World Professional Association for Transgender Health (WPATH) Files

CatFromHue

These are a bit more than low level depression

In reply to a nurse practitioner who is struggling with how to handle a patient with PTSD, major depressive disorder, observed dissociations, and schizoid typical traits who wishes to go on hormone therapy:

“I’m missing why you are perplexed… The mere presence of psychiatric illness should not block a person’s ability to start hormones if they have persistent gender dysphoria, capacity to consent, and the benefits of starting hormones outweigh the risks…So why the internal struggle as to ‘the right thing to do?’”

Dr. Dan Karasic, lead author of WPATH Standards of Care 8 mental health chapter

Mentally ill and homeless people are regarded as suitable for referring for genital surgery: “I have also intervened on behalf of people who have been diagnosed with major depressive disorder, cPTSD, homeless and got at least an orchiectomy… In the last 15 years I had to regrettably decline writing only one letter, mainly b/c the person evaluated was in active psychosis and hallucinated during the assessment session. Other than that - nothing - everyone got their assessment letter, insurance approval, and are living (presumably) happily ever after.”

Gender therapist

Patients with dissociative identity disorder are regarded as having the capacity to consent to hormones:

“One client who had [dissociative identity disorder], we worked on all alters giving consent to HRT before it was started. They had alters who were both male and female gender and it was imperative to get all the alters who would be affected by HRT to be aware and consent to the changes. Ethically, if you do not get consent from all alters you have not really received consent and you could be sued later, if they decide HRT or surgery was not in their best interest.”

Gender therapist

As for whether children and adolescents can consent to this type of treatment I'd very strongly disagree.

Grayson

https://www.boards.ie/discussion/comment/121864289#Comment_121864289

You said psychiatric illness, without qualification. And the part you quoted again still shows that what they're interested in is the capacity to consent. That the presence of a mental illness shouldn't automatically disqualify them. Are you saying that they shouldn't establish the capacity to consent and automatically disqualify everyone?

As for whether children and adolescents can consent to this type of treatment I'd very strongly disagree.

That's nice. let's change the best practice because you disagree.

Whenever they're looking to treat a child or adolescent, the child's wishes should come first and be the biggest factor in making the decision. The parents will listen to what their child says and they will factor that in. Plus you're once again ignoring the fact that parental consent and a referral is needed. So well done, at least you're consistent.

As for patients with DID, did you even read the discussions. They've selectively pasted certain parts of the discussion and left out others. but even with what they left in we can tell it's a discussion about how to approach these types of cases. One of the doctors said that they requested a letter from a DID specialist before considering surgery. Another says that they're complicated cases and there's no single solution.

What it actually shows is doctors doing research on how to approach particularly complicated cases. This isn't a group of people who don't care about their patients. They are looking for the best ways to treat their patients. They're pooling their knowledge and experience so they can offer the best care possible.

Or would you want them not to talk? Not to discuss? Not to ask for advice or share knowledge?

volchitsa

https://www.boards.ie/discussion/comment/121863921#Comment_121863921

Well here you go then.

First, nobody is claiming that they are going around saying "Hee hee hee, we're giving sh1t advice to our patients - but don't tell 'em!"

You need to know is what the current evidence actually says, and when the discussion goes against that without immediately being called out by others as obviously inappropriate, then there's a problem. And in this context it seems to happen because WPATH is more full of activists than objective researchers. So the ideology is given higher priority than the evidence.

For example, from around p117 on, the discussion is about puberty blockers for pre teens. There's a non medical person (psychologist perhaps?) expressing concern about a 10 year old patient being started on these, as approved by their doctor. So a 10 y-o is being given PBs, but if you read on, on P118 Marci Bowers (herself a TW, but who only transitioned in middle age after having had children) says that she is "unaware of anyone claiming ability to orgasm when they were blocked at Tanner 2" , ie started on PBs at Tanner stage 2 when the first signs of puberty are visible, which is the earliest PBs can be given.

Consent needs to be "informed" in order to be valid. How could a 10 year old possibly understand the significance of the ability to reach orgasm in adult relationships? It's not informed consent. That should be a major stumbling block right there. Yet the whole tenor of these discussions is about facilitating surgery, not querying it. In fact, some of the concern expressed is that the mere fact of expressing concern might strengthen "conservative" opposition to the treatments (eg bolded below).

