The US and other Anglophone countries have recently seen an exponential increase in young persons and their families pursuing professional therapy to prepare children as young as 12 for sex reassignment through puberty-blocking drugs, hormones, and in some cases even surgery. Credible scientific authorities have sharply varied opinions as to the wisdom of these radical approaches to treating children who present as gender dysphoric. Some experts oppose reassignment surgery altogether, saying its value is unproven, and that gender-roles and culture so mutually implicate each other that purely medical interventions may not be a solution. A plurality of informed scientific opinion today leans toward the view that hormonal or surgical interventions should only be performed after some years of careful evaluation and therapy by a conscientious “gatekeeper” who is not at the outset prejudiced either in favor of or against transition. Too many gender identity therapists and clinics are no longer providing the degree of careful gatekeeping and balanced education of patients and families that we believe is required. To make sure that all young persons and their parents receive balanced information on both sides of the debate, we have assembled the following resources, grouped around twelve frequently asked questions. We are neither pro-transition nor anti-transition; it may be the right solution for some young people, but not for many others who suffer confusion and uncertainty as they chart their course through adolescence.
I. Are religiously motivated “transphobic bigots” the only people who hesitate about immediate affirmation of a child’s desire to be the other sex?
No. This issue is one of the most hotly debated topics in academic sexology and bioethics today, with many pediatricians and experts who have worked at gender identity clinics for years raising voices of caution over the rapid recent rise in the number of children and adolescents seeking treatment. Some of these authorities are themselves gay or lesbian; none can be considered transphobic. On the other side are transsexual activists eager to see their numbers and political influence swell; in many cases they are bankrolled by pharmaceutical companies who make $20,000 to 30,000 a year off each prescription for “puberty-blocking” agents. Here are the reservations some well-credentialed experts have offered.
1) Andrew Gilligan, “Staff at Trans Clinic Fear Damage to Children as Activists Pile on Pressure.” The Sunday Times (Feb. 16, 2019).
Andrew Gilligan, “Surge in Girls Switching Gender.” The Sunday Times (June 29, 2019).
Former director of UK Gender Identity Clinic David Bell expresses doubts, noting the 700% increase in child referrals to his clinic in the past five years, and calling the process of assessment and care “woefully inadequate.” A high percentage of the children referred to his clinic have autism spectrum disorder or other serious mental health problems separate from gender dysphoria, histories of child abuse or homophobia in the family, and appear to have been coached by eager parents or transgender activists. Bell said the clinic was exposing young patients to “long-term damage” because of its “inability to stand up to the pressure” from “highly politicised” campaigners and families demanding fast-track gender transition. He said the true histories of “highly disturbed or complex” children were not being properly explored by doctors facing “huge and unmanageable caseloads” and afraid of being accused of transphobia if they questioned the “rehearsed” surface presentation.
The numbers, for the year to this April, also show marked rises in younger children seeking treatment. For the first time, the majority of patients referred to the clinic (54%) are aged 14 or under. The number of 13-year-olds seeking treatment rose by 30% in a year to 331. Referrals of 14-year-olds went up by a quarter, to 511. The number of 11-year-olds is up by 28%. The youngest patients were three.
2) S. Adams, “GPs Risk Transgender Backlash After Issuing Unprecedented Warning over ‘Lack of Evidence’ on Treatments that Pave Way for Children to Have a Sex Change.” Daily Mail (July 7, 2019).
The Royal College of General Practitioners says guidance on how to care for patients has been contradictory and ethically dubious. While the General Medical Council (GMC) advises doctors to ‘promptly refer patients requesting treatment’ to gender identity clinics, the RCGP warns there is ‘a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatments for people with gender dysphoria, particularly children and young people’. There are question marks over ‘long-term safety [of puberty blockers] in transgender adolescents’, while the effects of cross-sex hormones ‘can be irreversible’. The RCGP also highlights ‘difficulties with current IT systems which do not accommodate for transgender and non [gender] binary patients in relation to referrals and screening’.
3) J. Doward, “Politicised Trans Groups Put Children at Risk, Says Expert.” The Guardian (July 27, 2019).
Marcus Evans, a psychotherapist and ex-governor of the Tavistock and Portman NHS Foundation Trust, whose Gender Identity Development Service (GIDS) is the only NHS clinic to provide gender counselling and transitioning, said many experts were living in fear of being labelled transphobic, which was having an impact on their objectivity. “I believe the trans political agenda has encroached on the clinical environment surrounding and within the Gender Identity Development Service,” Evans told the Observer. “Young people need an independent clinical service that has the long-term interests of the patient at heart. To some extent, this requires a capacity to stand up to pressure coming from various sources: from the young person, their family, peer groups, online and social networking pressures and from highly politicised pro-trans groups.”
4) L. Bannerman, “It feels like conversion therapy for gay children, say clinicians: Ex-NHS staff fear that homophobia is driving a surge in ‘transgender’ young people.” The Times of London (April 8, 2019).
L. Bannerman, “Calls to end transgender ‘experiment on children.’” The Times of London (April 8, 2019).
L. Bannerman, “Families ‘exploited by gender lobby groups pushing for treatment.’” The Times of London (April 8, 2019).
5) C. Heneghan (Evidence-Based Medicine, Oxford University), “Doubts over evidence for using drugs on the young.” The Times of London (April 8, 2019).
6) Dianna Kenny (Psychology, Univ. of Sydney), “Is Gender Dysphoria Socially Contagious?” (Sept. 13, 2019).
Compares the rapid increase in adolescent girls claiming gender dysphoria to other better studied epidemics of adolescent social contagion such as suicide, marijuana use, and anorexia. The Pediatric and Adolescent Gender Dysphoria Working Group is a new international consortium of clinical psychologists, physicians, and academic experts who are concerned about the uncritical promotion of premature gender transition in minors. Monitor their website for the latest and best science in this area.
7) J. Whitehall (Pediatrics, Western Sydney University), “Gender Dysphoria and Surgical Abuse.” Quadrant Online (Dec. 15, 2016).
