysphoria: ‘Nicole will have no need for medical intervention for years’, she writes, ‘—until puberty will begin to ruin her girlish figure. But eventually, she may consider taking hormone blockers to prevent masculinization and then eventually begin to take feminizing hormones.’(Reischel, 2006) This was the year that the Amsterdam gender clinic published a landmark medical paper which described 54 patients who had been given GNRH agonist drugs to prevent the physical changes of puberty. (Delemarre-van de Waal & Cohen-Kettenis, 2006) This article established what became known as the ‘Dutch protocol:’ ‘puberty blockers’ at age 12 followed by cross sex hormones at 16 with surgeries available from 18. The fact that one patient died due to necrosis following genital surgery did not dampen enthusiasm for this medical intervention. In the US doctors adapted this approach to offer puberty blockers as soon as a child reached Tanner stage 2 of puberty, even if this meant medicating a nine-year-old, under the tagline ‘stages not ages.’ There was a new urgency for medical intervention as children had to be treated before puberty changed their bodies. All the elements that were to cement the idea of the transgender child were now in place.

vi. Affirmation by Media

The plan to turn Nicole into a ‘a poster child for childhood transsexuality’ kicked off the next year, 2007, when ‘Nicole Anderson’ became ‘Jazz Jennings,’ the six-year-old star of a Barbara Walters documentary called ‘My Secret Self: A Story of Transgender Children.’

“Jazz is transgender and one of the youngest documented cases of an early transition from male to female” says Barbara Walter. “From the moment he could speak Jazz made it clear he wanted to be a girl. At only 15 months he would unsnap his onesies to make it look like a dress.” This was affirmation by media – the public recognition and transmission of the idea of the transgender child. As medical historian Edward Shorter argues, patients draw on “the symptom pool” – the array of symptoms that their culture recognises:

Patients want to please doctors, in the sense that they do not want the doctor to laugh at them and dismiss their plight as imaginary. Thus they strive to produce symptoms the doctor will recognise.(Shorter, Edward, 1992, p. 1)

Parents like Lauren Anderson/Jeannette Jennings turned to the DSM to find a diagnosis and their response to this new ‘disorder’ was shaped by adult transgender activists. A boy who wanted to wear a tutu was now self-evidently a transgender child making a gender statement.

Doctors were ready to solve this newly defined problem by means of medication. In 2007, the same year that Barbara Walters interviewed Jazz Jennings, a Boston endocrinologist called Norman Spack opened the GEMS (or Gender Multispecialty Service) at the Boston Children’s hospital, the first US gender clinic for children. And that year too, the Harry Benjamin International Gender Dysphoria Association was renamed the World Professional Association for Transgender Health with activist Stephen Whittle as the first non-medical President at the head of the organisation. The fusion of activist and medical interests was complete as the new organisation sought to export a US approach to medical intervention across the world.

vii. Activist clinicians

Instead of specialists (like Kenneth Zucker) working in an esoteric field, a new breed of activist clinicians saw themselves as campaigners on behalf of a marginalized population. Norman Spack spread the word through inspirational TED talks which advertised puberty blockers in 2013 and 2014 . At a 2016 conference in the UK organised by the trans support group Mermaids (of which more later), Spack ‘led his audience in an impromptu rendition of “The Times They are a-Changin” in honour of Bob Dylan’s Nobel Prize – but also to highlight the generational shift in attitudes toward gender identity that we are witnessing: “Come senators, congressmen please heed the call… There’s a battle outside raging…”’(Adams, Tim, 2016)

But first the diagnosis of gender identity disorder had to be changed. In 2012, psychologist Diane Ehrensaft proposed that ‘the only diagnosis relevant and supportive of gender nonconforming and transgender children is gender dysphoria, a felt stress or distress about one’s gender placement or identity’.(Ehrensaft, 2012) Whereas Kenneth Zucker compared gender identity disorder to racial identity disorder – a cognitive error, Ehrensaft saw ‘transgenderism as akin to homosexuality’ and equally worthy of affirmation.(Spiegel, Alix, 2008) The 1980 diagnosis of Gender Identity Disorder of Childhood was replaced by ‘Gender Dysphoria’ in the fifth revision of the DSM the following year, becoming a condition which was not a pathology but required medical intervention.

