Has the UK become a police state? (And has Twitter become its informant?)

Inga Berenson is the mom of a teen girl who previously identified as transgender but has now desisted. She lives with her family in the United States.


By Inga Berenson

Freedom of speech took another big hit in the United Kingdom last month. In response to a complaint filed by Susie Green, CEO of Mermaids, the Yorkshire police interrogated Kellie-Jay Keen-Minshull because of some tweets she posted in 2016 and 2017. Known on Twitter as ThePosieParker, Ms. Keen-Minshull is a stay-at-home wife and mother of four.

Mermaids is a nonprofit organization based in the UK. According to its website, Mermaids “supports children and young people up to 20 years old who are gender diverse, and their families, and professionals involved in their care.”

The offending words

According to Ms. Keen-Minshull’s account, Ms. Green objected to a tweet stating that “the CEO of Mermaids took her 16-year-old to Thailand and got him castrated.”

For this tweet and others criticizing Mermaids for promoting pediatric transition, Ms. Keen-Minshull was “interviewed under caution” for 40 minutes on February 23, 2018. She now awaits the Crown Prosecution Service’s decision on whether she will be charged. According to Ms. Keen-Minshull, the potential charges against her are “nuisance, public order, malicious communications compounded with a potential hate crime.”

On the crowd-funder site she has set up to raise funds for her legal defense, Ms. Keen-Minshull writes, “This fight is not whether you agree with my views on [the] transgender issue as much as it is that you agree that I have a right to air my views, a right to voice an opinion, a right to free speech.”

Without question, Ms. Keen-Minshull’s tweets were strongly worded, but were they untrue?

Unmasking euphemisms

It is not disputed that eight years ago Ms. Green took her 16-year-old child to Thailand to receive gender reassignment surgery, which was and still is illegal for minors in the UK and is now illegal in Thailand. (In fact, the legal age for SRS was raised to 18 not long after the Greens went there for the surgery.)

In a 2012 BBC 3 documentary, Ms. Green confirmed that her child underwent full GRS in Thailand. The narrator [4:15] states that Ms. Green’s child was “the youngest person in the world to change gender through surgery.”

It must indeed have been painful for Ms. Green to see a tweet in which someone says she had her child castrated, but the statement is not untrue. In fact, this type of surgery involves far more than castration, which refers only to the removal of the testicles in natal males. But Ms. Keen-Minshull used the word “castrated” to make an important point: GRS is a euphemism that conceals the drastic nature of this medical intervention.

And if it seems unfair that Ms. Keen-Minshull singles out Ms. Green, we must remember that she is not merely a mother who did what she believed to be right for her child. As CEO of Mermaids, she is an advocate for the use of these interventions in other people’s children. Mermaids has provided training and education to various UK government agencies, including schools and (interestingly) the UK police force. Mermaids representatives regularly attend Pride parades and other events to reach out to gender-nonconforming children and teens to inform them about transition. Ms. Green cannot reasonably expect that others won’t point out the full reality of these interventions if she is promoting them for other children.

Ms. Keen-Minshull also came under fire for a tweet that said Mermaids “prey[s] on homosexual teens,” alluding to the organization’s efforts to reach out to gender nonconforming and gender dysphoric children, many of whom (many decades of research have shown) grow up to be gay or lesbian.

The 4thWaveNow website has previously featured articles about Mermaids and its influence on UK policymaking, as well as their efforts to circumvent parents and appeal directly to children and teens.

Although our website hosts authors from both North America and the UK,  4thWaveNow is based in the United States, which protects the freedom of speech via the 1st Amendment to the US Constitution. If that were not the case, we too might have been interrogated by the police, because Ms. Green’s complaint (which we have seen but are not at liberty to share at this time) also cited a tweet we issued in the summer of 2017:

mermaids candy and puppiesWe decided to raise this question in our tweet,  after seeing this one posted by Mermaids a few weeks earlier:

mermaids unsupportive parents

As parents of current or formerly trans-identified teens, we are concerned that Mermaids is trying to influence teens whose parents do not share the organization’s definition of “unsupportive.” (In fact, as parents who try to help our kids find ways to feel comfortable in their natural bodies – at least until they are adults, we are being supportive.) And the fact that Mermaids feels empowered to publicly state its intention to influence teens like ours is all the more troubling.