Such as: p158, 159 etc is about "patients who identify as eunuchs", and the sorts of "atypical surgery procedures" which either "don't exist in nature or represent the first of their kind" (I'd like to know the difference there). Another practitioner asks about "gender nullification surgery", and says they have no experience of doing this.

So what research data do you think exists for this "first of its kind" surgery? And yet that doesn't come up in the responses as a major problem. Several replies discuss how best to do it, and about how social responses of shock to this are not important. Nothing about whether the patient has any other mental health issues. If your patient wanted a healthy leg amputated, would the "best evidence" response really be for your colleagues to propose various ways of doing this technically without asking whether there are mental health issues involved? Instead they talk about the risk of "non standard surgery" being "weaponised" by conservatives - that's the biggest risk that presents itself apparently when you operate to make someone "gender nul". That's the talk of activists, not of carers.

Basically, the leaks show clinicians discussing patients receiving irreversible treatments who seem very unlikely to be able to receive informed consent, including some who are very young, and others who have serious mental-health disorders. Some of the conversations suggest that the clinicians themselves don’t know the long-term effects of treatments. In other conversations, it seems that they do know that cross-sex hormones or surgeries are likely to cause serious harm, but advocate for those treatments nonetheless. It suggests that some WPATH members brush off concerns about long-term patient outcomes, despite being aware of potentially debilitating and even fatal side effects of cross-sex hormones and other treatments. 

P88: Another one, about consent for people with known mental health issues: “In the last 15 years I had to regrettably decline writing only one letter, mainly b/c the person evaluated was in active psychosis and hallucinated during the assessment session. Other than that – nothing – everyone got their assessment letter, insurance approval, and are living (presumably) happily ever after.”

“presumably” happy ever after? That's some assumption, surely? No need for follow-up? That's from a gender therapist in California, who also said: “I have also intervened on behalf of people who have been diagnosed with major depressive disorder, cPTSD, homeless and got at least an orchiectomy…”.

So apparently homeless people with major mental disorders can have themselves castrated by removing their testicles. What could possibly be wrong with that? The discussion goes on to reject the very idea of being "a gate-keeper" by withholding treatment until existing MH conditions are "stabilised" - but if an anorexic girl went to a doctor for bariatric surgery, wouldn't that also be "gate keeping" to say that it's not appropriate treatment for her problem?

But of course if you're going to say "Ha, but they don't actually say that they know it's madness to make someone a eunuch just because he asks for that", then sure, you're right. They don't.

But TBH, if that's really your response, then all I can say is, we'll see how this all goes in ten years' time when the massive scandal of mentally ill people being given irreparable major surgery based on a mentally-ill image of themselves, and I'll be interested to see how many people currently nodding along to this will be around either still defending it, or (even less likely) admitting that they got it entirely wrong.

(The discussion around detransitioning is also fascinating, (around p106) and shows, well, several things: the newer problems arising from the fact that the profile of transgender people is so split, with older men transitioning to female and now, recently, young females for the first time wanting to transition to male. Those are the ones who are (according to the discussion, but also, unsurprisingly) expressing regret and wanting help with fertility and often how to detransition.

The split between clinicians who do really seem concerned about their patients above all, and others who say that patients should just take responsibility for their choices, and that even considering detransitioning risks providing a weapon for the bogeymen on the right (again, the need to prioritise the ideology over the people involved) is very noticeable there.

volchitsa

https://www.boards.ie/discussion/comment/121864244#Comment_121864244

How can a child who has never had an orgasm possibly consent to never having an orgasm in their lives?

They don't understand the role that adult sex lives play in a long term intimate relationship, so cannot consent to having a massive aspect of it removed for ever.

Same question concerning future infertility. If you ask a child about the desire to become a parent, chances are they'll say "No I don't ever want to do that." And if you tell them that the price to pay for doing something they really want to do now is that they won't have children later, then it's even more likely that they'll be certain that that's absolutely fine because that's not something they particularly want to do.

That doesn't mean that at 25 or 30 they will still think the same thing. FGS, we don't let them have tattoos for that reason - do you think that's wrong too?

ceadaoin.

Whenever they're looking to treat a child or adolescent, the child's wishes should come first and be the biggest factor in making the decision. The parents will listen to what their child says and they will factor that in. Plus you're once again ignoring the fact that parental consent and a referral is needed. So well done, at least you're consistent.