Many of the activist clinicians had a personal stake in the issue. Diane Ehrensaft was the feminist mother of a gender-nonconforming son who had written her dissertation on “Sex role socialization in a preschool setting.” Like Catherine Tuerk, she recognised that some gender nonconforming kids may grow up to be gay, but she also believed that ‘transgenderism, as homosexuality, is rooted in complex biological factors that exist at birth.’(Ehrensaft, 2011, p. 533) She wrote that ‘the original kernel of the true self is evident at birth.’ The job of the parent is to ‘allow the child’s authentic self to emerge.’(Ehrensaft, 2011, p. 533)

In 2008, Zucker’s approach was commonly accepted in the US but by 2015 Ehrensaft’s affirmative approach was dominant, popularised through her books for parents Gender Born, Gender Made (2011) and The Gender Creative Child (2016). Ehrensaft believes that parents can confidently distinguish between children who will persist in their cross-gender identification and those who will desist.(Ehrensaft, 2016, p. 53)

Once again, you’re talking apples and oranges, and we can tell the apples (the transgender children) from the oranges (the gender-nonconforming but not trans kids), sometimes as early as when they are three years old. So, why hold the apples back if they already know who they are? Oh and by the way, besides the apples and oranges, each of whom need different things from us, we’ve run across the fruit salads – children and youth with a mèlange of gender expressions and identities that are more than just gender-nonconforming but different from transgender. (Ehrensaft, 2016, p. 55)

Ehrensaft’s folksy style offers certainty and optimism. Today she is director and chief psychologist for the University of California-San Francisco children’s hospital gender clinic, and an associate professor of pediatrics. She is also on the board of Gender Spectrum, a San Francisco Bay area organization which campaigns for transgender and gender diverse young people. She has become an evangelist for the affirmative approach, recycling stories from journalism and media as if they carried medical authority. Addressing an audience of clinicians in 2016, Ehrensaft claimed that it was possible to detect gender identity in a pre-verbal child. Her evidence comes from the Barbara Walters’ 2007 documentary (a story that Reischel had told the year before in the Village Voice). This is what Ehrensaft said:

So you look for those kinds of actions….like tearing a skirt off. …There was one on that Barbara Walters special, this child wore the little onesie with the snap-ups between the legs. And at age one would unsnap them to make a dress, so the dress would flow. This is a child who was assigned male. That’s a communication, a pre-verbal communication about gender.

In this specialism, media stories become clinical indications and journal articles are recycled as personal testimony. In 2011, sociologist Tey Meadow described meeting Michelle, the mother of a 12 ½ year old natal boy called Willow who identified as a girl:

Michelle recounts a conversation she had with Willow shortly before our interview, in which Willow told her she’d known she was a girl since she was two. Michelle asked, ‘What is it that tells you that you’re a girl? Is it your brain? Is it your heart? What is it that tells you?’ Willow replied, ‘Mommy, it’s my soul. My soul tells me I’m a girl, deep down where the music plays.’ ‘To me,’ Michelle says with a smile, ‘That was very profound.’ (Meadow, 2011, p. 740)

This story was retold by trans psychologist Hershel Russell in a 2017 TV documentary with the sex/gender reversed and the age reduced. Russell tells the interviewer:

‘a mother of a gender diverse kid asked her 8-year-old “so come you know that you’re really a boy?” and the child said “I know way down deep where the music plays. And I think that’s so precise, it’s non rational, it’s profound, it’s beautiful, it’s deep. That’s how we know what gender we are and very young children know that.”’(Berk, Alex, 2017) (5:58)

Johanna Olson Kennedy is another activist clinician who has shaped the treatment of children with gender dysphoria. In 2019 she explained that ‘we are storytellers […] we talk fast and we tell lots of stories because they’re helpful for teaching us.’ (Olson-Kennedy, 2019) These are doctors as the purveyors of folk wisdom. Olson-Kennedy met her husband, trans man Aidan Kennedy, in 2011 at a conference where she was presenting a paper on transgender adolescents.(Olson, Johanna; Forbes, Catherine; Belzer, Marvin, 2011) In 2018 she dismissed the concern that an adolescent might later regret a mastectomy with the words: “Here’s the other thing: if you want breasts at a later period in your life, you can go and get them!”(Anon, 2018)

viii. The Triumph of Affirmation

In 2018, Ehrensaft’s ‘gender affirmative’ model became the official policy of the American Academy of Paediatrics (the AAP) in a statement called ‘Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.’ (Rafferty, Jason & COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS, 2018) This document assumes that biological sex is culturally assigned while gender identity is:

A person’s deep internal sense of being female, male, a combination of both, somewhere in between, or neither, resulting from a multifaceted interaction of biological traits, environmental factors, self­-understanding, and cultural expectations

A child’s account of their gender identity is held to be reliable whatever their age or developmental stage because even ‘children who are prepubertal and assert an identity of TGD [trans gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance.‍’ (Rafferty, Jason & COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS, 2018) This document echoes Ehrensaft’s claim that ‘children are the experts of their own gender self, and, at most, we adults are their translators – striving to understand what they are telling us about their gender in words, actions, feelings, thoughts and relationships.’ (Ehrensaft, 2016, p. 16)

ix. Proliferating gender clinics

As the affirmation approach became embedded in US culture, demand for medical intervention soared. By 2015 there were 50 gender clinics for children in the US. (Ehrensaft, 2016, p. xv) The US Human Rights Campaign provides a map of ‘clinical care programs for gender nonconforming children’.

