This article is a reworking and updating of some material taken from an essay on ‘affirmation,’ now commonly referred to as the ‘gender affirmative model,’ written by Stephanie Davies-Arai and first published by Civitas in 2019. A free download of the original article is available here and you can buy the book here.
The ‘gender affirmative model’ or ‘affirmation’ approach
The ‘gender affirmative model,’ or ‘affirmation,’ is an experimental approach towards children and young people with gender dysphoria. It is not a model which has been informed and developed through clinical research and evidence but one which has been promoted by transgender lobby groups and activists. The established global model of care for children with gender dysphoria is a ‘watch and wait’ approach which may include two other models which are sometimes distinguished separately: ‘developmental’ and ‘exploratary’. None of these models steers a child towards any pre-determined outcome, but all recognise developmental change as an intrinsic part of childhood and adolescence.
The current evidence base shows that around 80% of pre-pubertal children will outgrow their gender dysphoria during adolescence and that the most likely outcome in adulthood is gay or lesbian sexual orientation. The established treatment models recognise the variables in the incidence of cross-sex identification in childhood, which could be anything from a common developmental variant to, at the other extreme, a response to past sexual abuse or trauma. Every child’s circumstances are different and the established approaches reflect this.
Nevertheless, charities such as Gendered Intelligence and Mermaids would like to import the gender affirmative approach from the US as the only legitimate approach to every child who believes themselves to be the opposite sex. Probably the most influential proponent of the gender affirmative model in the US is Dr Johanna Olson-Kennedy of the Centre for Transgender Health in Los Angeles. In 2019 she was invited to the UK by Bristol Law School as a Benjamin Meaker visiting professor and she was a keynote speaker at the Re-Thinking Trans Healthcare conference, organised by Peter Dunne and Mermaids.
You can read about the US gender affirmative model in our review of that conference. The important thing to note is that it is extreme and it is the model that Mermaids and Gendered Intelligence would like to see in the UK. Johanna Olson-Kennedy is most notorious for saying that if a 13 year-old girl has her breasts removed and later decides she would like breasts “she can go get some.”
Olson-Kennedy gives testosterone to 13 and 14 year-old girls ‘frequently’ and to 12 year-olds ‘sometimes,’ with no concern if a girl later regrets the permanent change of voice and male-pattern body and facial hair, along with potentially compromised fertility and sexual function. The gender affirmative model is promoted as ‘acceptance of who a child really is.’ As the child knows best who they are, to refuse to accept them surely would be cruel?
The reality is not so simple: it is not a child’s ‘identity’ we affirm when we agree with a young boy that he is really a girl, but his (mis)perception of his sex. Proponents of the gender affirmative model are not being intentionally dishonest to the child, but true to their belief that a ‘girl’ is not a young human female but a personality type, a person of either sex who ‘identifies’ as female.
A child cannot distinguish between personally-held beliefs and facts, nor does the child know that this is a minority belief which involves the denial of biological reality. To the child, the adult knows best; the child’s developing understanding of reality and interpretation of the world depends on the information imparted to them by adults.
A child under the age of about seven will believe that putting a dress on a boy doll changes the doll into a girl. In early childhood, before the understanding of biological sex has developed, children are informed by gender stereotypes – girls love pink and ballet, boys love football and fighting – and these stereotypes are fed to children in direct and indirect ways from the moment they are born. To the boy who loves wearing princess costumes ‘I am a girl’ is the explanation which makes the most sense at this developmental stage of childhood. The gender affirmative model reinforces these stereotypes as true.
It is beyond children’s cognitive abilities to understand the biological impossibility of a male child growing up to become an adult woman or a female child growing up to become an adult man, that a ‘girl’ is not who you are, but what you are and that no amount of medical innovation can change the biological reality.
As the child does not yet understand that ‘boy’ and ‘girl’ are stable categories which do not change depending on clothes and hairstyles, a child is vulnerable to misinformation. When children are very young, before puberty, they are still on a developmental pathway of learning to distinguish between fact and fantasy. The Tavistock Gender Identity Development Service (GIDS) states this on their website:
“Children go through various stages of ‘magical thinking,’ during which they can get confused between reality versus fantasy, until at least middle childhood, and sometimes this makes it hard to know how much a younger child fully grasps about what they are saying or understands about their own gender.“
A paper by De Vries (2012) warns of the danger that a young child who is unduly affirmed does not yet fully understand the concept of natal sex:
“Another reason we recommend against early transitions is that some children who have done so (sometimes as pre-schoolers) barely realize that they are of the other natal sex. They develop a sense of reality so different from their physical reality that acceptance of the multiple and protracted treatments they will later need is made unnecessarily difficult. Parents, too, who go along with this, often do not realize that they contribute to their child’s lack of awareness of these consequences.”
Tavistock GIDS consultant clinical psychologist Bernadette Wren echoes this concern in a paper for the Journal of Clinical Child Psychology and Psychiatry, stating that “The younger the child, the more likely they are to hold inflexible and innate conceptualisations of gender” and “Before the age of around 10 years, they predictably hold to rigid gender stereotypes and are less aware of the possibility for further change in gender-related behaviour.”