We and Ms. Keen-Minshull are far from alone in believing that Mermaids oversteps appropriate boundaries in advocating for transgender services for children. In October 2016, a court removed a seven-year-old child from his mother’s custody because she was found to have essentially groomed her child into a transgender identity. The mother had been receiving support from Mermaids. The court reportedly ordered the child should have no further contact with the charity. (See “The boy who ‘lived in stealth’: Judge challenges ‘emerging orthodoxy.’”)

Twitter’s role in the interrogation of Ms. Keen-Minshull

Although it’s troubling enough to think that a supposed democratic Western nation would interrogate someone for expressing her opinion, it’s even more troubling to hear that a US-based company revealed the person’s identity to the government. According to Ms. Keen-Minshull, the police informed her that they had obtained her contact information from Twitter.

This is not the first time that Twitter has shown its bias in the battle between adherents of gender ideology and those who see dangers in it. Gender-critical individuals have had their Twitter accounts suspended for merely stating that “transwomen are men” while adherents of gender ideology regularly direct misogynistic language like “cunt” or “Kill All TERFs” at people who disagree with them.

It turns out that individuals associated with Mermaids are also guilty of mud-slinging on Twitter. “Helen” (@Mimmymum), who has frequently stated she is a member of Mermaids, regularly brandishes the word “bigot” at those who don’t share her opinions. In a tweet referring to Dr. Ray Blanchard, an American-Canadian sexologist, best known for his research studies on transsexualism and sexual orientation, she writes:

mimmymum blanchardBoth sides of this debate are exercising their democratic right to express their opinions and their concerns about public policy, but it appears that both the UK police and Twitter have chosen to respect the rights of the one while disregarding the rights of the other.

Uncomfortable truths

Ms. Green and her organization suggest that those who oppose the transitioning of minors are motivated by bigotry and hate. They refuse to acknowledge that this opposition could stem from genuine concern for the welfare of children and outrage that organizations like hers promote transition so eagerly and misrepresent the realities of it.

In a segment on BBC Newsnight in November 2016, Stephanie Davies-Arai, founder of the organization Transgender Trend, said that “the treatment pathway [for treating trans-identified children is] … cross-sex hormones…. It leads to children being sterilized and on medication for life.” When the interviewer asked Ms. Green if this were correct, she answered, “Well, no,” then changed the subject. (See “Should Mermaids be permitted to influence UK public policy on ‘trans kids’?”)

Yet this statement is correct, and it’s acknowledged to be so by clinicians who promote and administer these treatments. While the word “castration” may be jarring, Ms. Keen-Minshull used it because it exposed the reality that activists like Ms. Green would evidently rather conceal.

Ms. Keen-Minshull believes strongly, as do we at 4thWaveNow, that drastic interventions like these deserve public scrutiny. To be able to express our concerns about these interventions, we must be able to name them. If people no longer have the right to speak uncomfortable truths because others may find them offensive, a democratic society is no longer possible.

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Should Mermaids be permitted to influence UK public policy on ‘trans kids’?

by Artemisia

Mermaids is a UK charity. Its aims are ‘to relieve the mental and emotional stress of all persons aged 19 years and under who are in any manner affected by gender identity issues, and their families, and to advance public education in the same’.

The organisation began a number of years ago as a support group for parents, and it still maintains an online forum. It also undertakes casework, training, advocacy and political campaigning.