An Australian pediatrician systematically reviews studies of co-occurring psychiatric disorders and theories to explain them. Studies purporting to show self-harm or suicide attempts in gender dysphoric children may be skewed by the high proportion of children with co-occurring autism and other psychiatric morbidities. The author points to the intimidating effect of anti-reparative therapy legislation, which discourages proper gatekeeping on the part of gender identity therapists; many therapists with reservations about immediate affirmation of a child’s gender preference refuse to treat such children, leaving the field exclusively to those who are enthusiasts for transition. He calls for more research on the motivations of parents who encourage social transition of their children before even beginning therapeutic evaluation.
8) Interview with Dr. James Cantor (Psychiatry, University of Toronto), who criticizes the American Academy of Pediatrics guidelines as politically motivated, rather than grounded in science. He also illuminates fetal development factors that may affect gender manifestations, “watchful waiting” with pre-adolescent children who claim gender dysphoria, trans activism vs. scientific free speech, and much else:
9) Interview with therapist Sasha Ayad, LCSW, who specializes in treating teens, on recent changes in gender dysphoric manifestations: https://www.youtube.com/watch?v=0tF0Mykerjw
10) L. Littman (Public Health, Brown University), “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.” PLoS One (2018) 13.8: e0202330.
This article reported on a survey of 256 parents who reported that their children (82.8% natal female, average age of 15) had suddenly reported an interest in gender transition. 86.7% of these parents reported that this event was preceded by their child’s increase in social media use or participating in a friend group in which one or more peers were transgender-identified. This article was sharply attacked by transgender activists, who deny rapid onset gender dysphoria; they point out that the parents were all recruited through explicitly anti-transgender websites. For a subsequent interview with Littman, see:
11) M. Kearns, “The Trans Child as Experimental Guinea Pig.” National Review (April 22, 2019).
12) P. McHugh (Psychiatry, Johns Hopkins University Hospital), “Transgender Surgery Isn’t the Solution: A Drastic Physical Change Doesn’t Address the Underlying Psycho-Social Troubles.” Wall Street Journal (June 12, 2014).
Johns Hopkins was the first hospital to practice transgender surgery in the US. Their former chief of psychiatry explains why they stopped doing it: those who had the surgery did not show better mental health outcomes than those who didn’t. He criticizes as “child abuse” the over-hasty use of medical interventions to block puberty.
II. Do those who display transgender interests as children persist as adolescents?
All studies agree that the overwhelming majority do not, even studies by the developers of the Dutch 12-16-18 protocol (puberty blockers at 12, hormones at 16, surgery at 18).
1) J. Cantor. “Do trans-kids stay trans when they grow up?” Sexology Today! (Jan. 11, 2016).
Collects 11 follow-up studies from 1972 to 2013; most show that 60-90% of children who exhibit cross-gender behavior desist by adulthood, but a high proportion become gay or lesbian. Overall, 98 of the 493 children studied identified as trans in adulthood (19.9%).
2) T. D. Steensma, J. K. McGuire, B. P. C. Kreukels, A. J. Beekman, P. T. Cohen-Kettenis. “Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study.” Journal of the American Academy of Child & Adolescent Psychiatry 52.6 (2013) 582-90.
This study reports on 127 Dutch children who were seen at the Amsterdam gender clinic between the ages of 6-11 and then followed up after age 15. 47 of the 127 (37%) persisted (50% of the natal girls, 29% of the natal boys); persistence was most strongly associated with intense feelings of gender incongruence as children and a later age of presenting such feelings. Higher social class had a slight correlation with desistence, especially for the girls.
3) T. D. Steensma, R. Biemond, F. de Boer, & P. T. Cohen-Kettenis. “Desisting and Persisting Gender Dysphoria after Childhood: A Qualitative Follow-up Study.” Clinical Child Psychology and Psychiatry 16 (2011) 499-516.
A review of the previous published literature shows that gender dysphoria persists from childhood into adolescence in only 15.8% of the 246 adolescents studied. Most studies show that 60-80% of the non-persisting adolescents become gay, lesbian, or bi-sexual. A balanced group of 25 Dutch adolescents some of whom persisted and some of whom desisted were studied through intensive interviews. Those who persisted with their gender dysphoria into adolescence reported intense feelings of disgust and discomfort with their bodies even as children, whereas those who desisted reported more social discomfort with assigned gender roles. Those who persisted were all erotically attracted to their own natal sex, but preferred to identify as straight rather than gay; those who desisted said their first experience of falling in love (whether straight or gay) was key in motivating them to lose interest in cross-identifying with the opposite sex. The authors’ conclusion: “…parents and caregivers should fully realize the unpredictability of their child’s psychosexual outcome. They may help the child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse.”
III. How many young people who transition later regret their decision and change back to their birth sex?
It is hard to know, as gender identity clinics usually lose track of the individuals who decide to cease taking hormones. Since the widespread use of hormones and puberty-blocking agents in minor children is a fairly new course of therapy in the US, data does not yet exist about how many change their mind five, ten, or twenty years later. But “detransitioners” do exist and are making their presence on social media increasingly visible, warning other young people not to be drawn in by the enthusiasm of transitioning peers and transgender activists.
1) S. Lockwood, “’Hundreds’ of Young Trans People Seeking Help to Return to Original Sex.” Sky News (October 5, 2019).
A new charity has been formed in the UK called the Detransition Advocacy Network, to serve the needs of young people who regret their premature decisions to undergo gender reassignment. They complain of being shunned as “traitors” by mainstream GLBT organizations. Many say that transition did not help with their body image problems and that their therapists failed to address other mental health issues that they misdiagnosed as gender dysphoria.
2) J. L. Turban & A. S. Keuroghlian, “Dynamic Gender Presentations: Understanding Transition and ‘De-Transition’ Among Transgender Youth.” Journal of the American Academy of Child & Adolescent Psychiatry 57.7 (2018) 451-53.
Contends that de-transition is rare and that the side-effects of hormone therapy are minimal and easily reversible. For a critique of both positions, see:
R. D’Angelo, Psy.D. (Psychoanalyst, Sydney, Australia), “Dynamic Gender Presentations: Understanding Transition and De-Transition Among Transgender Youth.” (July 15, 2018).
3) C. McCann. “When Girls Won’t Be Girls.” The Economist (October/November 2017).
The story of Max Robinson, a FTM teen in California who later de-transitioned.