No, the child's wishes shouldn't come first because they are a child and can't consent. Should we also listen to a child's wishes if they want to have a sexual relationship, get a tattoo or take drugs or alcohol? Should we also let kids let demand whatever medication they want, despite it being inappropriate for their age group? If a kid has anorexia or body dyspmorphia and thinks they should be given a weight loss drug or surgery should we put their wishes first in that case? No, that would be ridiculous. This notion that kids should be able to consent to actions that have such long lasting consequences that they can't possibly understand is extremely creepy.

Shoog

https://www.boards.ie/discussion/comment/121865155#Comment_121865155

Your suggestion is that many/most people seeking treatment have underlying mental health issues driving their desire for treatment. Gender dymorphism is no longer considered a mental health illness and is not treated as such.

Also in Ireland and the UK extensive long term physchological assessment has to be carried out before any gender related treatment is offered or suggested to identify any mental health issues driving or resulting from gender dymorphism.

To be frank you are arguing a straw man as to what actually happens with regard to gender dymorphism treatment, but there is little to surprise me in this.

Arguing from an American perspective where treatment is primarily a profit driven area is deeply disgenious to those operating within the Irish health system where patient welfare is paramount.

Shoog

https://www.boards.ie/discussion/comment/121865778#Comment_121865778

The reality is that most children are very aware of their gender from the age ofaround five, and this includes people who identify as been the opposite gender to their biological sex. Most will not change that identification from that age to adulthood. This is not surprising since they are describing their lived experience of been born into the wrong sexed body for their gender.

How you deal with that up until the age at which they can take full control of their treatment at the ago of consent is really the only issue with regard to children. A parent is in full control of any decisions regarding treatment up until that point.

So what a child says about themselves with regard to gender is vitally important - but all treatment decisions are the parents until the age of maturity.

volchitsa

https://www.boards.ie/discussion/comment/121866045#Comment_121866045

I'm definitely not arguing "from an American viewpoint" - the exact opposite in fact.

I suspect you are using that claim as a way of dismissing a point of view you disagree with, rather than it being something you've actually identified, because I'm at a loss as to why you would think that of my take on these issues.

Tavistock trust whistleblower David Bell: ‘I believed I was doing the right thing’

https://www.theguardian.com/society/2021/may/02/tavistock-trust-whistleblower-david-bell-transgender-children-gids

The psychiatrist behind a critical report on the gender identity unit at the NHS trust on the efforts to silence him and his concerns about children’s access to treatment

I'm more influenced by people like Dr David Bell, former governor of the Tavistock clinic, quoted above. In fact it was his interventions that started alarm bells ringing for me. Because he is a medical professional, and not a right/left political ideologue - which is far more the US position on this issue.

It is a UK-centred report, since it's about GIDS/Tavistock, but as the HSE takes its lead directly from the Tavistock, it's directly applicable to clinical practices in Ireland too.

There's also this, rather more theoretical, publication by Dr Bell, entitled "First, do no harm":

https://www.maudsleyphilosophygroup.org/wp-content/uploads/2022/11/First-do-no-harm-IJPA.pdf

He analyses the current situation in the UK thus:

I think that in our current conjuncture we are witnessing a growing misogyny. What I have in mind here is this: from World War II up until the late 1970s a strong femininity, expressed by the increasing theorisation and respect for maternal caring, and in the British context the creation of the Welfare State, maintained a certain social dominance. However, that version of strong caring has been re-presented in its perverse form, the “nanny state”, a contemptuous attack on femininity. This is both expressed and reinforced by ideological forms that promote the delusion of the autonomous man, seeking to service only his own needs, enacting a hatred of all forms of dependence. This growing misogyny may be having profound effects on girls and, in conjunction with more individual factors, supports the internalisation of this hatred of femininity, transformed into a hatred of their female bodies. The internet/social media are major determining forces, occupying a position that is both causal and also the vehicle for other causes. Through a kind of viral social contagion, children who feel lost in the world become radicalised online, join trans groups that provide them at last with an identity and social belonging

Again, not a hint of the US culture wars approach to it.

volchitsa

https://www.boards.ie/discussion/comment/121866119#Comment_121866119

This claim makes very little sense in terms of what we know about childhood development though.

Adolescence is when the sense of personal identity develops, not before that. There is no theory of child development which identifies the existence of a strong sense of personal identity before that.