In interviews with the press, its Chief Executive Officer, Susie Green, has described her experiences as the perplexed mother of a small boy who was drawn to ‘girly dresses and dolls’ rather than ‘’trucks and football’. When Jackie was nine, permission was obtained for him to wear girls’ clothes to school.

At twelve, his mother took him to the United States for a consultation with Dr Norman Spack, an endocrinologist at Boston Children’s Hospital. Dr Spack prescribed a puberty-blocking hormone, a treatment that at that time was banned in Britain for any child younger than sixteen.

Later, when Jackie was thirteen, Spack put him on estrogen: again, a highly controversial approach. Current policy in the NHS prohibits the prescription of cross-sex hormones to children younger than about 16.

In recent years, under Susie Green’s leadership, Mermaids has pressed insistently, disregarding the concerns of clinicians, for cross-sex hormones to be prescribed to younger children.

For Jackie’s sixteenth birthday, he was flown to Thailand where he underwent a seven-hour operation to fashion a pseudo-vagina. This would not be legal nowadays; soon after Jackie’s operation new regulations were imposed by the Thai Medical Council, restricting ‘sex change operations’ to patients over the age of eighteen. Furthermore, since 2009, young adults aged 18-20 must now obtain parental permission to undergo sex change procedures in Thailand. As can also be seen in this excerpt from a 2009 Telegraph article discussing tightened restrictions, a Thai gay rights activist drew attention to the phenomenon of post-SRS regret experienced by some patients.

In England under the NHS, irreversible gender-related surgery is only available to patients eighteen and older. This is in accordance with international standards of care.

Mrs Green has promoted Mermaids energetically. As CEO, and before that, Chair, she has been regularly quoted and interviewed in the media. In recent years she has been an invited speaker at various forums and conferences. Convenors have included the Westminster Social Policy Forum and the Royal College of Paediatrics and Child Health.

In 2015, Mrs Green was selected to give evidence in person to the inquiry into Transgender Equality conducted by the Women and Equalities Committee of the House of Commons. Mermaids also submitted a written statement. Later in this post I shall have more to say about that.

In a previous post I discussed an episode in which local authority social workers handed over to Mermaids the effective management of a child welfare case. This did not end well. Ultimately the High Court ordered that the child be removed from his mother. The charity was excluded from further contact.

Mermaids also offers training to professionals:

With this in view, it is reasonable to enquire into Mrs Green’s qualifications for the kinds of activity she and her organisation undertake. Under ‘Education’ on her LinkedIn page there is only one institution listed: ‘prince2 academy’.

PRINCE2 is an acronym for PRojects IN Controlled Environment and as its name suggests, it is a project management system. The PRINCE2 Academy appears to be a set of courses delivering online training in the PRINCE2 method. It is not clear if Mrs Green is a registered PRINCE2 practitioner or whether she has simply taken the foundation course. But that is not particularly important.

Project delivery is about process. Training, advocacy, an advisory role with respect to public policy: these are primarily about content. Delivery of accurate information is key, accompanied with well-informed insight, perceptive analysis.

Let’s look at how Mermaids measures up.

Mermaids submitted erroneous evidence to the Women and Equalities Committee

 The following passage is taken from the written evidence submitted by Mermaids to the Transgender Equality Inquiry conducted by the Women and Equalities Committee in 2015.

Mermaids frequently quote the Equality Act, primarily to schools unwilling to accommodate trans children. Antithetically, a young person of 16 wanted their name changing at school but their parents did not consent to this. Although the Equality and Human Rights Committee found the schools refusal to comply was discriminatory, they could not proceed with action against the school as the young person was under 18.

[Recommendation]: Lower or remove the age the Commission could pursue a young person’s complaint without parental consent.