4) “Coercion & Abuse in the Gender ID Community” (Benjamin A. Boyce) – https://www.youtube.com/watch?v=QAMar22S0ck
“Help me reverse my sex change” – http://helpmereversemysexchange.org/
“I Was America’s First ‘Nonbinary’ Person. It Was All a Sham” – https://www.dailysignal.com/2019/03/10/i-was-americas-first-non-binary-person-it-was-all-a-sham/
“Apparently Not All (Formerly) Autogynephilic Trans People Hate Me or Science / Facts / Reality” – https://www.youtube.com/watch?v=NHLPk1JrPzQ
5) Interviews with members of the Pique Resilience Project (young females who reversed their transition) on social media influence and its effect on teen transitioners:
IV. Are young people with serious mental health issues or social disabilities sometimes drawn to gender transition as a panacea for problems that actually have a different origin?
Transgender advocates argue that gender incongruence itself is the root cause that produces depression and anxiety in this population. However, some clinicians argue that the other mental health conditions, such as autism spectrum disorder, or social problems, such as homophobic bullying, are primary and should be addressed first, as they may influence a developing child or adolescent’s ideation and decision-making.
1) A. C. Kafka, “Trans Students Are Found Far More Likely than Others to Suffer from a Host of Psychological Problems.” Chronicle of Higher Education (August 16, 2019).
S. K. Lipson, J. Raifman, S. Abelson, & S. L. Reisner, “Gender Minority Mental Health in the U.S.: Results of a National Survey on College Campuses.” American Journal of Preventive Medicine 57.3 (2019) 293-301.
The study found that about 2% of the 65,213 students in the Healthy Minds Survey (2015-2017) identified as gender minority. Among that group, 78% (4.3 times the rate for cisgender students) met the criteria for one or more mental health problems. 58% screened positive for depression in the last two weeks, and 52% reported non-suicidal self-injury, and more than one third suicidal ideation.
2) R. Kaltiala-Heino, M. Sumia, M. Työlöjärvi, & N. Lindberg, “Two Years of Gender Identity Service for Minors: Overrepresentation of Natal Girls with Severe Problems in Adolescent Development.” Child and Adolescent Psychiatry and Mental Health 9.1 (2015)
Of the 47 (41 female) adolescent patients from 2011-13 at one of Finland’s two gender identity clinics, 79% were already in treatment or referred to treatment for other psychiatric disorders, including depression, anxiety, self-harming (all over 50%), and Autism Spectrum Disorder (26%). Only about 10% recalled any gender dysphoria before puberty. While many of those whose symptoms began with adolescence now felt confirmed in their new gender identity, more were confused and uncertain, especially if they experienced high levels of social isolation. The authors’ conclusion: “In the presence of severe psychopathology and developmental difficulties, medical SR (sexual reassignment) treatment may not be currently advisable.”
3) S. D. Stagg & J. Vincent, “Autistic Traits in Individuals Self-Defining as Transgender or Non-Binary.” European Psychiatry 61 (2019) 17-22.
The study found that 14% of the transgender and non-binary group had a diagnosis of autism, while a further 28% of this group reached the cut off point for an autism diagnosis, suggesting a high number of potentially undiagnosed individuals. These figures were primarily driven by high scoring amongst those whose assigned gender was female at birth. The authors also found higher levels of systematising (a tendency to analyse, control and use rule-based systems) and lower levels of empathy amongst the transgender and non-binary group, characteristics often found in individuals with an autism spectrum disorder. “People with autism are also more likely to seek unequivocal answers to the complex issues surrounding gender identity. Our study suggests it is important that gender identity clinics screen patients for autism spectrum disorders and adapt their consultation process and therapy accordingly.”
4) J. H. Leef, J. Brian, D. P. VanderLaan, H. Wood, K. Scott, M.-C. Lai, S. J. Bradley, & K. J. Zucker, “Traits of Autism Spectrum Disorder in School-aged Children with Gender Dysphoria: A Comparison to Clinical Controls.” Clinical Practice in Pediatric Psychology (Sept. 2, 2019).
Abstract: Objective: Studies of children with gender dysphoria (GD) have reported an overrepresentation of autism spectrum disorder (ASD) or traits. One limitation of these studies has been the absence of a concurrent comparison group of children referred for other clinical problems. The present study addressed this gap by comparing 61 children referred for GD with 40 children referred for other clinical concerns (age range, 4–12 years). Method: ASD caseness was measured in 2 ways: (a) a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of ASD or cut-off scores for caseness or (b) dimensionally on 2 standardized measures. Results: Children with GD had a higher proportion with a co-occurring DSM diagnosis of ASD and a higher proportion who met the criterion for caseness on the Social Communications Questionnaire than the clinical controls. In contrast, on the Social Responsiveness Scale, the 2 groups were similar with regard to caseness and traits of ASD. Conclusions: The results of our study showed evidence of both specificity and nonspecificity with regard to ASD traits and caseness. Future research can adopt the principle of multifinality to understand better why only a minority of children with GD have a co-occurring diagnosis of ASD, but the majority does not.
5) A. I. R. van der Miesen, H. Hurley, A. M. Bal, A. L. C. de Vries. “Prevalence of the Wish to Be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder.” Archives of Sexual Behavior 47.8 (2018) 2307-17.
This study compared the self-reported wish to be of the opposite gender (one item of the Youth Self-Report [YSR] and the Adult Self-Report [ASR]) of 573 adolescents (469 assigned boys and 104 assigned girls) and 807 adults (616 assigned males and 191 assigned females) with ASD to 1016 adolescents and 846 adults from the general population. Emotional and behavioral problems were measured by the DSM-oriented scales of the YSR and ASR. Significantly more adolescents (6.5%) and adults (11.4%) with ASD reported the wish to be the opposite gender as compared to the general population (3–5%). In adolescents, assigned girls endorsed this item more than assigned boys. In addition, on all DSM-oriented scales of both the YSR and ASR, adolescents and adults with ASD who endorsed the gender item had significantly higher scores compared to those without.
6) D. Delay, C. L. Martin, R. E. Cook, & L. D. Hanish, (2017). “The Influence of Peers During Adolescence: Does Homophobic Name Calling by Peers Change Gender Identity?” Journal of Youth and Adolescence 47.3 (2017) 636-649.