Users are asked ‘Please send us feedback if you find any of these facilities less than affirming and welcoming.’ Time magazine (which had touted a ‘cure’ for homosexuality in 1965) announced the ‘Transgender Tipping Point’ in 2014 with a cover story on trans actor Laverne Cox. By 2019, Olson Kennedy’s Los Angeles clinic had ‘1400 active patients’ aged from ‘3 to 25’. Referrals, she said, ‘might be levelling off around 250/275 referrals a year.’ Her explanation follows the back to front logic of projecting numbers of referrals from a guessed prevalence:

Remember we live in a giant city – there are of 2.6 million young people under the age of 18 just in Los Angeles. So recent provenance data about trans experience is about 1.6, 1.7 %. I don’t like doing math too much so I’ll cut it about 1.0%. So that means 26,000 young people under 18 could potentially need medical services in Los Angeles.(Olson-Kennedy, 2019)

2. Affirmation in the UK

i. NHS care of gender dysphoria

The first UK service for children, the Gender Identity Disorder Unit (later Gender Identity Development Service) opened in 1989, a year after the first children’s gender clinic opened in the Netherlands. The interest of the founder, Domenico di Ceglie, was sparked by encountering a female teenager who ‘was claiming that she was a boy but in a female body’ early in the 1980s. (Di Ceglie, 2002) Di Ceglie set out to understand this puzzling case by reading work by Robert Stoller, the inventor of the concept of ‘gender identity’. At a conference in 1987, Di Ceglie met Stoller who encouraged him to open a clinic for children with this rare condition. In its first year of operation there were only two referrals.

But the service has grown in size rapidly over the last thirty years. In 2009-10, the year the service was nationally commissioned (and Polly Carmichael took over from Domenico di Ceglie as director), there were 97 patients referred to the service. Referrals have risen ‘exponentially’ since 2011. (Butler et al., 2018). In 2019-20 there were 2728 referrals to the service from England, Wales and the Republic of Ireland. (GIDS does not serve Scotland which has its own service based at Sandybanks, Glasgow). The rise in referrals has never been explained, indeed NHS clinicians appear to forget their earlier authoritative pronouncements on rates of transgenderism in a population: in 2011, James Barrett, the lead clinician at the NHS adult gender clinic at Charing Cross (which opened in 1967) claimed that:

the incidence of transsexualism is very roughly 1 in 60000 males and 1 in 100000 females, and it seems to have remained constant.(Barrett, 2016a, p. 381) 

When numbers were tiny, the rare disorder could be left to the intuition, or clinical judgement, of adventurous clinicians. Barrett likes to compare gender medicine to the Australasian platypus – an animal which no one knew how to categorise:

In the end, it was all solved by everyone admitting that the Platypus was real, important, couldn’t be dismissed and didn’t fit any existing category very well. It got its own, special category where it has paddled, very happily, ever since, albeit joined by echidnas and some long-extinct fossilised forebears.(Barrett, 2016b)

Gender medicine developed as a kind of craft, with experts sharing notes amongst a small professional group. The Tavistock Gender Identity Development Service (as it was soon renamed) organised a conference in 1996 to share knowledge. The resulting book includes chapters on ‘Child sexual abuse and gender identity development’, ‘Associated psychopathology in children’ (by Kenneth Zucker), ‘The complexity of early trauma’ and ‘Gender identity development and eating disorders’ as well, of course, as a review of the evidence on ‘Some developmental trajectories towards homosexuality, transvestism, and transsexualism’. (Di Ceglie & Freedman, 1998) It is clear from this volume that like Kenneth Zucker in Toronto, clinicians at the Tavistock approached cross sex identity in childhood as a disorder which might have a range of outcomes, including adult transition. The service started from a psychodynamic perspective which was respectful and accepting of a patient’s gender identity while it made no assumptions about the stability of the identity or the appropriate outcome. The approach was called ‘watchful waiting.’

ii. Support groups and the push for medication.

But from the start, there was conflict between professionals and support groups. Concerns raised by a staff whistle-blower in 2005 led to the commissioning of an internal report which noted that ‘the service was coming under pressure to recommend the prescription of drugs more often and more quickly, and that the independence of professional judgement was also coming under increasing pressure.’ (Taylor, 2006) Di Ceglie wrote that he ‘felt under extreme pressure to join one group or the other.’ (Di Ceglie, 2018) In 2005, the service still followed clinical guidelines which insisted that children must complete puberty (Tanner stage 5) before being prescribed hormone blockers. (Biggs, 2019) But that year two parent led organisations, the Gender Identity Research and Education Society (GIRES) and Mermaids organized a symposium to press the NHS to offer early physical intervention.