This passage was quoted in the Committee’s report, which duly recommended:

The Equality and Human Rights Commission must be able to investigate complaints of discrimination raised by children and adolescents without the requirement to have their parents’ consent. [See pp. 27, 74, 81]

Following which the Government Equalities Office looked into the matter. Here is the Government response:

No such restriction exists on the Equality and Human Rights Commission’s (EHRC’s) power to investigate complaints of discrimination, and we are not aware of any legal basis for the statement in Mermaids’ written evidence to the Committee that “a young person of 16 wanted their name changing at school but their parents did not consent to this. Although the Equality and Human Rights Committee [sic] found the schools [sic] refusal to comply was discriminatory, they could not proceed with action against the school as the young person was under 18.” The Committee may wish to note that, in order to comply with the Data Protection Act 1998, the Equality Advisory and Support Service may pass an individual’s details to the EHRC only with the explicit consent of the individual. The case referred to in Mermaids’ written evidence was not referred to the EHRC. EHRC staff have met with Mermaids recently to clarify how the referrals process operates. [p. 13]

Rather snarky, it seems to me, but civil servants don’t like having their time wasted.

So: for whatever reason, Mermaids included a claim without foundation in its submission to the Transgender Equality Inquiry. The Committee trusted the organisation to know what it was talking about — and found itself with egg on its face.

Does Mermaids understand how much this matters?

It matters because public policy should be founded on sound evidence — on facts. No one who peddles made-up claims should be advising government committees.  Nor should they be involved in training professional people with direct responsibility for children, sick people or families in crisis.

Susie Green refused to acknowledge on the BBC that cross-sex hormones cause sterility

susie green bbc newsnight

Susie Green

 The evidence is there on YouTube for everyone to see. On 1 November 2016 there was a short debate on BBC Newsnight between Susie Green of Mermaids and Stephanie Davies-Arai of Transgender Trend.

Here is a transcript of the key exchange, which begins at around 4:20. Important passages bolded:

 Stephanie Davies-Arai: The treatment pathway is the same as transsexual, it’s cross-sex hormones (not cross-gender hormones). It leads to children being sterilised and on medication for life in order to be ‘their authentic selves’.

Evan Davis (interviewer) to Susie Green: Is that correct or …

Susie Green: Well no. I think that in terms of the way that these young people are assessed, they go through very careful assessments before any medical intervention is offered, that’s never before puberty has at least begun and got through to a certain stage …

Susie Green’s denial—’Well no’—and avoidance of the key issues raised by Ms Davies-Arai–are remarkable. Note the following points:

  1. ‘The treatment pathway is … cross-sex hormones’

At the Tavistock and Portman Gender Identity Development Service (GIDS) the treatment pathway is cross-sex hormones from the age of 16.

Less than four months before she appeared on Newsnight Susie Green gave a statement to the Guardian in which she called for the age limit for prescribing cross-sex hormones to be lowered.

  1. ‘It leads to children being sterilised’

This is a well-recognised effect of administering cross-sex hormones. Here is a concise and comprehensive statement from a medical authority, which also covers the effects of so-called ‘puberty blockers’ and gonadectomy:

Medical treatments—effects on fertility

Pubertal suppression with gonadotropin releasing agonists (GnRH-a) not only prevents development of potentially distressing secondary sex characteristics but also suspends germ cell maturation. Puberty appears to progress normally after discontinuation. However, many transgender individuals initiate gender-affirming hormone therapy concurrently with pubertal suppression, and thus, germ cells never fully mature. …

Gender-affirming hormones produce impairments in gonadal histology that can cause infertility. Estrogen use by transgender women results in impaired spermatogenesis and an absence of Leydig cells in the testis. Testosterone use by transgender men causes ovarian stromal hyperplasia and follicular atresia.

Gonadal effects of gender-affirming hormones are thought to be at least partially reversible. For example, pregnancy has been reported in transgender men who have previously used testosterone. Thresholds have not been established for the amount and duration of exogenous testosterone or estrogen exposure necessary to have a permanent negative effect on fertility.

For patients who elect surgical transition, gonadectomy will render them permanently sterile.