“Homophobic name calling emerged as a form of peer influence that changed early adolescent gender identity, such that adolescents in this study appear to have internalized the messages they received from peers and incorporated these messages into their personal views of their own gender identity.”
V. Are untreated transgender youth more likely to commit suicide?
1) R. B. Toomey, A. K. Syvertsen, M. Shramko. “Transgender Adolescent Suicide Behavior.” Pediatrics 142.4 (2018).
Data from a large national online student survey (ages 11-19, collected over three years 2012-15) suggest that suicide attempt rates were significantly higher among FTM transsexuals (50.8% vs. 17.6% for all natal females), nonbinary individuals (41.8% vs. 14.1% for all adolescents), and MTF transsexuals (29.9% vs. 9.8% for all natal males). Even higher rates were reported by gay and lesbian-identified adolescents. The study does have some limitations, in that it does not reveal whether the suicide attempts were before or after medical intervention to treat gender dysphoria, or were intended as a way of pressuring parents and therapists to agree to medical intervention. Other researchers have pointed out that most suicide research focuses on actual suicides, rather than just self-reported attempts, many of which are better classified as “non-suicidal self-injury” (NSSI). Studies that rely on anonymous self-reported identities and histories by adolescents are also subject to a high proportion of statistical interference by “jokesters,” i.e. adolescents who maliciously misreport an identity or history that is not theirs.
2) H. Horváth (Epidemiology, UC-San Francisco), “The Theatre of the Body: A Detransitioned Epidemiologist Examines Suicidality, Affirmation, and Transgender Identity.”
A detailed criticism of the survey methods employed by Toomey (2018); other more rigorous surveys, such as the California Health Interview Survey suggest a rate of about 3% in youth who are “highly gender-nonconforming” (vs. 2% in gender-conforming youth). The suicide rates for gender dysphoric youth are not significantly different from those for gay, lesbian, or bi-sexual youth, youth experiencing bullying, or youth with psychiatric conditions, all of which are categories that overlap substantially with gender dysphoric youth. The overall rate of completed suicides for youth 15-24 was 13.2 per 100,000 in 2016, compared to 4.5 per 100,000 in 1950 (a time of much more rigid gender roles than today); the substantial increase in youth suicide rates beginning in the 1970s is due to far more complex social causations.
3) M. Aitken, D. P. VanderLaan, L. Wasserman, S. Stojanovski, & K. J. Zucker. “Self-Harm and Suicidality in Children Referred for Gender Dysphoria.” Journal of the American Academy of Child & Adolescent Psychiatry 55.6 (2016) 513-520.
Based on logistic regression analyses, gender-referred children were 5.1 times more likely than non-referred children to talk about suicide and 8.6 times more likely to self-harm/attempt suicide, even after overall behavior problems and peer relationship problems were accounted for. By parent-report, children with gender dysphoria show an increased rate of self-harm / suicidality as they get older. This risk was not simply an artifact of the presence of behavioral and emotional problems, although these problems were significant correlates of self- harm / suicidality.
VI. Are Lupron and other puberty-blocking drugs safe?
No. At present, these drugs are only approved by the FDA for use to delay premature puberty, where the negative health consequences outweigh the serious side effects of the drugs, including both bone health issues and lower IQ.
1) C. Jewett (Kaiser Health News), “Drug used to halt puberty in children may cause lasting health problems.” Stat (Feb. 2, 2017).
An overview of Lupron’s side effects and the long history of specialist warnings and litigation against the manufacturer. More than 10,000 adverse event reports have been filed with the FDA, including early osteopenia (bone-thinning), cracked spine, cracked teeth, degenerative disc disease and chronic pain, augmented depression, anxiety, suicidal urges, and seizures.
2) M. A. Schneider, P. M. Spritzer, B. M. B. Soll, A. M. V. Fontanari, M. Carneiro, F. Tovar-Moll, . . . M. I. R. Lobato. “Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression.” Frontiers in Human Neuroscience 11 (2017), Article ID 528.
This study reports lack of normal brain development in a natal male undergoing puberty-blocking GnRHa therapy: 9 points lower in operational memory and impairment of Global IQ.
3) S. Wojniusz, N. Callens, S. Sütterlin, S. Andersson, J. De Schepper, I. Gies, et al. . (2016). “Cognitive, Emotional, and Psychosocial Functioning of Girls Treated with Pharmacological Puberty Blockage for Idiopathic Central Precocious Puberty.” Frontiers in Psychology 7 (2016)1053.
This study finds significant the 8-point lower IQ in 15 GnRHa-treated girls with precocious puberty vs. 15 controls (94 vs. 102). See also the commentary by P. Hayes (2017):
4) D. Mul, H. J. M. Versluis-den Bieman, F. M. E. Slijper, W. Oostdijk, J. J. J. Waelkens, S. L. S. Drop. “Psychological Assessments Before and After Treatment of Early Puberty in Adopted Children.” Acta Paediatrica 90 (2001) 965–971.
Found a 7 point drop in IQ (100 to 93) in 25 children treated with GnRHa for two years compared to their IQ before treatment.
5) D. Hough, M. Bellingham, I. R. H. Haraldsen, M. McLaughlin, M. Rennie, J. E. Robinson, A. K. Solbakk, N. P. Evans. “Spatial Memory Is Impaired by Peripubertal GnRH Agonist Treatment and Testosterone Replacement in Sheep.” Psychoneuroendocrinology 75 (2017) 173-82.
The same research team subsequently published a study showing that even after discontinuation of treatment, adult sheep are 1.5 times slower in progressing through a maze.
“A Reduction in Long-Term Spatial Memory Persists After Discontinuation of Peripubertal GnRH Agonist Treatment in Sheep.” Psychoneuroendocrinology 77 (2017) 1-8.
6) V. Gilsanz, J. Chalfant, H. Kalkwarf, et al. “Age of Onset of Puberty Predicts Bone Mass in Young Adulthood.” Journal of Pediatrics 158.1 (2011) 100-5.
Although not directly concerned with the use of puberty blocking agents, this study of 163 young people shows that delay in the onset of puberty correlates with lower bone mass density and thus premature development of osteoporosis and osteopenia in adulthood.
7) C. Marrs. “Lupron, Estradiol and the Mitochondria: A Pathway to Adverse Reactions.”
