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Transgender Kids: why doctors are right to be cautious about childhood transition

Just as it's cruel to deny treatment to trans people who need it, so it's unethical to railroad youngsters into decisions they later regret.

 

The BBC Two documentary Transgender Kids: Who Knows Best? won’t be broadcast until 9pm this evening, but that hasn’t stopped a lot of people from forming very firm opinions about it. There has been the inevitable petition, and yesterday, the Guardian published a critical article stating that “the transgender community is ‘very scared and very worried’” by a programme that no one interviewed had, as yet, seen. The focus of that concern is a Canadian doctor called Ken Zucker, who, according to his critics, is a discredited proponent of “conversion therapy” who has prevented trans children from obtaining appropriate treatment and was fired for gross misconduct.

But in his decades-long career, Zucker supported hundred of children and adolescents with gender identity disorder (GID), some of whom went on to live happily in their birth sex and some of whom eventually had sex reassignment surgery (SRS). The allegations against him stem from an external review commissioned by his employer, the Centre for Addiction and Mental Health in Toronto (CAMH) – a review which was withdrawn from CAMH’s website after investigations showed that many claims were unsubstantiated and one key charge was demonstrably false. As the journalist Jesse Singal wrote: “it’s hard not to come to an uncomfortable, politically incorrect conclusion: Zucker’s defenders are right. This was a show trial.”

Even so, these claims continue to recycled by those who endorse a “gender affirmative” approach to trans children - where the child's assertion of their identity is accepted immediately and uncritically - and reject Zucker’s more critical practice. Such claims are very hard to reconcile with the thoughtful Zucker who appears in the BBC documentary, who exudes neither the sinister bigotry his detractors credit him with nor the bitterness that might seem reasonable in the victim of an intellectual witch hunt. However, this much is clear: he’s adamant that reflexively deferring to children who say their physical sex is wrong risks not only putting children on an inappropriate pathway to surgery, but also missing the varied issues and strains that might be behind such feelings.

In other words, children who present as trans might not simply be “girls born in boys’ bodies” and “boys born in girls’ bodies”, and appropriate treatment might involve far more subtle approaches than altering a child’s body to match their “true” gender. Highlighting this view makes Transgender Kids: Who Knows Best? an oddity in coverage of trans issues, and a valuable one. Trans people are more prominent than ever before in news, factual programming and drama; but presentation of the underlying causes is, almost without exception, extremely basic. For example, a 2015 item on trans children for the BBC’s Victoria Derbyshire show begins with images of fashion dolls overlaid with a child’s voice saying: “I didn’t want to be a boy. I feel like I’m in the wrong body.” (The charity Mermaids, which offers support for families with trans children and has criticised tonight’s documentary, recommends this video on its “resources for parents” page.)

Trans campaigners are often at pains to distinguish gender stereotypes from gender identity, and yet parents of trans children consistently refer to their child’s behaviour and tastes when they’re supplying backstories. The segue in sexism here is obvious. At one point in Transgender Children: Who Knows Best?, the father of a socially and surgically transitioned teenage transgender girl tells the documentary that he knew his family had made the right decision when he saw his child running, and thought “that’s just like a girl running” rather than “look at my son, he runs like a girl”.

Stories from the other side, though, can be similarly as disquieting: the father of a teenage girl who vehemently identified as a boy but ultimately desisted (as approximately 80% of children with GID eventually do) sounds ragged with anger as he talks about battling the girl’s wish to have short hair and dress in boyish clothes. Watching the programme, one wonders whether the care the girl received at CAMH wasn’t as much about adjusting her family’s ideas about how to be female as it was about treating her dysphoria. Context, after all, is everything. As the neuroscientist Gina Rippon puts it in the documentary, briskly dismissing beliefs in inherently sexed brains: “We live in a gendered world […] A gendered world produced a gendered brain.”

The costs of putting a child on the wrong path can be huge. We hear a lot about the dangers of suicide for trans children who don’t receive affirming treatment (although Zucker points out that his research has found suicidality among trans children is no higher than among children with depression, anxiety or ADHD), but inappropriate affirmation is no less damaging. A young woman called Lou, who started hormone treatment and had a double mastectomy before realising she didn’t want to be a man, tells the documentary that she now feels “grotesque”. The female body that had horrified her so much during puberty now seems normal to her. The flat-chested, bearded self she has now appears to her as grotesque.

It’s a deeply upsetting sequence, but an important one because it’s a reminder that there is no one simple answer here. Having to live in a body that you know is not right is surely a profound and terrible anguish: that’s true whether you think you’ve been denied vital gender-affirming treatments, or if your body has been irreversibly altered by operations you now regret. The challenge for doctors is to recognise which is which, and give children the right support. The attacks on Zucker have been effective. Around the world, clinicians now keep their concerns about gender affirmation to themselves: they know what the price of speaking out might be. But, as this documentary shows, the price of stifling that discussion can be almost unimaginable harm.

Sarah Ditum is a journalist who writes regularly for the Guardian, New Statesman and others. Her website is here.

