The UK Government has promised to issue guidance for teachers on how to support children in schools who present with distress or discomfort around their “gender identity” or who express wishes to be treated as though they were the opposite sex (“transgender”) or as not belonging to any sex (“non-binary”).
This refers to a process that has come to be abbreviated as “social transition”, where a child is said to be “affirmed” in her or his preferred gender identity.
Social transition’s clinical importance is that it is the start of a process; it may make it more likely that the child will continue on a pathway toward more invasive and medical and surgical procedures to alter the sexed body. These may result in sterility and other irreversible consequences, to which a child does not yet have the cognitive maturity or life experience to give informed consent.
The Interim Report of the Cass Review of gender services for children states:
“Social transition – this may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning. There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes”.
The Cass Review: Independent review of gender identity services for children and young people: Interim report February 2022
Surgical interventions to change their sexed bodies are currently prohibited for young people under the age of 18 in the UK, and controversial medical interventions such as the use of hormones in younger teenagers are coming under increasing scrutiny But social transition does occur in this age range, and it is, as Cass observes, an active, non-neutral intervention, which may have significant effects on children, and whose processes and clinically relevant outcomes need to be better understood.
Definitions – what are we talking about?
Descriptors of social transition tend to differ according to the perspective or position taken by those defining it.
They commonly describe certain behaviours and social roles, which are connected with being female, male, or, according to some definitions, neither sex (“non-binary”). These social roles and behaviours vary to a greater or lesser extent according to their societal, cultural and historical context; most of the focus of interest relevant to the debates around sex and gender has been on the USA, the rest of the Anglophone world and some parts of Europe.
The relevant social roles tend to be described in terms of the kinds of associations that a decade or more ago would have been understood as societal stereotypes, i.e. modes of dress or behaviours stereotypically regarded as “feminine” or “masculine” in a given culture. The concept of social transition also requires attention to the related concept of gender identity, and how this is understood, which itself may vary considerably according to the source. However, this association is often taken for granted as being unnecessary to expand on, as here:
“A full social transition may help children feel that their gender identity is accepted; interact more confidently with peers; feel more securely a part of their social groupings; experience less anxiety in facing new situations and new people”.
Social transition for younger children GIDS Gender Identity Development Service
The UK-based Gender Identity Development Service (GIDS) for children and their families explains social transition to parents as being a process that takes a child “from living in the social role associated with their birth-assigned sex (male or female) to living, across all contexts, in the social role with which they identify”. The GIDS goes on to qualify that when children “wish to be known as neither male nor female, as some do, we do not usually speak about social role transitioning, as these children are sidestepping the traditional public categorisation of binary gender roles”.
A US website, in a guide to “Allyship” with persons identifying as transgender, spells out in more detail the kinds of social role changes which could constitute social transition. These include using a different name and pronouns, changing one’s physical appearance, and using the toilet facilities or living in college accommodation designed for the opposite sex..
A Canadian organisation, Rainbow Health Ontario, advises on a similar list of signs to communicate social transition, including also “binding, packing, tucking or padding” and playing in sports leagues “with other people of your true gender”. They add: “There is no set list or correct order in which to transition socially. Whatever changes you want to make, if any at all, are entirely up to you”.
The Clare Project, a UK organisation, goes into further detail about aspects of what is involved in social transition, including lists of pronouns which might be adopted, and it also includes advice on the healthcare implications of social transition:
“If you have changed your name, you will need to let your GP practice know. They can either add your new name as a ‘preferred name’ on the system or change your name completely. You also need to decide if you want to change the sex you are registered as. You will be registered as Male or Female. Your GP can change your sex on your records – male and female are unfortunately the only options available at the moment! You can also ask your GP to put an ‘alert’ on their system with your gender and preferred pronouns”.
The Clare Project UK
A comment is added: “Some GPs do refuse, and expect the Gender Identity Clinic to do this sort of stuff. I think a lot of them just don’t know that they actually can do it and that it is easy”.
Such recommendations from advocacy groups about the “easy” process of changing the way sex is registered in healthcare records raise clinical concerns about potentially serious medical consequences. The risks apply to the healthcare needs of people identifying as transgender as much as to the vast majority of patients who do not.
In contrast to the GIDS, the Clare Project does include “non-binary” as an example of social transition, and goes further, in describing its target audience as comprising “TBNI”, defined as “Trans, Non-Binary and Intersex people”.