Lupron side effects including brain and nervous system disorders, chronic fatigue, muscular atrophy, cardiovascular problems, loss of bone mineral density, and gastrointestinal symptoms can be linked to its influence on mitochondrial dysfunction.
8) J.-C. Carel, E. A. Eugster, A. Rogol, et al. “Consensus Statement on the Use of Gonadotropin-Releasing Hormone Analogs in Children.” Pediatrics 123.4 (2009) 752-762.
Conclusion: “Few controlled prospective studies have been performed with gonadotropin-releasing hormone analogs in children. … Use of gonadotropin-releasing hormone analogs for conditions other than central precocious puberty requires additional investigation and cannot be suggested routinely.”
9) J. A. Yanovski, S. R. Rose, G. Municchi, et al. “Treatment with a Luteinizing Hormone-Releasing Agonist in Adolescents with Short Stature.” New England Journal of Medicine 348 (2003) 908-17.
This study found that use of this drug in adolescents over a period of 2.6-4.4 years resulted in significant loss of bone mineral density (resulting in premature osteoporosis and osteopenia). The risks are sufficient that use of the drug to treat short stature should not be recommended. While this study does not directly speak to the use of the drugs to facilitate gender transition, it does suggest risks are sufficiently high that they should only be used when absolutely necessary.
10) M. Biggs (Sociology, Oxford University), “The Tavistock’s Experiment with Puberty Blockers.” (July 29, 2019)
This paper (published version forthcoming) argues that the experimental study by the Gender Identity Service of the Tavistock & Portman NHS Foundation Trust did not properly inform children and their parents of the risks of triptorelin. It demonstrates that the study’s preliminary results were more negative than positive, and that the single published scientific article using data from the study is fatally flawed by a statistical fallacy. Its conclusion is that GIDS and their collaborators at UCL have either ignored or suppressed negative evidence.
11) Prof. Kim Wallen (Psychology & Behavioral Neuroendocrinology, Emory University) reports the following, based on his primate research in the 1980s (e-mail received Jan. 2019):
“Years ago (1984) we did studies in monkeys where newborn male monkeys had testicular function blocked using either a GnRH agonist, or antagonist. Even though the treatment only occurred in the first year of life it delayed puberty in the treated males by a year (5 years instead of 4). There was an even bigger side effect in that significantly more treated males died within the 7-8 years post treatment. In later investigations we found that the GnRH agonist/antagonist treatment produced chronic immune suppression. We didn’t see this if males were treated as adults, but only if they were treated as newborns. We didn’t test prepubertal males, so I don’t know whether the immune suppression would occur if given to juvenile males. At the time we did these studies GnRH agonists/antagonists were being considered for male contraception, but after our immune suppression findings that program was dropped and instead became a model system for studying immune suppression. There is reason to be concerned about the long-term effects of treating prepubertal kids with agonists/antagonists. As far as I know no one has looked at this in kids who have had puberty delayed with agonist/antagonist treatment.”
VII. Have follow-up studies of adults with hormone treatment or sex-reassignment surgery shown that their lives improved?
Yes, at least from the standpoint of self-evaluation. But systematic studies also show a continuing high rate of suicide and mental disorders, as well as physical health problems, compared to the general population.
A. Mental Health Outcomes
1) R. Bränström & J. E. Pachankis, “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Reaffirming Surgeries: A Total Population Study.”
American Journal of Psychiatry (published online Oct. 4, 2019).
Of the 2,679 individuals who received a diagnosis of gender incongruence in Sweden during 2005-15, the study found no improvement in utilization of psychiatric services for anxiety and depression among those who underwent hormone therapy alone, but did find an improvement of about 8% per year for individuals who underwent sex reassignment surgery, who were 38% of the group. Nevertheless, their continuing utilization of mental health services even 10 years after surgery was higher than that of the general population (21.1% vs. 12.5%).
2) Simonsen, R. K., Giraldi, A., Kristensen, E., Haid, G. M. “Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality.” Nordic Journal of Psychiatry 70.4 (2016) 241-47.
This study tracked 104 Danish individuals who underwent sex-reassignment surgery from 1978-2010 (98% of the total who did). 27.9% showed “psychiatric morbidity” before surgery, and 22.1% did after surgery; however, they were mostly not the same individuals (only 6.7% were psychiatrically morbid both before and after). What this shows is that surgery can improve the mental condition of some patients and worsen that of others. The rate of psychiatric diagnoses was considerably higher among FTM transsexuals.
3) Dhejne, C., Lichtenstein, P., Boman, M., Johannson, A. L., Lângström, N., & Landen, M. “Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden.” PLoS One 6.2 (2011) e16885.
This study followed all 324 post-surgical sex-reassigned persons in Sweden from 1973-2003. Although many measures of well-being were positive, they had a suicide rate 19.1 times that of the general population, an attempted suicide rate 4.9 times higher, and a rate of inpatient psychiatric care 2.8 times higher.
4) M. H. Murad, M. B. Elamin, M. Z. Garcia, et al. “Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes.” Clinical Endocrinology (Oxford) 72.2 (2010) 214-31.
A review of all relevant follow-up studies up to its time. 70% of the MTF transsexuals and 84% of the FTMs self-report significant improvement in their psychiatric symptoms post-treatment; 84% of MTF and 78% of FTM transsexuals report an improved quality of life. However, the authors acknowledge that most of these previous studies are of “low quality” due to problems with selection bias and reliance on self-evaluations rather than clinical interviews.
5) U. Hepp, B. Kraemer, U. Schnyder, et al. “Psychiatric Comorbidity in Gender Identity Disorder.” Journal of Psychosomatic Research 58.3 (2005) 259-61.
This cross-sectional analysis of 31 patients under treatment at a Zürich gender clinic showed that 38.7% had a current diagnosis of psychiatric comorbidity, and 71% had at some point in their life. There was no statistical difference in rates of comorbidity between those who had completed surgery, were on hormone treatment only, and were still undergoing psychotherapy, but not yet on hormones.
6) G. De Cuypere, E. Elaut, G. Heylens, et al. “Long term follow up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery.” Sexologies 15 (2006) 126-33.