This is why adolescence is the time when young people "try out" different identities, like being a goth or whatever, particularly identities different from those society or their family expect of them.

It's also why talking about "trans kids" is misleading. To quote David Bell again, they are children with gender dysphoria (often accompanied by mental health issues of varying severity). Some may persist past adolescence and become transgender adults, but most will desist. And the problem is that there are really only statistical measures of who will persist and who will not. So it's impossible to identify the minority for whom going straight onto the pathway of blocking puberty (that period that allows a sense of self to develop fully) might work out well because that was where they were going to be anyway.

For the rest, the majority, taking puberty blockers is more likely to stop the sense of self from developing, IOW to "block" the child in their gender dysphoria. And there is no certain measure to identify which child/teen belongs in which of those two groups.

No. I don’t think it’s helpful to ever call a child a trans child. I think we should say it’s a child with problems who is expressing themselves in a particular way that needs understanding and may become a trans person and may not. But once you call them a trans child, you’re doing what we call foreclosure rather than exploring.

They now realise that they were expressing their difficulties with their sexual body through calling themselves to the other sex. That was supported culturally and socially and also by the clinic that they attended. And they now feel that that was a terrible mistake. As one young woman put it to us, I look in the mirror. I do not see a male body. I see a mutilated female body.

And that is what WPATH tends to elide - as the files show. That fundamental problem of the very idea of a "trans child", as opposed to a child with gender issues, which may in fact be more the reflection of other issues the child has, and not an actual "trans identity".

volchitsa

https://www.boards.ie/discussion/comment/121866119#Comment_121866119

https://www.boards.ie/discussion/comment/121866045#Comment_121866045

Also I've just noticed: what do you mean by "gender dymorphism"? I don't know what that is, but I first read it as gender dysphoria. If it's something else, could you explain please?

Secondly, can you explain how someone could be "born into the wrong-sexed body"? What part of them is the "right-sexed" part? Their brain? How does that show up? Can we identify it at all or do we have to prescribe drugs and/or surgery based on what the person says?

In which case, should we also prescribe weight loss drugs for the same reason? (The person may genuinely feel obese, even though they are only slightly over the normal weight for their age/height?) Or does this only work for sex? If someone is born blind, were they born with the "wrong" eyes?

Shoog

Volchitsa, you obviously don't agree with the reality of the medically recognized condition of gender dysphoria so there is actually no common ground on which to have a discussion.

volchitsa

https://www.boards.ie/discussion/comment/121866496#Comment_121866496

No, you're mistaken. I think if you read what I said it will be clear that I'm certain that gender dysphoria exists.

And aren't you the one who said it's not a medical condition anyway? Although you were calling it gender dymorphism which AFAIAA is a different thing. Did you mean gender dysphoria?

Shoog

As to when children self identify their gender (including transgender);

"Research shows that children recognize their own gender and gender in others starting when they are very young. You may notice children behaving in ways typical of their gender as early as two or three years old. By the age of five, most children can identify the gender of other people.

Children whose gender identity doesn’t match the gender they were assigned at birth may behave in ways that don’t match their assigned gender. For example, a child who was assigned female at birth might prefer to play with "boy toys" like trucks and tools. This can start when children are toddlers."

https://www.medicinenet.com/at_what_age_does_gender_identity_develop/article.htm

There is little doubt that children are aware and live their gender roles from a very early age (2-5years) and so can start to make decisions about their gender at a very early age. Gender identity rarely radically changes from this very early identification and to not respect a childs self identity can directly lead to child abuse and mental illness.

To suggest that children are just experimenting like a fashion, such as been a goth, is fairly offensive to transgender people and the sort of attitudes which causes such mental distress in children that leads directly to mental health issues and self harm - with the ultimate outcome been suicidation for a large number of transgender people.

Shoog

One very good thing about the Tavistock crisis is that it will lead to an expansion and diversification of services to transgender people - meaning that waiting lists should go down and treatments increase. This is hardly how many anti-trans activists imagined it would pan out when they saw the closure of the Gids unit, a unit which buckled under exponential growth in demand.

volchitsa

https://www.boards.ie/discussion/comment/121866410#Comment_121866410

Just LOL

You don't know the difference between dimorphism (not dymorphism, which doesn't even exist) and dysphoria, but you still feel entitled to dismiss with a wave of the hand an expert like David Bell?

Hmm.