Older protocols required adult patients requesting “sex change” to live as if they were the opposite sex for a defined period before they could access medical or surgical interventions. This process appears to have required public cross-dressing and other behaviours now grouped together and referred to by the term “social transition”.
The World Professional Association for Transgender Health (WPATH) has published guidelines for health professionals in assessing patients who request “gender affirming medical or surgical treatment (GAMST). Notably, WPATH discusses the place of surgical and hormonal interventions to “facilitate social transition”.
In doing so, WPATH reverses the historical order of types of intervention, and seamlessly interweaves medical, surgical and social interventions, presenting this as a multi-faceted clinical package which is recommended as being beneficial to the patient’s mental health:
“Statement 5.4 … Social transition and gender identity disclosure can improve the mental health of a TGD person seeking gender-affirming interventions. In addition, chest and facial surgeries prior to hormone therapy can facilitate social transition”.
WPATH Standards of Care for the Health of Transgender and Gender Diverse People, Version 8
The UK Government’s Equalities Office refers throughout its online guidance to “gender change”, rather than sex change. This is unsurprising, given that the relevant legislation is titled the Gender Recognition Act 2004, but is also an important example of conflation of sex with gender, including contested language such as “gender assigned at birth”.
What is known and what is not known?
It is commonplace for children, especially very young ones, to enjoy dressing up, or pretending to be different characters or animals. Some children do not conform to stereotypically gendered norms in terms of their play preferences or style of dress, in other words, they are gender-non-conforming. This does not mean that they were born in the wrong body or that their sex was somehow wrongly “assigned” at birth.
Many of these gender non-conforming children will grow up to be gay or lesbian adults.
But if a young person who does not conform to gendered stereotypes is told that their non-conformity means they must really have another “gender”, then they may conclude that their sex is wrong. And when that young person has an emergent homosexual or lesbian orientation, the message they hear is that they are really heterosexual, but in a wrongly sexed body. This can create or reinforce a form of internalised homophobia. Indeed, so common has this now become that it is being described as a form of “modern conversion therapy”, where a homosexual or lesbian orientation is being suppressed.
The UK Government’s current non-statutory guidance to schools refers to gender non-conformity and social stereotyping as follows:
“You should not reinforce harmful stereotypes, for instance by suggesting that children might be a different gender based on their personality and interests or the clothes they prefer to wear … Materials which suggest that non-conformity to gender stereotypes should be seen as synonymous with having a different gender identity should not be used and you should not work with external agencies or organisations that produce such material”.
House of Commons Briefing Paper Number 9078, 10 December 2020
There is emerging evidence that children who are “affirmed” by the adults around them, i.e. told to believe that their body has been wrongly sexed, and encouraged to adopt the behaviours and attributes stereotypically associated with the opposite sex, are less likely to change their minds about having a transgender identity than other children whose social transition is not endorsed in this manner. This is especially the case for girls, and for those for whom this process begins relatively early in childhood.
There is a lack of consensus about why this might be, and whether outcomes are harmless, neutral or harmful. Advocates for early social transition may claim that persistence in a cross-gender identity must be a good outcome, because these children were always “trans” and therefore early social transition will have protected them from unnecessary distress, or even possible suicide.
Parents have sometimes been advised to affirm their child in a cross-sex or non-binary identification, on the basis that it is better to have a live daughter than a dead son, (or vice-versa), as though there were a binary choice between social transition or the suicide of their child. This is clearly a terrifying dilemma for parents of a gender-questioning child. However, there has been debate about the accuracy of widely reported statistics of elevated rates of suicidality among transgender-identifying young people, and whether there are possible causal and confounding factors which have not been properly accounted for, such as depression or autism (Biggs, 2022)
A paper by Levine et al examines in detail the ethical considerations when discussing issues of informed consent with affected families. It summarises the evidence for predictors of outcome from embarking on social as well as medical and surgical transition, and describes the debate around risks of suicide.
Another study published in 2022 sought to examine outcomes from early social transition among children aged 6 to7 years old. The US-based Society for Evidence-Based Gender Medicine (SEGM) has critically analysed this study. In its analysis, SEGM makes ten separate criticisms of the study’s methodology, one of which is to question its hypothesis. SEGM observes that:
“children who are socially transitioned at an early age, and who end up persisting with their trans identity, lose touch with biological reality, and as a result, may have unrealistic expectations of what “gender-affirming” hormones and surgeries can realistically deliver”.