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Lord Empey: Northern Ireland likely to be without government for a year

The former UUP leader says Gerry Adams is now in "complete control" of Sinn Fein and no longer wants to be "trapped" by the Good Friday Agreement

The death of Martin McGuinness has made a devolution settlement in Northern Ireland even more unlikely and has left Gerry Adams in "complete control" of Sinn Fein, the former Ulster Unionist leader Reg Empey has said.

In a wide-ranging interview with the New Statesman on the day of McGuinness’ death, the UUP peer claimed his absence would leave a vacuum that would allow Adams, the Sinn Fein president, to consolidate his hold over the party and dictate the trajectory of the crucial negotiations to come. Sinn Fein have since pulled out of power-sharing talks, leaving Northern Ireland facing the prospect of direct rule from Westminster or a third election in the space of a year. 

Empey, who led the UUP between and 2005 and 2010 and was briefly acting first minister in 2001, went on to suggest that, “as things stand”, Northern Ireland is unlikely to see a return to fully devolved government before the inquiry into the Renewable Heat Incentive scheme is complete -  a process which could take up to a year to complete.

“Adams is now in complete control of Sinn Fein,” he said, adding that it remained unclear whether McGuinness’ successor Michelle O’Neill would be “allowed to plough an independent furrow”. “He has no equal within the organisation. He is in total command of Sinn Fein, and that is the way it is. I think he’s even more powerful today than he was before Martin died – by virtue of there just being nobody there.”

Asked what impact the passing of McGuinness, the former deputy first minister and leader of Sinn Fein in the north, would have on the chances of a devolution settlement, Empey, a member of the UUP’s Good Friday Agreement negotiating delegation, said: “I don’t think it’ll be positive – because, for all his faults, Martin was committed to making the institutions work. I don’t think Gerry Adams is as committed.

Empey added that he believed Adams did not want to work within the constitutional framework of the Good Friday Agreement. In a rebuke to nationalist claims that neither Northern Ireland secretary James Brokenshire nor Theresa May can act as honest or neutral brokers in power-sharing negotiations given their reliance on the DUP’s eight MPs, he said: “They’re not neutral. And they’re not supposed to be neutral.

“I don’t expect a prime minister or a secretary of state to be neutral. Brokenshire isn’t sitting wearing a hat with ostrich feathers – he’s not a governor, he’s a party politician who believes in the union. The language Sinn Fein uses makes it sound like they’re running a UN mandate... Gerry can go and shout at the British government all he likes. He doesn’t want to be trapped in the constitutional framework of the Belfast Agreement. He wants to move the debate outside those parameters, and he sees Brexit as a chance to mobilise opinion in the republic, and to be seen standing up for Irish interests.”

Empey went on to suggest that Adams, who he suggested exerted a “disruptive” influence on power-sharing talks, “might very well say” Sinn Fein were “’[taking a hard line] for Martin’s memory’” and added that he had been “hypocritical” in his approach.

“He’ll use all of that,” he said. “Republicans have always used people’s deaths to move the cause forward. The hunger strikers are the obvious example. They were effectively sacrificed to build up the base and energise people. But he still has to come to terms with the rest of us.”

Empey’s frank assessment of Sinn Fein’s likely approach to negotiations will cast yet more doubt on the prospect that devolved government might be salvaged before Monday’s deadline. Though he admitted Adams had demanded nothing unionists “should die in a ditch for”, he suggested neither party was likely to cede ground. “If Sinn Fein were to back down they would get hammered,” he said. “If Foster backs down the DUP would get hammered. So I think we’ve got ourselves a catch 22: they’ve both painted themselves into their respective corners.”

In addition, Empey accused DUP leader Arlene Foster of squandering the “dream scenario” unionist parties won at last year’s assembly election with a “disastrous” campaign, but added he did not believe she would resign despite repeated Sinn Fein demands for her to do so.

 “It’s very difficult to see how she’s turned that from being at the top of Mount Everest to being under five miles of water – because that’s where she is,” he said. “She no longer controls the institutions. Martin McGuinness effectively wrote her resignation letter for her. And it’s very difficult to see a way forward. The idea that she could stand down as first minister candidate and stay on as party leader is one option. But she could’ve done that for a few weeks before Christmas and we wouldn’t be here! She’s basically taken unionism from the top to the bottom – in less than a year”.

Though Foster has expressed regret over the tone of the DUP’s much-criticised election campaign and has been widely praised for her decision to attend Martin McGuinness’ funeral yesterday, she remains unlikely to step down, despite coded invitations for her to do so from several members of her own party.

The historically poor result for unionism she oversaw has led to calls from leading loyalists for the DUP and UUP – who lost 10 and eight seats respectively – to pursue a merger or electoral alliance, which Empey dismissed outright.

“The idea that you can weld all unionists together into a solid mass under a single leadership – I would struggle to see how that would actually work in practice. Can you cooperate at a certain level? I don’t doubt that that’s possible, especially with seats here. Trying to amalgamate everybody? I remain to be convinced that that should be the case.”

Accusing the DUP of having “led unionism into a valley”, and of “lashing out”, he added: “They’ll never absorb all of our votes. They can try as hard as they like, but they’d end up with fewer than they have now.”

Patrick Maguire writes about politics and is the 2016 winner of the Anthony Howard Award.