“This is why at GIDS, we would prefer that young children (below 10 years of age, say), while receiving plenty of genuine support and affirmation for their gender preferences (in play, clothing, etc.), not make a full, legally confirmed social transition to the ‘other’ sex at a young age, since this runs the risk of making entry into their biologically-programmed puberty even more unexpected and agonising and reducing their scope for a greater range of identificatory options later.“
This raises questions about what we are setting children up for when we affirm their gender identity in early childhood. As the affirmation of a child’s gender identity necessitates denial of their biological sex, the child is unprepared for the significance of the changes of puberty, the point at which reality hits. We cannot know the extent to which ‘affirmation’ may be a contributing factor to the suicidal feelings experienced by some children as they are brought face to face with the biological reality they had been led to believe was immaterial.
De Vries explicitly warns of the difficulty a child would face in changing their mind after social transition:
“…we recommend that young children not yet make a complete social transition (different clothing, a different given name, referring to a boy as “her” instead of “him”) before the very early stages of puberty. In making this recommendation, we aim to prevent youths with non-persisting gender dysphoria from having to make a complex change back to the role of their natal gender.”
Dr Thomas Steensma from the Netherlands is another expert who, at the Hot Topics in Child Health conference in London in 2017, warned of this difficulty, citing the case of a girl who waited two years to move to a new school before she felt able to ‘transition back’.
If social transition is difficult to come back from, there must be a question about how possible it is, realistically, for some children to change their minds at all, when their mind has been influenced, through affirmation, by parents, teachers, other trusted adults and their peer group, during critical developmental years.
Unquestioning affirmation of a child’s belief is not a neutral act of kindness, but an active intervention that shapes and changes a child’s understanding and development. Affirmation by trusted adults forms or reinforces a child’s perception of reality. Living, and being affirmed daily, as the opposite sex will affect and change the child’s developing sense of self, which risks creating a self-fulfilling prophesy of outcome.
The claim by activists that as ‘affirmation’ is not a medical treatment it is benign, shows a lack of understanding of the power of psychological intervention, especially in a very young child. The finding of a 2013 research study by Dr Steensma that social transition is the most powerful predictor of persistence of childhood gender dysphoria should come as no surprise to anyone with a knowledge of child development.
It is also a disingenuous claim. ‘Affirmation’ is only the first step on the path to full social transition followed by puberty blockers and cross-sex hormones, and the lobby groups such as Mermaids and the Gender Identity Research and Education Society (GIRES) who promote the gender affirmative model are the same organisations who campaign for earlier and earlier medical intervention for children. The ‘solution’ to the created crisis at puberty for children who have been affirmed as the opposite sex is medical intervention to block their puberty and stop those changes from happening.
If very young children are not developmentally equipped to understand the reality of the transition pathway, what of adolescents? Respect for autonomy and agency are key principles as children grow up but just as young children form their understanding of the world through their primary care-givers, teenagers look outwards to the peer group and society. This is a critical stage of development as young people make the transition from childhood to adulthood and the key task is the search for a sense of self and personal identity, through an intense exploration of personal values, beliefs, and goals.
Teenagers are sensitised to their social world which becomes their overriding focus of attention and motivation. The fundamental task of adolescence—to achieve adult levels of social competence—necessitates a great deal of learning about the complexities of human social interactions. Teenagers’ intense emotions are due to the surge of hormones coupled with a loosely connected frontal lobe: feelings are experienced more intensely but ‘executive control’ over those feelings is less accessible to a teenager than to an adult.
Teenagers’ poor decisions are not a matter of poor reasoning abilities, but because neural reward systems are more intensely activated – teenagers get more of a thrill out of rewarding stimuli than adults do – and because a teenager’s frontal lobes are still only loosely connected to other parts of the brain, so there is less ‘connectivity’ to assess risks, rewards and consequences.
Teenagers are uniquely vulnerable to indoctrination, social contagion and peer pressure. This is also the age when mental health issues may emerge. The recent exponential rise in the number of adolescents and young people, predominantly girls, who ‘come out’ as transgender with no previous indication of dysphoria in childhood is unexplained and not yet understood. There is a high correlation with pre-existing mental health problems, neurobiological disorders such as autism, previous trauma and sexual abuse and troubled and chaotic family backgrounds.
However, teenagers who suddenly self-diagnose as transgender have been offered undifferentiated diagnosis and treatment which was originally intended to be available only for a small minority of adolescents with profound and persisting gender dysphoria since early childhood: the ‘persisters.’
This new cohort of adolescents are not ‘persisters.’ They are part of a generation bombarded with online social media messages that if they feel uncomfortable with the sex stereotypes they are supposed to live up to they are probably trans; if they feel different or don’t fit in, they are probably trans. For teenagers looking online, the message that their ‘gender identity’ is real and their biological sex immaterial is now reinforced in schools. A sudden onset of gender dysphoria in the teenage years – ‘rapid onset gender dysphoria’ as it has been termed, or ROGD – has arisen out of a cultural background which is in itself a historically unique phenomenon.