Society for Evidence Based Gender Medicine
The SEGM analysis continues by quoting a similar point made by Dutch researchers in 2012.
“Another reason we recommend against early transitions is that some children who have done so (sometimes as preschoolers) 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.”
de Vries and Cohen-Kettenis, 2012, p. 308
These observations go to the heart of what it means to be a child, and to have a child’s view of him or herself and of the world around us.
Do children really decide to socially transition, or are they victims of a process driven by adults?
Unless we accept the proposition (as some do) that there is such a phenomenon as the fully-formed “trans child”, then there has to be a process of social and psychological influences acting upon children to bring them to these conclusions about themselves.
Multiple influences and influencers lay the groundwork that leads a child to the conviction that s/he has somehow been wrongly identified as being, essentially, someone or something else. This is a profoundly confusing and disturbing state for a child to be in.
We make sense of ourselves and of our environment incrementally as we grow up; the human brain develops through infancy into middle and late childhood and on into adolescence and early adult life. This process of brain maturation directly affects the capacity for decision-making, and it determines how children and young people appraise the multiple sources of information and evidence which affect their actions.
Children have only limited cognitive ability to tell the difference between males and females. They tend to focus on external appearance such as style of hair or dress, and they are relatively concrete in their understanding of what makes a girl a girl, or a boy a boy. Very young children have yet to develop a concept of sex constancy, therefore they believe that people can change sex by donning different clothing or changing hairstyles. Their understanding of their own biological sex is determined by their developmental stage, as is their capacity to generalise from the specific to their wider environment.
School is the environment where children are expected to focus on both formal and social learning. Schools have numerous targets to deliver and they are assessed and rated on prescribed outcomes. Ofsted inspections cause considerable pressure on teachers and can be a source of stress for all involved. It is therefore unsurprising that busy teachers willingly adopt ready-prepared packages of resources when these are offered to them as meeting a school’s mandated goals.
However, many of these materials are written and marketed by external third sector providers who have been described as lobby groups, and whose motives may be ideological/political rather than educational.
Sold to local authorities and schools under the banner of anti-bullying initiatives, or for promoting the worthy goals of tolerance and inclusion, these resources tend to be accepted by schools as bona-fide teaching materials. Teachers, understandably, have a tendency to trust their local councils and the NHS to be advising them in good faith.
One such package, used in primary schools, is the “Rainbow Flag Award”, which operates along similar lines to Stonewall’s “Champions” scheme for private and public corporations. It also has parallels with the “Rainbow Badge” and “Pride in Practice” schemes, delivered by the LGBT Foundation and adopted by, respectively, many NHS hospital trusts and primary healthcare settings.
The materials produced for use in schools by the external agencies are replete with rainbows, and also with unicorns and other symbols attractive to children. The same colourful symbols are also commonly found in the context of gender identity activism. The rainbow flag, in particular, has been a widely recognised and respected symbol of gay and lesbian activism and pride for many decades, but it has more recently been adapted to reflect gender identity via an added insert consisting of pastel pink and blue chevrons. Gender identity politics has now widely been merged with the gay rights movement, but the latter was founded to advocate for equality for people with homosexual or lesbian sexual orientation and not transgender identity.
How might materials used in schools to promote gender identity ideology persuade children to accept and act upon their message?
Classical conditioning theory, as described by 19th century Russian physiologist Ivan Pavlov, predicts that by pairing stimuli, implicit or unconscious associations can be made which can influence behaviour. Conditioning theory was further developed in the early 20th century by two psychologists: Edward Thorndyke, and, later, BF Skinner, whose concept of operant conditioning sought to explain how voluntary behaviours can be modified or changed by their consequences.
According to operant conditioning theory, behavioural responses are increased or decreased via processes of “reinforcement”. Relevant examples are an everyday occurrence in the classroom: children are praised or rewarded for responding in ways that the teacher desires, and punished when they fail to do so. Younger children, who already associate unicorns and rainbows with cuddly toys and play, are likely to experience such infographics and flags adorning their classrooms as benign or adorable. They will be inclined to be receptive to any messages that accompany such images, however confusing or developmentally inappropriate they might be, but they will not be consciously aware of the nature of or the reason for their response.
Social learning theory, which was developed by psychologist Albert Bandura, explains human behaviours and responses beyond classical and operant conditioning. Social learning theory proposes that humans learn by observing and imitating other people. When their teachers and peers are unanimous in promoting the notion that there is such an entity as gender identity, and that this is either independent of or more important than their sex, children will be motivated to pay attention, absorb, and retain this information. And, due to their limited life experience, they are likely to believe it.