Source: Johnson EK, Finlayson C (2016) ‘Preservation of fertility potential for gender and sex diverse individuals’, Transgender Health 1:1, 41–44

  1. ‘It leads to children being … on medication for life’

Here are a couple of relevant statements by medical authorities:

  1. a) ‘Cross-sex hormone treatment has an important role in acquiring the secondary sex characteristics of the desired sex. Transsexuals often start taking sex hormones at young to middle age and in higher than recommended dosages. Fearing loss of secondary characteristics of the reassigned sex, transsexual subjects usually continue hormones lifelong.’

Source: Asscheman, Henk, Giltay, Erik J et al, ‘A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones’, Eur J Endocrinol April 1, 2011 164, 635-642

  1. b) ‘After reassignment surgery, which includes gonadectomy, hormone therapy must be continued.’

Source: Gooren, Louis J., Giltay, Erik J, Bunck, Mathijs C. ‘Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal Experience’ The Journal of Clinical Endocrinology & Metabolism, Volume 93, Issue 1, 1 January 2008, Pages 19–25


Considering her position as the CEO of an organisation that claims to speak with authority on the transition of children and young people, it is shocking that Susie Green should go on television and mislead the public on these crucial matters.

To say the very least: this is not professional behaviour.

Immediately after saying ‘Well no’, Mrs Green changed the subject with very noticeable promptness. Let’s look at what she said next: ‘in terms of the way that these young people are assessed, they go through very careful assessments before any medical intervention is offered’.

We might find this just a little bit glib, coming as it does from a woman who ignored the settled opinion of experienced clinicians and arranged for her son to have a gonadectomy when he had barely turned sixteen–in a country (Thailand) which now bans such surgeries to people under the age of 18.

Mermaids has falsely stated the survey population when purporting to cite statistics for suicidality among ‘trans youth’

In presentations aimed at concerned professionals, Mermaids has exhibited a PowerPoint slide with the heading ‘Statistics’. It displays a set of figures designed to chill. But let me quickly say: these are not what they seem. They have been fiddled to support an agenda. They are, in fact, completely worthless.

Mermaids-suicide-stats-compressor

Here are the phony statistics in question:

  • ‘59% trans youth considered suicide
  • 48% attempted suicide
  • 57% actively self-harm’

A subheading claims that the figures come from a survey of ‘more than 2000 trans people in the UK’. The survey, cited at the foot, was conducted by academics from three universities in collaboration with PACE, a now-defunct LGBT+ mental health charity. The report was published in 2014.

There is no mention of the report’s title: LGB&T Mental Health — Risk and Resilience Explored. The foreword records that ‘Over 2000 people completed our survey…’

Spot the obvious mistake. The trans participants in the survey were only a subset of the total number of people who took part. The statement that ‘more than 2000 trans people’ were surveyed is not true.

And this matters enormously, because unless the survey population is of adequate size, the results of the survey have very little meaning. It is not possible to use those results to make useful generalisations about the target population, the group about which the survey is intended to provide information.

In the case of the survey into ‘LGBT&T Mental Health’, the overwhelming majority of respondents were lesbian, gay or bisexual. Only a minority, just over 17%, identified themselves as trans.

And here’s the clincher: Only 27 of the trans respondents were under 26. This is the total size of the survey population on which the claim is based that 48% of ‘trans youth’ have attempted suicide.

There is absolutely no way that the results of such a tiny survey can be mapped onto the whole population of trans-identifying young people in the UK.

That twelve of the 27 reported such an attempt is very sad for them and their families. However, it tells us nothing about the prevalence of suicide attempts among ‘trans youth’ in general. This micro-survey is of no value whatsoever as a basis for determining social policy.

This is not an abstruse matter: it should be obvious to anyone with common sense.

Mermaids has used the supposedly high risk of suicide attempts by trans-identified young people to support its campaign to lower the age at which the NHS prescribes cross-sex hormones to children. It claims that medical transition reduces the likelihood that a gender dysphoric child will commit suicide. In reality, there is no persuasive evidence that this is true.