Despite the fact that this is a completely new presentation which is not yet understood, the watchful waiting, developmental or exploratory approaches have not been considered as safer options for this cohort of adolescents until more research has been done and we have more evidence. This is despite the fact that available evidence indicates that persistence of gender dysphoria is rare under ‘watchful waiting’ models but is increased through social transition. Yet the parents of this group have been denied any choice of approach in the treatment of their child.
The Position Statement from the Royal College of General Practitioners (June 2019) acknowledges the lack of research into different approaches in the clinical management of gender dysphoria in youth:
“The promotion and funding of independent research into the effects of various forms of interventions (including ‘wait and see’ policies) for gender dysphoria is urgently needed, to ensure there is a robust evidence base which GPs and other healthcare professionals can rely upon when advising patients and their families. There are currently significant gaps in evidence for nearly all aspects of clinical management of gender dysphoria in youth. Urgent investment in research on the impacts of treatments for children and young people is needed.”
Without any professional clinical assessment or debate, the approach towards this new group of adolescents has automatically and unquestioningly been the activist model: the gender affirmative approach, including full social transition. Parents have discovered that in school their adolescent daughter has been affirmed as a boy, or son affirmed as a girl, without their knowledge or consent. There is no evidence to support the gender affirmative approach, or research to show that it is a safe and effective model. The increasing number of detransitioners such as Keira Bell, suggests that it is not; it is a model of care that carries serious lifetime effects and known and unknown long-term risks to health.
In schools and youth organisations, transgender guidance mandates the affirmation of young people who self-identify as transgender and the NHS joins in with validation of everything an adolescent has learned on Tumblr, YouTube and Reddit. A clinician who worked at the Tavistock satellite clinic in Leeds described the treatment pathway for adolescents aged 16 and over like this:
“It isn’t a psychosocial assessment, it is a tick-box exercise to ensure that the young person has correctly learnt from the Internet about how to self-diagnose as meeting the criteria for gender dysphoria.’”
We recognise the social contagion factor with other teenage problems such as anorexia, bulimia and self-harm but adolescents today are growing up with technology which can spread contagion much faster and more widely than anything we have known before. The online promotion and glamorisation of a transgender identity teaches teenagers a very modern way to conceptualise their body-hatred, alienation and non-conformity to the extremes of femininity and masculinity they are exposed to as ‘normal’ today. Psychiatrist Stephen B. Levine writes:
“It is exceedingly rare to encounter a trans teenager who has not developed “friends” through the Internet, where they are often counselled that they are trans and directed to numerous websites that help them to stabilize their identities.”
In a first exploratory study of parental reports by Dr Lisa Littman of Brown University, 86.7% of the parents reported that, along with the sudden onset of gender dysphoria, ‘their child either had an increase in their social media/internet use, belonged to a friend group in which one or multiple friends became transgender-identified during a similar timeframe, or both.’
The results of a detransition survey of 203 females (2016) indicate that transition is not a cure for underlying trauma or mental health issues. 65% of respondents received no counselling at all before transitioning and only 6% felt they had received adequate counselling.
The exponential rise in the number of referrals of children and young people to the Tavistock has coincided with the rise of transgender rights activism and the regulatory capture of government, schools, youth organisations and the NHS. For the ‘gender dysphoric child’ a psychotherapeutic support pathway may be developed with the aim of alleviating the dysphoria. However, for the ‘transgender child’, as the emblem of a social justice movement, the only acceptable treatment is the gender affirmative model: validation, reinforcement and consolidation of a transgender identity.
After the Keira Bell High Court judgment, children and young people now have more protection from medical intervention while they are still immature, at least through the NHS whose response to the judgment was to suspend the use of puberty blockers. But there are loopholes. Unscrupulous private clinics and online providers are willing to sell blockers, hormones and double mastectomies to children and young people. There are parents who are willing to pay and crowdfunding options for young people who go it alone.
The current demands on government to ban conversion therapy includes ‘gender identity conversion therapy’. Activist campaigning is a thinly-disguised attempt to establish the gender affirmative model as the only legitimate approach towards children and young people with gender dysphoria, framing any other approach such as watchful waiting, developmental or exploratory, as ‘conversion therapy.’
The gender affirmative model is not neutral. It steers a child towards one outcome only: a persistent transgender identity, with no other options considered. Stonewall frames non-acceptance of a person’s gender identity as ‘transphobic’. This is the political treatment of a clinical condition, its very aim is to facilitate persistence of a transgender identity. Until we are honest about that, the most vulnerable children and young people will continue to be at risk. The 17 – 25 year-old age group who progress directly to adult services are particularly vulnerable. In adult services, unquestioning ‘affirmation and informed consent’ is the established model of care, with no exploratory therapeutic support offered.
The Keira Bell case asked whether children under the age of eighteen have the capacity to give fully-informed consent to medical intervention that will physically shape their bodies to ‘match’ their inner feelings. The High Court judged no.
Perhaps we now need to ask the question: do children and young people have the capacity to give fully-informed consent to an extreme psychological intervention that profoundly influences and shapes their minds?