Things began to change in 2009 when Polly Carmichael took over as Director of the GIDS. Under the guise of the Early Intervention study, puberty blockers were offered from ‘age 12 and above’ in 2011. From 2014, age was replaced by ‘stage’ and blockers became available from Tanner stage 2, potentially as early as age 10. This experimental treatment was effectively halted at the end of 2020 when the High Court ruled that children under 16 were highly unlikely to be able to give informed consent for the intervention. The results of the Early Intervention Study which were published in early 2021 were inconclusive.(Carmichael et al., 2020)

iii. The role of support groups

In the UK, as in the US, parents who believed that their children were transgender and required medical intervention have been powerful lobbyists, especially through support groups. Mermaids started in 1994 as a support group for parents of children attending the GIDS and to start with it echoed the official GIDS approach. In 2000, the Mermaids website said this:

Gender Identity Disorders in infancy, childhood and adolescence are complex and have varied causes: in the majority of cases the eventual outcome will be homosexuality or bisexuality, but often there will be a heterosexual outcome as some gender issues can be caused by bereavement, a dysfunctional family life, or (rarely) by abuse. Only a small proportion of cases will result in a transsexual outcome.’ (Mermaids, 2000)

Susie Green contacted Mermaids in 1999 when her son Jack was aged 6. Like Jeannette Jennings, Green socially transitioned her feminine son. But as Jackie, the child encountered bullying at school and made a series of suicide attempts, a story that Susie Green has shared repeatedly. In 2005, Susie took 12-year-old Jackie to Boston to be treated by Norman Spack. A Mermaids presentation from about 2007 tells the story of ‘Denis/Denise’ who was refused endocrine treatment in the UK and instead travelled to the US to be treated by Norman Spack.

The case of ‘Denis/Denise’ from a Mermaids presentation

Jackie would go on to undergo genital surgery in Thailand on her sixteenth birthday.

Like Jeannette Jennings, Susie Green courted publicity for her transitioning child. In 2012, 18-year-old Jackie Green featured in ‘Transgender Teen Beauty Queen’, a BBC documentary which followed her entry for the Miss England contest. The story of a feminine boy who knows he is a girl was fictionalised in 2018 in the ITV drama Butterfly starring Anna Friel.

Anna Friel and Callum Booth-Ford in BBC Drama Butterfly

The programme carries Mermaids branding in some scenes.

Mermaids is now fully committed to an affirmation approach and to early medical intervention. Under Green’s leadership, Mermaids has argued that affirmation is the only way to prevent suicidality in gender nonconforming young people. On “World Suicide Day’ in 2019 they issued an Open Letter calling for ‘Change now to save transgender children from suicide:’

For the happiness and safety of our service users, we call for affirmative care to be a requirement in both guidance and law. It is nothing short of a national scandal that the current system is leading smart, talented, creative, motivated, kind and loved young people to consider ending their lives.

The claim that puberty blockers reduce suicide is unfounded. (Biggs, 2020) We know that people with gender dysphoria commit suicide at an elevated rate both before and after social and medical transition. But we do not have the evidence to be sure that transition is beneficial. In 2017, GIDS director Polly Carmichael said: ‘the truth is we have very little published long-term outcome data.’

iv. The first ROGD teen?

On both sides of the Atlantic the campaign for affirmation was led by the mothers of feminine boys who believed that their sons were transgender. Teenage girls with gender dysphoria began to dominate the activist and the media agenda in the second decade of the twenty-first century when girls rather than boys fuelled the exponential rise of referrals to gender clinics across the developed world.

Channel 4 Documentary ‘The Boy who was Born a Girl’

One of the first to attract media attention was Natasha Edwards who joined Mermaids at the end of 2008, along with her mother Luisa. Soon after they joined, a filmmaker called Julia Moon contacted the organisation looking to record the transition story of a child. Luisa and Natasha/Jon answered her call and the film ‘The Boy who was Born a Girl’ aired on Channel 4 in April 2009. A book by Jon and Luisa Edwards followed in 2013 and it makes fascinating reading.(Edwards, John & Edwards, Luisa, 2013, p. 200)

The book opens with the claim that ‘Each year 100 children and adolescents in the UK are affected by gender dysphoria’. But referral rates were about to change dramatically. By 2012 girls had overtaken boys and by the end of the decade girls made up three quarters of the children arriving at the GIDS.

Graph from Transgender Trend.

Unlike the feminine boys who had established the figure of the transgender child in the popular imagination, these girls often had no gender issues in childhood. In 2015, Bernadette Wren, Head of Psychology at the GIDS, told the Parliament Trans Equality Inquiry of a surprising new phenomenon ‘that many of the young people, and increasing numbers of them, have had a gender-uncontentious childhood, if you like, and it is only when they come into puberty and post-puberty that they begin to question.’(UK Parliament, Women and Equalities Committee, 2015) Natasha Edwards describes her early childhood as ‘a very “normal” one’, ‘Nothing whatsoever to suggest any inner boy, nothing out of the ordinary from any other little girl’s childhood’.(Edwards, John & Edwards, Luisa, 2013, p. 13) At primary school, she recalls:

I wore dresses in the summer and I remember loving the costumes that my grandma, a brilliant seamstress, made me for the days when you could dress up as your favourite historical figure or book character. Gender never seemed to be an issue at that time.(Edwards, John & Edwards, Luisa, 2013, p. 20)