This study questioned 62 of the 107 patients who underwent surgery from 1986-2001 at the Ghent clinic. Psychological and social outcomes were generally much better for patients after surgery than before. 29.3% had attempted suicide before surgery, only 5.1% since surgery, but the follow-up period was only 4.1 years on average for MTF transsexuals (vs. an average age at surgery of 37.7). Notably, the 5.1% overall rate of suicide attempts post-surgery was still 34 times the rate of suicide attempts in the general population (0.15%).
B. Physical Health Outcomes
7) Simonsen, R. K., Haid, G. M., Kristensen, E., & Giraldi, A. “Long-term Follow-Up of Individuals Undergoing Sex-Reassignment Surgery: Somatic Morbidity and Cause of Death.” Sexual Medicine 4.1 (2016) e60-e68.
Using the Danish sample of #2 above, this study showed 19.2% had somatic morbidity (poor physical health) pre-surgery, 23.1% post-surgery. The average age of death among the sample was 53.5 (ranging from 45 to 61).
8) N. M. Nota, C. M. Wiepjes, C. J. M. de Blok, L. J. G. Gooren, B. P. C. Kreukels, M. den Heijer, “Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy: Results from a Large Cohort Study.” Circulation 139.11 (2019) 1461-62.
A follow-up study of 3927 patients receiving transgender hormone therapy from a major Dutch clinic from 1972-2015. MTF transsexuals (median age 30) showed statistically significant higher rates of stroke and venous thromboembolism than age-equivalent men or women in the general population. Both MTF and FTM transsexuals showed significantly higher rates of heart attack than females (but not males) in the general population.
9) T. Alzahrani, T. Nguyen, A. Ryan, et al. “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population.” Circulation: Cardiovascular Quality and Outcomes 12.4 (2019).
Based on 2014-17 data from the CDC, transgender men suffer heart attacks at twice the rate of cisgender men, four times the rate of cisgender women.
10) D. Getahun, R. Nash, W. D. Flanders, et al. “Cross-Sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study.” Annals of Internal Medicine 169.4 (2018) 205-13.
A follow-up study of 2842 trans women demonstrated significantly higher rates of venous thromboembolism, stroke, and heart attack.
11) C. J. M. de Blok, C. M. Wiepjes, …, M. den Heijer. “Breast Cancer Risk in Transgender People Receiving Hormone Treatment: Nationwide Cohort Study in the Netherlands.” The BMJ l1652 (2019).
Study of 2260 adult trans women shows that they are 46.7 times as likely to develop breast cancer as cisgender men, but still lower than the rate among cisgender women.
12) R. P. Fitzgibbons. “Transsexual attractions and sexual reassignment surgery: Risks and potential risks.” Linacre Quarterly 82.4 (2015) 337-50.
A practicing psychiatrist surveys multiple studies.
VIII. Have there been similar long-term follow-up studies specifically of children using puberty blockers or adolescents starting hormones?
Not yet, as the widespread extension of these approaches to children and adolescents is still fairly new. If readers have found any such studies, please send us the reference and we will include it in this section.
IX. Can children give informed consent to such life-altering medical treatment?
California and federal law posit, rightly or wrongly, that minors below 18 cannot give informed consent to an act of sexual intimacy. Aren’t the issues surrounding sex reassignment even more life-changing and complex? We are puzzled that the same advocates who claim minors are capable of deciding to change their sex, even against parental wishes, take no position on a broader menu of youth sexual rights. Debate over children’s capacity to assert their autonomy over their own bodies, both medically and sexually, should look at these issues in a broader, intersectional context.
1) M. Priest. “Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm.” American Journal of Bioethics 19.2 (2019) 45-59.
This author argues that they can, and believes they should be given the right to self-determination even against their parents’ wishes.
2) R. M. Harris, A. C. Tishelman, G. P. Quinn, & L. Nahata. “Decision Making and the Long-Term Impact of Puberty Blockade in Transgender Children.” American Journal of Bioethics 19.2 (2019) 67-69.
This article suggests that they cannot, given the complexity of the issues and the amount of scholarly and medical disagreement over the long-term effects.
3) Letter to Archive of Disease in Childhood by C. Richards, J. Maxwell, & N. McCune (Jan. 2019), “Use of Puberty Blockers for Gender Dysphoria: A Momentous Step in the Dark.”
The letter argues that too much about the long-term effects is unknown, particularly with regard to the development of the adolescent brain, and that puberty blockers prevent the usual consolidation with natal gender identity that occurs in 73-88% of Gender Clinic patients who receive no such treatment.
4) D. Kenny, “Key Issues in Decision Making for Gender Transition Treatment: Questions and Answers” (August 9, 2019).
Q&A format posing the basic questions about drug safety, health effects, suicide, autism and other psychiatric co-morbidities in trans-identifying children, the influence of family dynamics, and the capacity of children to give informed consent when so much is uncertain.
5) E. Ikuta, “Overcoming the Parental Veto: How Transgender Adolescents Can Access Puberty-Suppressing Hormone Treatment in the Absence of Parental Consent under the Mature Minor Doctrine.” Southern California Interdisciplinary Law Journal 25 (2016) 179-228.
Argues for adolescents being able to access puberty-blocking treatments even against parental wishes by going to court under the “Mature minor” doctrine, which is sometimes applied in abortion cases. The article shows little familiarity with the complex medical controversies over the safety of these drugs.
X. What causes transgender identification?
It is not as simple as “being born in the wrong body.” Science has long suspected hormonal factors in the mother’s womb to be a contributing factor, but the latest work suggests a very complex interplay between prenatal hormone exposure and factors in the child’s postnatal environment, suggesting that parental socialization and attitudes still constitute a major influence. While prenatal hormones have been shown to play a role in early childhood cross-gendered behavior and toy choice, they do not correlate with gender identity, cognition, or peer choice. Hence, it is difficult to see them as predictive of later transgender identification. Some behavioral scientists point toward the influence of psychological and sociological factors in adolescence and adulthood. The exact mix of causations varies greatly from individual to individual, and is not well understood on a global scale.
A. Prenatal Hormone Exposure
1) S. A. Berenbaum, “Beyond Pink and Blue: The Complexity of Early Androgen Effects on Gender Development.” Child Development Perspectives 12.1 (2018) 58-64.