When Susie Green gave oral evidence to the Transgender Equality Inquiry she argued that the treatment protocols followed by the Gender Identity Development Service are too restrictive and should be relaxed. She claimed that children waiting to be put on cross-sex hormones become ‘self-harming and suicidal’ and referred to ‘a 48% suicide attempt risk’.

This claim was picked up and repeated in the report from the Committee: ‘Mermaids said there was a significant risk of self-harm or suicide where hormone treatment is not yet being given; they drew attention to evidence that the attempted suicide rate among young trans people is 48 per cent.’ [p. 52]

For the 48% figure a footnote refers to an article in the Guardian published in November 2014. The Guardian in turn cites ‘findings released by Pace’. Evidently the journalist had had an advance view of a press release from PACE dated 20 November. This press release predated the publication of the full report of the survey.

The press release gives an overall figure of 485 for ‘survey participants under the age of 26’. Rather strangely, however, it omits to give an overall number for the ‘young trans* participants’ while stating that ‘48.1% … have attempted suicide’. The use of percentages at this point conceals the very small number of respondents. The other figures in the Guardian post also come from PACE: the Guardian has simply rounded them down, so that 48.1% becomes a snappier 48% and the figure of ‘59.3%’ for suicidal thoughts becomes 59%.

It is, perhaps, not coincidental that these misleading and alarmist figures were initially presented by a charity that was forced to shut its doors for lack of funding just over one year later.

Meanwhile, the Guardian confused matters further by implying that all of the ‘more than 2,000 people’ surveyed were ‘trans’. Presumably this was due to a careless misreading of the statement from PACE.

Given that the Mermaids PowerPoint slide refers to a ‘survey of more than 2000 trans people’ it seems likely that the figures on the slide came by way of the Guardian report. Even assuming that this is the case, it does not let Mermaids off the hook.

It is simply not professional to quote statistics from a newspaper report without attempting to check them at source. In this case the survey report is easily found on the web. Although PACE has closed down, the report has been archived on several sites by interested parties.

Regardless of what it was intending to do, Mermaids deceived the audiences to whom it presented that PowerPoint slide. Even more important and worrying, it gave misleading information to the Women and Equalities Committee.

There is more. The problems with the figures on the PowerPoint slide have been pointed out in detail in at least two important blog posts:

So far as I am aware Mermaids has never acknowledged either of these critiques, nor has it qualified Susie Green’s statement to the Women and Equalities Committee.

The organisation does not seem to have cited the 48% figure recently. But last month Mrs Green was back beating the same old drum, this time in an article on Huffington Post UK. This time she kept things vague, asserting that there are ‘shockingly high statistics for suicide attempts by transgender young people’ without citing any source at all.

These serious misstatements of fact are not acceptable

Mermaids presents itself as a repository of wisdom on the subject of transgender children and youth and in many quarters it is accepted as such. The inaccurate statements detailed above are not minor matters. The UK, as a society, cannot afford such lapses in an organisation that trains professionals and advises on public policy.

Moreover, none of this is helpful to children who show symptoms of gender dysphoria or gender identity disorder (as currently defined), or their anxious and more or less bewildered parents. They deserve a more professional service than Mermaids is currently providing.

Meanwhile, it should, unfortunately, be recognised that it is never safe to take on trust any statement that comes from Mermaids.

 

‘Bridging hormones’: Increasing number of UK GPs leery of prescribing treatment

by SunMum

SunMum is a UK parent with kids who have been affected by gender ideology. She can be found on Twitter @Mum3Sun


 If you are a medical care provider and you have concerns about the safety and appropriateness of prescribing hormones and surgery to young people who are uncomfortable with their bodies, you are not alone. Trans activists frequently cite the non-existent ‘consensus of the medical community’ to argue that the only effective way of treating gender dysphoria is social and medical transition. However, in this carefully researched piece, SunMum reveals that a growing number of general practitioners (GPs) in the UK appear to feel uncomfortable providing transgender health services.