At secondary school, Natasha made friends with girls and recalls: ‘I can only say that I enjoyed feeling pretty and good about myself.’ (Edwards, John & Edwards, Luisa, 2013, p. 53)

Things began to change after Natasha’s grandmother died, her mother became bipolar, and Natasha was bullied at school. ‘I don’t think the nature of the bullying changed my perceptions of gender’ she writes. But she began to explore her sexual identity: ‘up until 2008,’ she writes, ‘I identified as a weird gay woman who had crushes on guys.’(Edwards, John & Edwards, Luisa, 2013, p. 67) After a suicide attempt at age fifteen, Natasha spent a short while in Bethlem hospital where she was ‘out’ as a lesbian. Later she recalled hearing the term ‘genderqueer’ and joined the Queer Youth Network. It was on the online message boards that she discovered her transgender identity.(Edwards, John & Edwards, Luisa, 2013, p. 91). At a Gendered Intelligence event for parents in 2014, the keynote speaker described how her daughter had watched ‘The Boy who was Born a Girl’ and announced the next morning at breakfast that she was a boy.

v. Queering the Clinic

Gendered Intelligence, established in 2008 by a trans man called Jay Stewart together with his partner Catherine McNamara, catered from the start to this new cohort of (largely female) adolescents whose transgender identity had developed after puberty. Whereas Mermaids subscribed to the ‘born in the wrong body’ model of innate trans identity, Gendered Intelligence is run by adult trans activists and follows a postmodern theory of gender as performance. Stewart was a lesbian art student who graduated from the University of East London in 1997 ‘With no clear idea what to do with my life’. Studying for an MA in visual cultures at Goldsmiths College Stewart ‘became interested in theories of gender politics.’ (Burns, 2019) ‘Queer theory was the roadmap to my own self-understanding’ he explains. Catherine McNamara teaches at the Royal Central School of Speech and Drama where she helps young people to explore gender in performance.

Queer theory claims that all categories (including biological sex) are culturally constructed, and that body modification is a personal choice rather than a medical necessity. The Gendered Intelligence ‘Trans Youth Sexual Health Booklet’ (part funded by the National Lottery) explains that a ‘woman is still a woman, even if she enjoys getting blow jobs. A man is still a man, even if he likes getting penetrated vaginally. How you have sex need not affect your identity.’ (Gendered Intelligence, nd) Queer theory necessitates an affirmation approach for there can be no legitimate challenge to a patient’s self-declared identity.

It is undeniable that Gendered Intelligence has exerted an influence over the direction that the GIDS has taken: GIDS psychologist Sarah Davidson has acted as advisor to Gendered Intelligence, spoken at the launch of a Gendered Intelligence drawing project and collaborated on research with Jay Stewart. Answering ‘Frequently asked questions’ from child psychotherapists in 2018, Stewart identifies ‘a scene of power imbalance between the clinician and the young person’ and offers ‘to dismantle the culturally ascribed power of the biological.’ The ‘main thing’ he thinks ‘is that trans people should do the things that feel right for them.’ (Stewart, 2018) Under the influence of queer theory, the GIDS has attempted to hand over power and authority to the young people it serves.

With the rise of queer theory, trans clinicians increasingly began to shape clinical approaches. In 2011, Christina Richards was a Senior Specialist Psychology Associate under the supervision of Dr Penny Lenihan and the first openly trans person to be employed at the Charing Cross GIC. At the time Richards had not yet completed her MA. But in 2013 (along with non-binary psychologist Meg John Barker) Richards published Sexuality and Gender for Mental Health Professionals.(Richards & Barker, 2013) This guide sums up the new professional culture. The section on ‘Sexuality: Practices and Identities’ opens with a chapter on ‘Bondage and Discipline, Dominance and Submission and Sadomasochism (BDSM)/Kink’. A chapter on ‘Heterosexuality’ is sandwiched between ‘Lesbian and Gay Sexuality’ and ‘Cross-dressing and Further Sexualities’ (with advice on the furry community). The index has two references to Cognitive Behaviour Therapy, but the glossary defines CBT as

Cock and ball torture – strong sensations to the male genitals. Also an acronym for cognitive behaviour therapy. The two should not be confused.

Richards’ 2016 thesis explores how a group of 18 trans people conceptualise sexuality. Participants were asked to build models using Lego ‘because it does not require artistic ability, is playful, and is likely to be familiar to participants and will therefore be a comfortable form of medium for anyone who may be concerned about their artistic ability.’ (Richards, 2016) The study includes such discoveries as that ‘Jenbury Handlebar-Smythe made use of colour to represent multiplicity stating that “the gender one is one solid colour” and “the one that represents sexuality is lots of different colours.”’