Prenatal androgens apparently have large effects on interests and engagement in gendered activities; moderate effects on spatial abilities; and relatively small or no effects on gender identity, gender cognitions, and gendered peer involvement. These differential effects provide an opportunity to move beyond identifying sources of variation in behavior to understanding developmental processes. These processes include links among gendered characteristics, psychological and neural mechanisms underlying development, and the joint effects of biological predispositions and social experiences.
2) S. A. Berenbaum & A. M. Beltz, “How Early Hormones Shape Gender Development.” Current Opinions in Behavioral Science 7 (2016) 53-60.
Increasing evidence confirms that prenatal androgens have facilitative effects on male-typed activity interests and engagement (including child toy preferences and adult careers), and spatial abilities, but relatively minimal effects on gender identity. Ongoing and planned work is focused on understanding the ways in which hormones act jointly with the social environment across time to produce varying trajectories of gender development, and clarifying mechanisms by which androgens affect behaviors. Such work will be facilitated by applying lessons from other species, and by expanding methodology. Understanding hormonal influences on gender development enhances knowledge of psychological development generally, and has important implications for basic and applied questions, including sex differences in psychopathology, women’s underrepresentation in science and math, and clinical care of individuals with variations in gender expression.
3) M. Hines, V. Pasterski, D. Spencer, S. Neufeld, P. Patalay, P. C. Hindmarsh, I. A. Hughes, C. L. Acerini, “Prenatal Androgen Exposure Alters Girls’ Responses to Information Regarding Gender-Appropriate Behaviour.” Philosophical Transactions of the Royal Society B: Biological Sciences 371 (Feb. 19, 2016).
Abstract: Individual variability in human gender-related behaviour is influenced by many factors, including androgen exposure prenatally, as well as self-socialization and socialization by others postnatally. Many studies have looked at these types of influences in isolation, but little is known about how they work together. Here, we report that girls exposed to high concentrations of androgens prenatally, because they have the genetic condition congenital adrenal hyperplasia, show changes in processes related to self-socialization of gender-related behaviour. Specifically, they are less responsive than other girls to information that particular objects are for girls and they show reduced imitation of female models choosing particular objects. These findings suggest that prenatal androgen exposure may influence subsequent gender-related behaviours, including object (toy) choices, in part by changing processes involved in the self-socialization of gendered behaviour, rather than only by inducing permanent changes in the brain during early development. In addition, the findings suggest that some of the behavioural effects of prenatal androgen exposure might be subject to alteration by postnatal socialization processes. The findings also suggest a previously unknown influence of early androgen exposure on later processes involved in self-socialization of gender-related behaviour, and thus expand understanding of the developmental systems regulating human gender development.
B. Family-Related Factors
4) A. Dawson, A. Pike, & L. Bird. “Associations Between Parental Gendered Attitudes and Behaviours and Children’s Gender Development Across Middle Childhood.” European Journal of Developmental Psychology, 13 (2016) 452–471.
The complexities of gender socialization in the family have not been fully explored, thereby underestimating the family’s role in gender development. Children are reliant on parents to provide opportunities for activities, and therefore, parents may shape children’s gendered preferences for activities. This study of 106 families, although not relating directly to families with transgender children, does suggest the strong influence of parental gender role attitudes on children’s perceptions of what is gender appropriate.
5) J. Rust, S. Golombok, M. Hines, K. Johnston, J. Golding. “The Role of Brothers and Sisters in the Gender Development of Preschool Children.” Journal of Experimental Child Psychology 77.4 (2000) 292-303.
The study examined whether the sex of older siblings influences the gender role development of younger brothers and sisters of age 3 years. Data on the Pre-School Activities Inventory, a measure of gender role behavior that discriminates within as well as between the sexes, were obtained in a general population study for 527 girls and 582 boys with an older sister, 500 girls and 561 boys with an older brother, and 1665 singleton girls and 1707 singleton boys. It was found that boys with older brothers and girls with older sisters were more sex-typed than same-sex singletons who, in turn, were more sex-typed than children with other-sex siblings. Having an older brother was associated with more masculine and less feminine behavior in both boys and girls, whereas boys with older sisters were more feminine but not less masculine and girls with older sisters were less masculine but not more feminine.
C. Other Causations
6) A. A. Lawrence, MD, Ph.D. “Autogynephilia and the Typology of Male-to-Female Transsexualism: Concepts and Controversies.” European Psychologist 22 (2017) 39-54.
A transsexual researcher’s examination of the controversy over autogynephilia, i.e. whether non-gay MTF transsexuals are motivated by a narcissistic attraction to themselves as women.
7) J. Serano, “Making Sense of Autogynephilia Debates.” Medium (Oct. 15, 2019).
A skeptical critique of autogynephilia as an overly rigid theory that does not explain most non-gay female embodiment fantasies, reviewing the author’s many previous publications in peer-reviewed outlets.
8) Interview with Prof. J. Michael Bailey (Psychology, Northwestern University) on Rapid Onset Gender Dysphoria, autogynephilia, and other forms of transgenderism:
9) On the influence of social contagion on youth, see the items in Section I, #6 and #10, and in Section II, #5.
XI. Does transgender promotion encourage old-fashioned essentialist notions of masculinity and femininity that have mostly been rejected by progressive gender theory?
1) H. Lawford-Smith (Philosophy, Univ. of Melbourne), “How the Trans Rights Movement in Turning Academic Philosophers into Sloganeering Activists.” Quillette (Sept. 20, 2019).
On the refusal of trans-activist philosophers to debate or even appear on the same platform as lesbian gender-critical feminist philosophers who argue for a conceptual separation of sex and gender and believe that biologically-sexed women deserve private spaces.
2) Andrew Sullivan, “When the Ideologues Come for the Kids.” New York Magazine (Sept. 20, 2019).
Criticizes the silence of gay activists in response to the gender-norming practiced by trans ideology, whereby sensitive boys who would otherwise become gay are encouraged to become girls instead and competitive girls who would otherwise become lesbian are taught that women are universally oppressed and that they should instead become men.
Andrew Sullivan, “Hard Questions About Young People and Gender
Transitions.” New York Magazine (November 1, 2019).
3) H. Joyce, “Understanding the Propaganda Campaign Against So-called ‘TERFs.’” Quillette (Oct. 2, 2019).