 Special note to UK readers: If you are concerned about proposed changes regarding transgender health services in this country, please complete the NHS survey by October 16. A helpful guide can be found here.


The recent sudden increase in young people identifying as trans presents a quandary for the UK’s National Health Service. Trans activists demand access to ‘life saving’ health care but there are simply not enough gender specialists to deal with all the new patients. Currently NHS England is holding a twelveweek public consultation on specialised gender identity services for adults who, worryingly, they define as ‘17 and above’. But it seems that not all GPs are happy with the role they are being asked to play. The current arrangement is that the patient’s own GP is responsible for ‘prescribing, on the recommendation of the specialist team’. But according to the Guide to Consultation ‘a small but significant and increasing proportion of GPs do not feel able to accept responsibility for prescribing’.

Why are GPs increasingly unhappy to prescribe gender medicine? Surely the profile of transgender has never been higher as trans charities work to ‘Embrace. Empower. Educate’?

Zara Aziz, a GP partner in Bristol writing in the Guardian newspaper in August 2017 in response to the consultation, is concerned about the demands placed on GPs by what she describes as ‘a niche field’ of medicine. GPs are asked to monitor gender treatment through blood and hormone levels. And since 2016, new British Medical Association guidelines ask them in some circumstances – where patients are self-medicating with hormones or where there is self-harm or risk of suicide – to provide “bridging prescriptions” for emergency hormones. This new demand has met with resistance from the General Practitioners Committee which states that GPs ‘should not be obliged to prescribe “bridging prescriptions’’’. So the BMA and the GPs own organisation are in conflict. According to the GPC, the British Medical Association’s report ‘fails to address the resulting significant medicolegal implications for GPs, and neglects the non-pharmacological needs of [gender dysphoric] patients.’ It almost sounds as if GPs would prefer psychotherapy to medication for these patients. As Dr Aziz put it, GPs are worried about ‘the risk of complaints and litigation against family doctors’.

GPs have clearly noticed the sudden increase in demand for gender medicine. Zara Aziz reports that ‘this year I have seen three gender dysphoria patients (although I have not prescribed any treatment for them yet), but before that it was that many in nine years.’ Like many of us, these reluctant GPs seem to be waking up to the realisation that something strange is going on. Just 10 years ago the number of adolescents who wanted to transition to the opposite gender was vanishingly small; today they seem to be in every school.

If a GP does go ahead and offer a ‘bridging prescription’ for hormones, she will be doing so off-label; these drugs are tested and licensed for other uses. As the NHS consultation document points out: ‘This arrangement differs from prescribing practice in many other secondary and tertiary care services, particularly when prescribing for ‘off label’ indications.’

Gender medicine asks GPs to behave in ways for which they have not been trained.  Perhaps the protocols of gender specialists are increasingly diverging from those of other medical specialties, and this gives the doctors pause?

2015 miller enquiry sunmum

From left: Susie Green, CEO Mermaids, and Anna Lee, first “queer trans disabled lesbian woman” to run for women’s officer at the National Union of Students, listen to Bernadette Wren (on right), consultant clinical psychologist at Tavistock clinic.

Or perhaps these GPs are concerned about the influence that activist groups like Mermaids and Action for Trans Health are having on transgender health care. After all, these groups are pushing for earlier and swifter intervention. In evidence to the UK Parliament Transgender Equality Inquiry in 2015, Susie Green of Mermaids spoke of the frustration of parents with NHS treatment pathways and explained that her organisation helped them to access early intervention abroad:

 ‘We have current conversations going on; I have at least six families who have children who are pubertal who are looking at that option now and are actively contacting the Hamburg centres and America to access that treatment, because they know that they are not going to get it here within the NHS.’ (Q58)

Many activist groups believe the role of the clinician is only to supply the drugs and medication requested by the transgender  patient. Perhaps GPs are concerned that activists are driving treatment decisions that rightfully belong in the hands of medical professionals.