By 2021, Richards was Lead Consultant and Head of Psychology at the GIC, Lead Chapter author for Adult Assessment in the WPATH Standards of Care Version 8.00, chair of the Division of Counselling Psychology at the British Psychological Society and visiting full professor at Regent University. The influence of Richards on the adult GIC and of Stewart on the child and adolescent service at the GIDS have pushed both towards affirmation. The GIDS has become increasingly unable to question the treatment of patients who presented with complex backgrounds.

vi. 2017: The Memorandum of Understanding on Conversion Therapy

In 2015, the main UK psychological professional organisations signed a joint agreement that conversion therapy aimed at changing a client’s sexual orientation was ‘unethical and potentially harmful.’ This was a public statement that sexual orientation should be affirmed.

But activist psychologists including Christina Richards and Meg-John Barker were campaigning to include gender identity, mirroring the move from affirmation of sexual orientation to affirmation of gender identity that had allowed the creation of the transgender child as a naturally occurring identity back in 2006.

The second version of the MOU agreed in October 2017 states that:

For the purposes of this document ’conversion therapy’ is an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual’s expression of sexual orientation or gender identity on that basis. (Memorandum of Understanding on Conversion Therapy in the UK Version 2, n.d.) [emphasis added]

Any attempt to explore the development of a gender identity belief might now be misrepresented as conversion therapy. In 2019, Bernadette Wren (then GIDS Head of Psychology) reassured clinicians that the Memorandum of Understanding offered protection against legal action from patients who later regret their transition:

Clinicians also have a defence in the fact that many professional bodies now endorse the diagnosis of Gender Dysphoria and the affirmative approach to care via the Memorandum of Understanding. (Wren, 2019)

An ex-GIDS patient, Keira Bell describes how she discovered the existence of transsexuals on the internet and was referred to the GIDS ‘where I was welcomed and affirmed as a boy.’(Bell, Keira, 2020) She argues that the Memorandum of Understanding led by default to the affirmation approach:

The current MoU associates exploring the origins of a person’s gender identity with gay conversion therapy. This stigmatises such explorative psychotherapy and limits the ability of clinicians to provide an appropriate therapeutic response.

Keira Bell is now an activist working to ‘Protect Gender Dysphoric Children from the Affirmation Model.’

vii. Private Gender Clinics

The NHS has struggled to respond to the exponential rise in gender dysphoria over the last decade. In 2010, Stuart Lorimer, consultant psychiatrist at the NHS Charing Cross adult gender clinic set up GenderCare as a private service staffed by NHS gender clinicians. Lorimer has argued that ‘Medical decision-making in the private sector – where the individual themselves is funding their own treatment – is […]arguably “purer”.(Lorimer, 2017) Lorimer is an activist clinician, drawing on his own struggle to come out as gay to further access to trans health care. Although Lorimer claims to offer ‘the same standard of assessments for private as for my NHS patients’, his clinic offers access to hormones in a single consultation.

In 2015, GPs Helen and Mike Webberley opened GenderGP, a private online clinic which provides puberty blockers and cross sex hormones to under 18s. Their mission is ‘to make gender-affirming healthcare, advice and education available to gender diverse people, and those who support them.’ Both Helen and Mike Webberley have been suspended by the General Medical Council and Helen Webberley has been prosecuted for running an unlicensed clinic. In 2018, a tribunal judged Helen Webberley unfit to practise because she ‘lacks the essential attributes of integrity and candour which are essential to suitability. She also lacks insight.’(Dr Helen Webberley v. NHS Wales FTT Decision, 2018) Helen Webberley hosted Jo Olson Kennedy on her visit to the UK in April 2019 and presents herself as a ‘passionate advocate for the transgender community.

Conclusion

The meaning of affirmation changed between 1998, when feminine boys were helped to express themselves at home on the assumption that they would mature into gay adults, and 2006 when it came to describe the social transition of prepubertal children, potentially followed by hormonal and surgical interventions. Affirmation had previously aimed to reduce shame and allow the emergence of a mature sexual orientation but the new form of affirmation sought to realise a subjective gender identity.

Whereas the affirmation movement grew from a desire to afford gender dysphoria the same respect that homosexuality had finally achieved, many have come to see that the desire to affirm gender can be driven by homophobia whether in parents or in young people. In April 2019, five clinicians who had left Tavistock GIDS told The Times that ‘there was a dark joke among staff that “there would be no gay people left”.’ (Bannerman, 2019) One said that “It feels like conversion therapy for gay children.” A clinician “frequently had cases where people started identifying as trans after months of horrendous bullying for being gay.” And a female clinician noticed that “Young lesbians considered at the bottom of the heap suddenly found they were really popular when they said they were trans.” Homophobia was also an issue with some parents: “We heard a lot of homophobia which we felt nobody was challenging.”

Affirmation only makes sense if gender identity is innate and stable and if gender identity can be confidently distinguished from sexual orientation. The recent increase in detransitioner voices questions the first assumption, the complex relationship between gender identity and sexual orientation evident throughout this history should raise serious questions about the second. We know that many factors, including trauma, emergent sexual orientation, bullying, autism spectrum and body dysmorphia can play a part.