The term “source monitoring” refers to the developmentally-influenced capacity to distinguish between knowledge which is derived from a child’s own experience, versus information provided by an external source. The younger the child, the less personal experience s/he will have to draw upon, with which to weigh up how to know whether something is true or whether it really happened. All parents will recognise the cognitive limitations of very young children in distinguishing between reality and fantasy, or having the capacity to fully understand metaphor. Belief in fairies, Father Christmas or unicorns are universal stages in childhood.
The teaching notes accompanying books on transgender topics advise teachers to instruct their pupils in now-common linguistic sleights of hand such as “gender” (not sex) being “assigned” at birth, (rather than observed), as though sexing a newborn baby were some arbitrary exercise akin to a child’s game of random “ip dip dip”, and the term “trans” is taught as applying to whole human bodies rather than molecules in the chemistry class.
There is a significant body of research around children’s suggestibility and relatively concrete thinking, their difficulties with source monitoring, and how far they can be influenced by constant repetition of certain messages. Much of this research has been undertaken in the context of seeking to improve outcomes in legal proceedings involving child witnesses, with particular relevance to cases of alleged child sexual abuse.
In 2002 a review paper on children’s suggestibility outlined six areas about which little is known and where there is a need for further study (Warren, A, & Marsil, D; 2002).
Among these are: “suggestibility in older children, suggestions outside of leading questions and outside formal interview settings, individual differences in suggestibility”. Whilst there has been much research into how children can be helped to resist immediate suggestions made to them in legal interviews, these authors observed that there is far less research into “undoing the damage of suggestions already provided”. The authors remarked: “It is difficult to train children to resist potentially suggestive questions or to ‘gate out’ previously suggested information”.
Important questions arise concerning the ability of children to resist the suggestive messages repetitively delivered by ideologically-driven teaching in schools, paired as they are with cute, glittery unicorns, pretty rainbows, and posters celebrating trans and non-binary “gender identities”, and reinforced via membership of special lunchtime clubs.
Some commentators have observed how social transition is portrayed as desirable, or something to be emulated and celebrated, so that children who go down this path are applauded and acclaimed by their peers, both in school and in social media forums. Peer group influence is particularly powerful for adolescents, and social contagion has been hypothesised to account for the observation that many more adolescent girls have “come out” as transgender in recent years, without necessarily having shown any sign of gender dysphoria in their earlier childhood (Littman, L; 2019).
Another commentator has described Rapid Onset Gender Dysphoria (ROGD) as a “pseudo-medicalised youth subculture” (Az Hakeem; Detrans: When Trans is not the Solution, 2023). He compares the zeal with which young people are eagerly embracing transgender identities with other ways in which teenagers have perceived themselves as rebellious, such as becoming a goth. Being goth and being trans are, however, both similarly conformist within their peer group, where everyone dresses, speaks and behaves in the same manner in an effort to be recognised as a member of the cool set. Teenagers, in fact, are remarkably conformist in their intense strivings not to conform.
What are some examples of materials used in schools to promote gender identity theory?
There are many examples, with rainbows and unicorns in abundance. An infographic known as the “gender unicorn” was conceived by the Trans Student Educational Resources group in the USA and has been used in many UK schools to teach children the idea that there are five supposed dimensions of human gender and sexuality. The first of these is “gender identity”, which is depicted as a rainbow floating in a cloud of thought bubbles emanating from the unicorn’s head.
It is challenging for any primary school child to appraise the information in a video which has been shown to children in some UK schools. This video is narrated by a seven year old in a dress, whose parents, “when they saw that that was truly who I was, they let me live as a girl”. Developmental limitations in the ability to source monitor can also be considered in relation to how children like the one appearing in the video arrive at the conclusion that they were always really a member of the other sex. When their adults have told them this, on the basis of a preference for clothes and toys stereotypically associated with the other sex, a young child will have difficulty in distinguishing whether this was always their own belief or experience.
A story about Thomas, a teddy bear, is delivered as part of the “No Outsiders” programme aimed at Key Stage 1, ie children aged between 5 and 7 years. When presented with this story about a teddy bear who changes sex, primary school children of this age have only a limited frame of reference within which to be able to arrive at an informed opinion about the meaning of the content, because for them it is entirely possible that people can change sex by putting on different clothes.