(Do you have any evidence that he actually "sought his position" specifically to disrupt their work? You need to be careful because that sounds potentially defamatory - as well as entirely different from my knowledge of the timeline of events)

Shoog

https://www.boards.ie/discussion/comment/121866622#Comment_121866622

Please forward my sentiments to Dr Bell and I will await his injunction shortly😚

volchitsa

https://www.boards.ie/discussion/comment/121866659#Comment_121866659

So you have no evidence then?

Having worked as a consultant at the Tavistock for more than 25 years, he was one of its most senior doctors: for 10 years, he was in charge of its scientific programme; in 2018, he was also an elected staff governor of the trust, for the second time.

https://www.theguardian.com/society/2021/may/02/tavistock-trust-whistleblower-david-bell-transgender-children-gids

25 years before he started trying to "disrupt" their work - that really is playing a long game isn't it?

Or are you just making stuff up? Like when you were spoofing about things that don't exist such as "dymorphism" (while accusing me of not believing that gender dysphoria exists, which is something I never said! Quite the opposite in fact)

volchitsa

https://www.boards.ie/discussion/comment/121866547#Comment_121866547

If playing with "boy toys" is evidence of gender identity, in what way is that not simply gender stereotyping?

It's going back to the 1950s when girls could be nurses and hairdressers, and boys could be engineers and train drivers.

Only now instead of preventing girls from studying maths to become engineers, we're going to start telling them that liking maths or wanting to be a train driver means they are actually boys.

Shoog

https://www.boards.ie/discussion/comment/121866732#Comment_121866732

The point been, the one you so studiously ignored, is that children understand gender and can identify their own gender from at least 5years old. This is so well established in child development as not to be remotely controversial. You seem to have a fundamental problem with accepting that a child can identify their gender as different from their birth sex - but would have no problem if that gender conforms with their birth sex.

volchitsa

https://www.boards.ie/discussion/comment/121866760#Comment_121866760

That's because, as you've demonstrated, gender is no more than stereotypes: to my mind if a girl likes playing with trucks and wants to be train driver, then she's a girl who likes playing with trucks and wants to be a train driver. Full stop.

That does not mean she was "born in the wrong body". Because that's impossible.

And if this girl thinks that at age 2 or 3 (an age when children still believe that a magic man can fly around the earth in one night), then it's because she's been told that. Just like she believes in Santa because she's been told that too.

Of course she believes it, because she has no way of knowing yet what's possible and what isn't. My son used to be certain that if only he had a Superman cape he'd be able to fly. And he was older than two! I think he was about 4 or 5. And he really did believe it. He still remembers believing it.

But it does mean that the adults around her should be encouraging her to play with what you call "boys' toys" without leading her to believe that this might even possibly mean she's a boy.

BTW: I don't know "techy" means. Is it to do with the talk of engineering?

Shoog

https://www.boards.ie/discussion/comment/121866791#Comment_121866791

Your arguing against well established child development research that gender identity is established at a very early age (2-5yrs), your opinion disagrees with this body of evidence so I am happy to dismiss it for the value it offers. Your fixation on toys as a useful metric of gender identity is telling to say the least - almost as if you want to belittle a what a child expresses about themselves.

ceadaoin.

For example, a child who was assigned female at birth might prefer to play with "boy toys" like trucks and tools. This can start when children are toddlers."

What a load of nonsense that's based on nothing but gender stereotypes. Remember when the done thing was to tell girls it's ok to play with "boys toys" because they are just toys and vice versa? Now people seem to want to tell them that if they like "boys things" they literally are a boy. Talk about taking a step backwards.

Also, your statement about gender identity being set in stone is also nonsense. Prior to this madness, gender questioning children overwhelmingly turned out to be "cis" and gay and not trans at all, with only a small minority deciding to transition in adulthood. Of course, that won't happen now when the slightest sniff of gender non conformity is met with affirmation, pronoun/name changes and hormone blockers. It's a recipe for disaster and a lot of angry, messed up adults, which is already starting to happen.

volchitsa

https://www.boards.ie/discussion/comment/121866839#Comment_121866839

LOL you're the one who mentioned boy toys, not me! If it belittles the child (and I think it does), that's on you. I think toys are just toys, for any child who wants them, and not just for either boys or girls.

You don't know what the issues even are, when you talk about dymorphism, and you make up stuff to fit your opinions (like David Bell joined Tavistock to disrupt their work, when he'd been there for a 1/4 century before this all happened.)