A paper co-authored by Polly Carmichael in 2019 suggests that a ‘share of adolescent non-cisgender identity experiences may be a part of normative identity exploration.’ And for this reason:

It is important that adolescents can explore identity options and express themselves freely, but hasty medical interventions may not always be advisable. Psychotherapy may facilitate identity exploration. (Kaltiala et al., 2019)

But finding adequate psychotherapy, and finding time for exploration, is increasingly difficult. In September 2020 the NHS announced a review of the Gender Identity Development Service for Children and Adolescents to be led by Dr Hilary Cass.(NHS England, 2020) The terms of reference state that ‘In recent years there has been a significant increase in the number of referrals to the Gender Identity Development Service, and this has occurred at a time when the service has moved from a psychosocial and psychotherapeutic model to one that also prescribes medical interventions by way of hormone drugs.

References

Adams, Tim. (2016, November 13). Transgender children: The parents and doctors on the frontline. The Observer. https://www.theguardian.com/society/2016/nov/13/transgender-children-the-parents-and-doctors-on-the-frontline

Anon. (2018, July 6). Dr. Johanna Olson-Kennedy explains why mastectomies for healthy teen girls is no big deal. https://youtu.be/5Y6espcXPJk

Bannerman, L. (2019, April 8). It feels like conversion therapy for gay children, say clinicians. The Times. https://www.thetimes.co.uk/article/it-feels-like-conversion-therapy-for-gay-children-say-clinicians-pvsckdvq2

Barrett, J. (2016a). Doctors are failing to help people with gender dysphoria. BMJ, 2.

Barrett, J. (2016b). Doctors are failing to help people with gender dysphoria: Rapid response BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1694 (Published 30 March 2016) Cite this as: BMJ 2016;352:i1694. BMJ, 352(1694). https://doi.org/10.1136/bmj.i1694

Bell, Keira. (2020). Protect Gender Dysphoric Children from the Affirmation Model. https://www.crowdjustice.com/case/challenge-innate-gender/

Berk, Alex, C., John. (2017, January). Transgender Kids: Who Knows Best?

Biggs, M. (2019). The Tavistock’s Experiment with Puberty Blockers. http://users.ox.ac.uk/~sfos0060/Biggs_ExperimentPubertyBlockers.pdf

Biggs, M. (2020). Puberty blockers and suicidality in adolescents suffering from gender dysphoria. Archives of Sexual Behavior, 49, 2227–2229. https://doi.org/10.1007/s10508-020-01743-6

Boyce, Benjamin. (2019). Taking on the Gender Identity Industry with Maritza Cummings. https://youtu.be/GWWIhZNZrdU

Bryant, K. (2006). Making gender identity disorder of childhood: Historical lessons for contemporary debates. Sexuality Research and Social Policy, 3(3), 23–39. https://doi.org/10.1525/srsp.2006.3.3.23

Burns, C. (2019). Trans Britain: Our journey from the shadows.

Butler, G., De Graaf, N., Wren, B., & Carmichael, P. (2018). Assessment and support of children and adolescents with gender dysphoria. Archives of Disease in Childhood, archdischild-2018-314992. https://doi.org/10.1136/archdischild-2018-314992

Canadian Broadcasting Corporation. (2018, October 7). CAMH reaches settlement with former head of gender identity clinic.

Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. (2020). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK [Preprint]. Sexual and Reproductive Health. https://doi.org/10.1101/2020.12.01.20241653

Delemarre-van de Waal, H. A., & Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: A protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, 155(suppl_1), S131–S137. https://doi.org/10.1530/eje.1.02231

Di Ceglie, D. (2002). Castaway’s Corner. Clinical Child Psychology and Psychiatry, 7(3), 5.

Di Ceglie, D. (2018). Between Scylla and Charybdis: Exploring atypical gender identity development in children and adolescents. In G. Ambrosio (Ed.), Transvestism, Transsexualism in the Psychoanalytic Dimension (1st ed., pp. 55–71). Routledge. https://doi.org/10.4324/9780429484261-3

Di Ceglie, D., & Freedman, D. (Eds.). (1998). A stranger in my own body: Atypical gender identity development and mental health. Karnac Books.

Dr Helen Webberley v. NHS Wales FTT Decision. (2018). http://phl.decisions.tribunals.gov.uk/Documents/FTT%20Decision%2022%20October%202018%20-%20[2018]%203251.PHL.pdf

Edwards, John, & Edwards, Luisa. (2013). The Boy who was Born a Girl. Arrow Books.

Ehrensaft, D. (2011). BOYS WILL BE GIRLS, GIRLS WILL BE BOYS. 21.

Ehrensaft, D. (2012). From Gender Identity Disorder to Gender Identity Creativity: True Gender Self Child Therapy. Journal of Homosexuality, 59(3), 337–356. https://doi.org/10.1080/00918369.2012.653303

Ehrensaft, D. (2016). The Gender Creative Child: Pathways for Nurturing and Supporting Children who live outside Gender Boxes. The Experiment.

