Intended for healthcare professionals

Practice Practice Pointer

Safeguarding LGBT+ adolescents

BMJ 2019; 364 doi: (Published 31 January 2019) Cite this as: BMJ 2019;364:l245

Linked Opinion

NHS staff are in a perfect position to be advocates for LGBT+ people when they most need it

The importance of an appropriate understanding of the literature

In their response to the present article, Susan Bewley and colleagues point out that the Royal College of Psychiatrists has supported a ban on therapies aimed at changing sexual orientation, but that “working with people with gender dysphoria requires a different model of understanding” (1). However, it should be noted that therapies aimed at changing gender identity have also been strongly opposed by the Royal College of Psychiatrists. Indeed, despite occasional claims that attempting to change sexual orientation and gender identity are ethically very different, professional associations and guidelines have largely concluded that both are unethical. In the United Kingdom, a memorandum of understanding against conversion therapy for gender identity was signed by 13 leading healthcare groups including the British Psychological Society, Royal College of General Practitioners, NHS England, and NHS Scotland (2). In my work, which focuses on trans reparative therapy, I have recorded over 49 professional associations which oppose attempts to change or discourage trans outcomes (3).

To these statements opposing reparative therapy must be added the growing consensus over the affirmative approach for trans people. The approach has been endorsed in most guidelines drafted in the last few years and has garnered the support of the Australian and New Zealand Professional Association for Transgender Health, American Academy of Pediatrics, the Pediatric Endocrine Society Special Interest Group on Transgender Health, and The Lancet to name but a few (4,5,6). In other words, Bewley’s characterisation of the current state of science and professional knowledge is inaccurate.

Professor Bewley and colleagues' reliance on the 85% desistance metric is also mistaken. Firstly, this number has been severely challenged by the academic literature (7,8,9). As critics have highlighted, most children included never asserted a trans identity, questionable assumptions were made regarding the up to 40% of youth lost to follow-up, and follow-up wasn’t sufficiently long to adequately capture youth who repressed their identity until later in adulthood. The 85% figure is wholly unreliable.

Even if the figure of 85% was reliable, it would not be relevant to the present discussion. Bewley and colleagues' intervention concerns trans adolescents, yet the reported percentage comes from studies on youth. Another study by the Dutch team, one of the main sources of the 85% metric, has revealed that all of the children who received puberty blockers continued to identify as trans and desire medical transition in late adolescence (10). The claim that a worrisome percentage of trans youth do not grow up to be trans may be questionable with children, but it is plainly false from puberty onwards.

Although youth who later cease desiring medical transition must be considered when developing our approaches to clinical care, Professor Bewley and colleagues' use of the literature is misleading. They cite a composite case report by Jack Turban and Alex Keuroghlian as evidence of increasing awareness of de-transitioning, but do not mention that the case study showed that youth who underwent hormonal treatment and later changed their mind were grateful for the opportunity to explore their gender identity through transition even if they ultimately found their identity to be in alignment with the gender they were assigned at birth (11). This result is in line with my own work which suggests that gender exploration operates not before transition, but through it (12). The idea that youth who de-transition must regret transition is an unwarranted projection of transantagonistic attitudes on gender variant youth, some of whom have experienced or are still experiencing body dysphoria. There is nothing disgusting about having a body that has been altered by hormones.

Open futures should, all other things being equal, be promoted. Social transition and puberty blockers open futures rather than foreclose them (12). Allowing a pubescent youth to undergo puberty does much more to foreclose futures than puberty blockers do. Puberty is symmetrical: whether you take hormone replacement therapy or merely stop blockers, your body is changing in partially irreversible ways. By the time hormone replacement therapy is on the table, the values of bodily autonomy and self-actualisation more than justify access; in case this does not suffice to convince, access to transition-related interventions have been shown to significantly improve mental health (13,14).

While I appreciate Bewley and colleagues' interest in trans youth health, it is important to be familiar with the relevant literature and take care not to misrepresent it before commenting in an academic forum.

(1) Royal College of Psychiatrists. Supporting transgender and gender-diverse people. PS02/18. 2018. Position Statement.

(2) Memorandum of Understanding on Conversion Therapy in the UK, Version 2. 2017.

(3) Florence Ashley. Resources.

(4) Telfer MM, Tollit MA, Pace CC, Pang KC. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. Version 1.1. Melbourne: The Royal Children’s Hospital; 2018.

(5) Rafferty J. Ensuring Comprehensive Care and Support for Transgender and GenderDiverse Children and Adolescents. Pediatrics. 2018;142(4): e20182162.

(6) Gender-affirming care needed for transgender children. The Lancet. 2018;391:2576.

(7) Newhook JT, Pyne J, Winters K, et al. A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. International Journal of Transgenderism. 2018;19(2):212-224.

(8) Newhook JT, Winters K, Pyne J, et al. Teach your parents and providers well. Canadian Family Physician. 2018;64(5):332-335.

(9) Olson K. Prepubescent Transgender Children: What We Do and Do Not Know. J Am Acad Child Adolesc Psychiatry. 2016;55(3):155-156.

(10) de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276-2283.

(11) Turban JL, Keuroghlian AS. Dynamic Gender Presentations: Understanding Transition and “De-Transition” Among Transgender Youth. J Am Acad Child Adolesc Psychiatry. 2018;57(7):451-453.

(12) Ashley, F. Thinking an Ethics of Gender Exploration: Against Delaying Transition for Transgender and Gender Creative Youth. Clinical Child Psychology and Psychiatry. 2019. In press.

(13) What We Know Project. What does the scholarly research say about the effect of gender transition on transgender well-being?

(14) Bauer G, Scheim AI, Pyne J, et al. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health 2015;15:525.

Competing interests: No competing interests

10 March 2019
Florence Ashley
Jurist and bioethicist
LL.M. Candidate, Fellow of the Research Group on Health and Law, McGill University
Montreal, Quebec, Canada