4) L. L. Baker, “True Autonomy/False Dichotomies? Genderqueer Kids and the Myth of the Quick Fix.” American Journal of Bioethics 19.2 (2019) 63-67.
5) S. Lewis, “How British Feminism Became Anti-Trans.” New York Times (Feb. 7, 2019):
6) Thomas Olver. “Disaffirming Gender: Somatic Incongruence as a Co-function of Ideological Congruity.” The Psychoanalytic Review 106.1 (2019) 1-28.
XII. Are there compassionate and supportive alternatives to immediate affirmation of a child’s wish to identify with the other gender?
1) K. J. Zucker, H. Wood, D. Singh, & S. J. Bradley. “Developmental, Biopsychosocial Model for treatment of children with gender identity disorder.” Journal of Homosexuality 59.3 (2012) 369-97.
The Toronto clinic recommended a cautious approach grounded in the recognition that most children exhibiting cross-gender behavior do not persist into adolescence. Their practice emphasized parental education and addressing the often serious pathologies of the child’s home environment which may contribute to cross-gender behavior. Social transition was not recommended, but allowing children to experiment with the clothing or toys of the other sex was allowed if confined to the home environment. Zucker, who is also Professor of Psychiatry at the University of Toronto and long-time editor of the Archives of Sexual Behavior, drew the ire of transsexual activists for this conservative approach, and his clinic was forced to shut down, but he won a lawsuit for wrongful termination.
2) W. I. Wong, A. I. R. van der Miesen, T. G. F. Li, L. N. Macmullin, D. P. VanderLaan, “Childhood Social Gender Transition and Psychosocial Well-Being: A Comparison to Cisgender Gender-Variant Children.” Clinical Practice in Pediatric Psychology 7.3 (2019) 241-53.
This study meta-analyzes childhood behavior criteria for 266 gender-variant children, some of whom were socially transitioned and some of whom were not. There was little evidence that psychosocial well-being varied in relation to gender transition status. Parents of the non-transitioned children were generally accepting of childhood gender variance, but only poor peer relations predicted lower psychological well-being among these children. Socially transitioned children appear to experience similar levels of psychosocial challenges as gender-variant children who were not socially transitioned. While further research is needed to evaluate possible effects of childhood social gender transition on well-being, this study suggests experiences of psychosocial challenges among gender-variant children require monitoring irrespective of transition status, and relationships with peers may be especially important to consider.
We also recommend the recent publication:
M. Moore & H. Brunskill-Evans (eds.), Inventing Transgender Children and Young People (Cambridge Scholars Press, 2019).
This is a vital contribution to one of the most contested areas in contemporary society; one where proper scholarship and informed data has been lacking.
The essays in this volume are written by clinicians, psychologists, sociologists, educators, and parents. Contributors demonstrate how transgender children and young people are ‘invented’ in different medical, social and political contexts: from specialist gender identity development services to lobby groups and their school resources, gender guides and workbooks; from the world of the YouTube vlogger to the consulting rooms of psychiatrists; from the pharmaceutical industry to television documentaries; and from the developmental models of psychologists to the complexities of intersex medicine.
Essential reading for teaching and research in fields including gender studies, medical ethics, sociology, psychology, public policy, LGBTQ studies, and feminist studies.
Michele Moore is professor in the School of Health and Social Care at the University of Essex, UK, and editor of the journal Disability and Society. She has worked internationally for more than 30 years, building research-led expertise to support inclusive education and communities. Her widely published work is focused on consultative participatory and human rights projects across the world to support children and families. She is currently leading UN projects to advance the global agenda for inclusion.
Dr Heather Brunskell-Evans is a philosopher and social theorist, with particular expertise in the politics of medicine, the sexed body, and gender. Her current research analyses the relationship between surrogacy, pornography, prostitution and transgenderism. She is co-founder of the Women’s Human Rights Campaign (www.womensdeclaration.com). Her most recent publication is “The Medico-Legal ‘Making’ of ‘The Transgender Child’” in the Medical Law Review.
Part One: Clinical Perspectives
The Tavistock: Inventing ‘The Transgender Child’ Heather Brunskell-Evans
Britain’s Experiment with Puberty Blockers Michael Biggs
Transgender Children: The Making of a Modern Hysteria Lisa Marchiano
Psychiatry and the Ethical Limits of Gender-Affirming Care Roberto D’Angelo
Gender Development and the Transgendering of Children Dianna T Kenny
Intersex: Beyond Binaries, Beyond Spectrums Nathan Hodson
Be Careful What You Wish For: Trans-identification and the Evasion of Psychological Distress Robert Withers
Part Two: Cultural Perspectives
- ‘Gender Identity’: The Rise of Ideology in the Treatment and Education of Children and Young People Stephanie Davies-Arai
- Trans Kids: It’s Time to Talk Stella O’Malley
- Our Voices Our Selves: Amplifying the Voices of Detransitioned Women Twitter.com/ftmdetransed and twitter.com/radfemjourney
- Detransition was a Beautiful Process Patrick
- Transmission of Transition via Youtube Elin Lewis
- Queering the Curriculum: Creating Gendered Subjectivity in Resources for Schools Stephanie Davies-Arai and Susan Matthews
- Gender Guides and Workbooks: Understanding the Work of a New Disciplinary Genre Susan Matthews
- Truths, Narratives and Harms of Rapid Onset Gender Dysphoria Michele Moore
Marcus Evans, Psychoanalyst, and former Consultant Adult Psychotherapist in the Tavistock and Portman NHS Foundation Trust, UK reviews the book as follows:
“This book is a thoughtful, measured and much-needed contribution to the debate about transgendering children. Many parents and clinicians are gravely concerned that too often children and young people are affirmed in their gender self-identification without rigorous, extended psycho-social examinations. In the present cultural climate, it is difficult to examine the complex issue of children’s gender self-identification from different points of view since debate is continually shut down, characterized as ‘transphobic’ or ‘conversion therapy’. This book refuses to be brow-beaten and fearlessly examines the topic from many different angles, including the issue of hormone therapy and the quality of research evidence, and it does so with an absolute commitment to child welfare and safeguarding.”
For further information and to purchase this book, go to https://www.cambridgescholars.com/inventing-transgender-children-and-young-people. A 20% discount is available if you pre-order with the code Transgender20.