Gendered Intelligence. (nd). Trans Youth Sexual Health Booklet.

Gill-Peterson, Julian. (2018). Histories of the Transgender Child. University of Minnesota Press.

Green, R. (1992). Robert Jesse Stoller. Archives of Sexual Behavior, 21(4), 337–346. https://doi.org/10.1007/BF01542023

Green, Richard. (1987). The ‘Sissy Boy Syndrome’ and the Development of Homosexuality. Yale University Press.

Hacking, Ian. (1998). Mad Travellers: Reflections on the Reality of Transient Mental Illnesses. University Press of Virginia.

Hausman, Bernice L. (1995). Changing Sex: Transsexuality, Technology and the Idea of Gender. Duke University Press.

Kaltiala, R., Bergman, H., Carmichael, P., de Graaf, N. M., Egebjerg Rischel, K., Frisén, L., Schorkopf, M., Suomalainen, L., & Waehre, A. (2019). Time trends in referrals to child and adolescent gender identity services: A study in four Nordic countries and in the UK. Nordic Journal of Psychiatry, 74(1), 40–44. https://doi.org/10.1080/08039488.2019.1667429

Lorimer, S. (2017). The History of GenderCare. https://gendercare.co.uk/history-of-gendercare.shtml

Meadow, T. (2011). ‘Deep down where the music plays’: How parents account for childhood gender variance. Sexualities, 14(6), 725–747. https://doi.org/10.1177/1363460711420463

Memorandum of Understanding on Conversion Therapy in the UK Version 2. (n.d.). https://www.psychotherapy.org.uk/wp-content/uploads/2017/10/UKCP-Memorandum-of-Understanding-on-Conversion-Therapy-in-the-UK.pdf

NHS England. (2020). TERMS OF REFERENCE FOR REVIEW OF GENDER IDENTITY DEVELOPMENT SERVICE FOR CHILDREN AND ADOLESCENTS.

Olson, Johanna; Forbes, Catherine; Belzer, Marvin, O. (2011). Management of the Transgender Adolescent. Archives of Pediatrics & Adolescent Medicine, 165(2), 171–176.

Olson-Kennedy, J. (2019, April 4). ‘Transgender Youth—An overview of medical and mental health needs of gender non-conforming children and transgender adolescents.’ https://www.bristol.ac.uk/law/events/2019/transgender-youth.html

Rafferty, Jason, & COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS. (2018). Ensuring Comprehensive Care and Support for Transgender and Gender- Diverse Children and Adolescents. Pediatrics, 142(4).

Reischel, J. (2006). See Tom Be Jane.

Richards, C. (2016). Trans sexuality: A phenomenological-hermeneutic enquiry into the sexuality of trans and non-binary people—With implications for the practice of existential-phenomenological counselling psychology and psychotherapy.

Richards, C., & Barker, M.-J. (2013). Sexuality and Gender for Mental Health Professionals: A Practical Guide. Sage.

Shorter, Edward. (1992). History of Psychosomatic Illness in the Modern Era: From paralysis to fatigue. Free Press.

Showalter, Elaine. (1997). Hystories: Hysterical Epidemics and Modern Culture. Picador.

Singal, Jesse. (2016, February 7). How the Fight Over Transgender Kids Got a Leading Sex Researcher Fired. The Cut.

Spiegel, Alix. (2008, May 7). Two Families Grapple with Sons’ Gender Identity: Psychologists Take Radically Different Approaches In Therapy. NPR. https://www.npr.org/2008/05/07/90247842/two-families-grapple-with-sons-gender-preferences?t=1613228745472

Stewart, J. (2018). Frequently asked questions about children’s gender identity and expression. Journal of Child Psychotherapy, 44(1), 47–54. https://doi.org/10.1080/0075417X.2018.1446455

Taylor, D. (2006). Report on GIDU review (May—Oct. 2005).

Tuerk, C. (2011). Considerations for Affirming Gender Nonconforming Boys and Their Families: New Approaches, New Challenges. Child and Adolescent Psychiatric Clinics of North America, 20(4), 767–777. https://doi.org/10.1016/j.chc.2011.07.005

UK Parliament, Women and Equalities Committee. (2015). Transgender equality: First report of session 2015–16 (London: The Stationery Office Limited, Ed.).

Wren, B. (2019). Ethical issues arising in the provision of medical interventions for gender diverse children and adolescents. Clinical Child Psychology and Psychiatry, 24(2), 203–222. https://doi.org/10.1177/1359104518822694

Zucker, K. J., & Spitzer, Robert L. (2005). Was the Gender Identity Disorder of Childhood Diagnosis Introduced into DSM-III as a Backdoor Maneuver to Replace Homosexuality? A Historical Note. Journal of Sex & Marital Therapy, 31, 31–42. https://doi.org/10.1080/00926230590475251