In 2009, one of the leading British gender specialists, Dr Stuart Lorimer, a psychiatric consultant at Charing Cross Gender Identity Clinic and founder of GenderCare, a London private gender clinic, was asked what he saw as his biggest impediment in the development of gender identity services. The answer was ‘medical colleagues, GPs, other psychiatrists’. Lorimer mentioned a survey of 1,000 doctors of which 84 percent felt that gender services are ‘not legitimate, not deserved, should not be in the NHS’.

It is clear that a consensus on the protocols of transgender medicine does not exist outside the small group of specialists. A much-cited Swedish study from 2011 describes the standard treatment for gender dysphoria as ‘a unique intervention not only in psychiatry but in all of medicine’. Searching for parallels, one contributor to 4thwavenow had to go as far back as lobotomy. No other contemporary psychiatric therapy, after all, includes ‘the surgical removal of [healthy] body parts.’

Transgender medicine is not just a specialized field but something of a club. A 2003 Dutch study asked 382 Dutch psychiatrists about their experience of ‘diagnosing and treating patients with gender identity disorder’ and found that ‘[a] small number of psychiatrists’ were responsible for a large proportion of the referrals to ‘specialized sex reassignment therapy centres’. The study concludes that ‘the therapy options proposed to patients with gender identity disorder depend heavily on the personal preferences of psychiatrists’. (Am J Psychiatry 2003; 160:1332–1336) Personal preference is not a reassuring basis for medical treatment.

In the UK it seems that nothing much has changed in the 14 years since the Dutch study. Transgender medicine continues to be in the hands of a small group of clinicians and the NHS consultation guide cited above notes that ‘there is limited collaboration and sharing of best practice across the current providers’. A small number of treatment centres operate on the basis of limited evidence about outcomes.

It’s both welcome – and worrying – that the NHS is only now bidding for research into gender medicine. The commissioning brief acknowledges ‘the lack of a UK evidence base for the NHS to inform decisions about gender identity health services’. And the research bid notes that ‘the long-term iatrogenic impacts of hormonal treatments and surgeries on young people and adults are largely unknown, but some studies show some treatments increase risks of several long-term conditions including cardiovascular and renal diseases, and fracture risk, while research on user satisfaction and psychological outcomes in the UK is of small scale and duration.’ These treatment protocols, in other words, could be causing long term damage – we don’t know enough to rule this out.

When evidence is lacking, we might expect doctors to be cautious. But instead of trying to understand the reluctance of so many GPs, trans activists demand swifter interventions and ascribe medical caution to bigotry. Zara Aziz explains that ‘any reticence on our part to prescribe can be challenged and can sometimes be misinterpreted for prejudice.’ Specialists and activists work to bypass the caution of mainstream doctors. Lorimer’s private GenderCare clinic is designed specifically to get round the reservations of GPs. He explains that:

 In my GenderCare clinic, I saw those people who’d yet to reach a GIC, whose GPs had stalled, dismissed or, in one memorable case, informed them that no such service had ever existed in the UK.

Guidance for NHS clinicians who also offer private treatment issued in May 2009 recommended that ‘specialists should as a general rule make it clear to members of the public that they usually do not accept patients without a referral from a GP or other practitioner.’lorimer summer reading

GPs may not subscribe to the conventions of gender clinicians, but they do tend to know their patients and their family situations. And that, more than anything else, may explain the increasing reluctance of many GPs to provide transgender health services. Just as parents know their children, GPs know their patients. Perhaps more and more of them are seeing young patients who never expressed discomfort with their bodies as children suddenly demanding transgender health services. That would certainly be enough to make a good GP think hard before writing a prescription for cross-sex hormones.