Podge_irl

https://www.boards.ie/discussion/comment/121866839#Comment_121866839

A child being able to understand there is a difference between men and women conceptually is not the same as them having a well established gender identity or even knowing what that means. Though I'm happy to be see this well established child development research?

Shoog

https://www.boards.ie/discussion/comment/121866856#Comment_121866856

Dr David Bell was a clinician in adult mental health services at the Tavistock. He had no connection to the GIDs clinic. He has and always had the opinion that transgenderism was a mental illness and as a result of trauma. He injected himself into the GIDs clinic under his own volition and produced a report which was exclusively critical of the work been done in GIDs. He has subsequently gone on to host conferences of anti-trans activists to further his anti-trans agenda. He paints himself as a victim here buit he set out with the intent to disrupt and see the disbandment of the GIDs clinic.

---

Let me correct you here, I have never suggested that toys are any sort of metric to judge gender identity.

volchitsa

https://www.boards.ie/discussion/comment/121866872#Comment_121866872

Well going by the single link he's given so far, it seems he's gone for the US site WebMD. Which is amusing because he accused me of taking an American approach here, when I've mostly talked about people involved with the NHS and the HSE.

The link he gave refers to WPATH as the foundation of all knowledge on the subject.

Which is interesting, given the topic of the OP.

Because the much-vaunted WPATH 'Standards of Care' have turned out to be little more than a dangerous hash of nonsense, guesswork, in-vivo experimentation, obfuscation, stupidity, professional irresponsibility, adherence to a crazed ideology and general, unadulterated, fuckwittery.

@Shoog

I've reported your defamation of Dr David Bell rather than reply to it and risk making the situation worse for the site, but I will say that your mind reading abilities are awesome. Any chance you could PM me the Euromillions numbers for this evening? Should still be time!

Oh, and you really did suggest that toys were a metric for gender identity, in post 105 (first mention of boys' vs girls' toys on this thread AFAICT. Certainly not something I did anyway)

Children whose gender identity doesn’t match the gender they were assigned at birth may behave in ways that don’t match their assigned gender. For example, a child who was assigned female at birth might prefer to play with "boy toys" like trucks and tools. This can start when children are toddlers."

Shoog

https://www.boards.ie/discussion/comment/121866872#Comment_121866872

A simple question here, at what age should we start to accept what a person says about their gender identity ?

If that person has been consistently saying the same thing about their gender from been a pre-teen, what should we do about those statements.

Is a person not allowed to describe themselves as trangender until they are an adult ?

volchitsa

https://www.boards.ie/discussion/comment/121866925#Comment_121866925

Have you seen "I am Jazz"?

Podge_irl

https://www.boards.ie/discussion/comment/121866925#Comment_121866925

I don't know. Its a perfectly reasonable question. I think "not 5" is a perfectly reasonable answer but it is clearly a complicated area, all the moreso when there are adjacent psychiatric issues.

Equating the abstract concept of realising there are two sexes with such a nuanced and detailed sense of self, and using toys to represent it, is clearly patently absurd though.

Medical intervention in this area should be subject to the same rigour as all other medical intervention. So far, it seems, that that has not always been the case. I can understand why those who view it as denying treatment to those in need are frustrated or even angry but it is incredibly important to take children's health care especially very seriously and a lot of the approaches advocated for lack sufficient rigour. Individual doctors doing what they think best is not how we approach other areas of medicine.

Shoog

https://www.boards.ie/discussion/comment/121866951#Comment_121866951

Lets repeat this, I never injected toys into this discussion - I pointed out how absurd it was as a metric.

I think most of the issues been experienced here are directly attributable to the gross under resourcing of the Tavistock and the failures of care that this engendered - and this was the primary conclusion of the Cass report.

Its a none issue to say that 5year olds present a serious risk because no 5year old ever goes forward for treatment. End of story. Most transgender patients are lucky to get seen before they are 20years and at that point many have already entered mental health services for the harms caused by lack of treatment for their primary problem - and many have already committed suicide. These are the real issues - lack of care kills people.

We should respectfully listen to what a child as young as 5years says about themselves, including their gender and work out ways in which their beliefs about themselves can be managed until they are of an age where appropriate care can be administered. the emphasis here is that we should listen to our children and not silence them when they say things about themselves which make us feel uncomfortable.