It is similarly likely that children in Key Stage 2 will be confused by the metaphor intended by “Alien Nation”. This is a story book featuring alien babies who have found themselves originally on the wrong pastel-coloured planet, but who become trans-babies, crossing over bridges to a pink or blue planet, or to a purple planet for “non-binary” alien babies.
CBeebies is BBC television for children, and is aimed at younger children under the age of six. Children’s TV has many examples of messages about “special” children who are ordinary on the outside but can transform into superheroes and perform great feats. We would all recognise this as an almost universal childhood fantasy, and there are numerous examples in characters from children’s literature, comic books and films. In the context of the gender identity beliefs that are now prevalent in our society, secret heroes such as this are now often depicted as transgender ikons, with attractive and colourful symbolic signifiers such as bright blue or green hair.
Miraculous transformation is the central theme of the famous fairy tale of Pinocchio. As an example, for those adult viewers expecting the eponymous CBeebies series to be just a story about a wooden puppet, there are other characters to meet, some of them updated for the 21st century. The “Fairy with Turquoise Hair” (FWTH), (a character who does feature in the original tale), is initially taunted because she is “different”, but she steals a phone belonging to one of the bullies and changes the language in the phone’s software to “Eelish”. When the bully complains that she cannot now use her own phone because she cannot understand its language, another character scornfully remarks that she herself has a certificate in Eelish, and that everyone needs to speak Eelish these days. Thus, the previously bullied FWTH, always a sympathetic character, has now also been transformed into somebody who triumphs over adversity, who controls the language and communication of others, and has a recognised ally who supports her.
We may be reminded here of the imperatives around pronoun use, including neologisms, which are prescribed by their advocates as an essential component of social transition, and which others are expected to use or else be accused of intolerance and transphobia. “As well as changing our names, people may also want to change their pronouns (how people refer to them). Example pronouns include: he/him/his • she/her/hers • they/them/theirs • xe/xem/xyr • ze/hir/hirs • ey/em/eir • it/it/its • e/em/ems”.
In the series, ‘Pinocchio’, there are also characters such as a toy robot, which is coloured purple, green and white, and a toy dinosaur. In Pinocchio, these characters are depicted as bullies who tyrannise the others and are transformed back into harmless inert toys by the power of waving a rainbow flag. These messages are subliminal but effective, and they can act on children’s brains to shape their thinking, attitudes and behaviours, in subtle but powerful ways.
Who is particularly at risk?
Whilst it is the norm for teenagers and young people to have a strong desire to fit in with the group, and to be uncertain about the type of adult they are growing up to become, there are certain groups of children who are especially vulnerable to persuasive influences around social transition:
A child who may experience him or herself as different from their peers may achieve both a sense of belonging and an elevated social status by publicly identifying as “trans” or “non-binary”. Neurodivergent children such as those on the autistic spectrum do not easily “fit in” with their peers, and there is evidence that they are over-represented in referrals to gender clinics.
A child with low self-esteem and confusion about his or her identity, may attribute his or her newfound sense of confidence about personal identity to having discovered their “true” gender, in a context where this is repeatedly presented as something to be celebrated and displayed. Children who are adopted or in the care system are among those who tend to have low self-esteem, a sense of not belonging, and generalised issues with their identity, and they are also over-represented in referrals to gender services. Their novel social acceptance rewards those who social transition, and is a powerful positive reinforcer for the accompanying beliefs and behaviours.
A child’s mental health problems may be underestimated or overlooked once social transition has begun. This phenomenon, described as “diagnostic overshadowing”, is a specific concern of Dr Cass, who states: “many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be overlooked”.
Hannah Barnes, in her book Time to Think (2023) interviewed staff at GIDS, who observed that “With some young people, the dysphoria appeared to have been immediately preceded by a traumatic event” (page 158). Clinicians highlighted to Barnes the extraordinarily complex nature of the patients they were seeing at GIDS, and how the solution they were offered always seemed to be the same.
Is social transition a child safeguarding issue?
There is a prominent and growing body of opinion which sees social transition as a part of a wider political movement which centres adult needs and wishes, and has co-opted children as a necessary tool for the mainstreaming and survival of its aims.
Aspects of social transition such as breast-binding have been conceptualised as a form of grooming or child exploitation, linked with the modern day mainstreaming of pornography which objectifies women and girls.
Others observe the phenomenon of “Drag Queen Story Hour” as an example of age-inappropriate targeting of children with highly sexualised parodies of womanhood.
“Grooming” is a term most associated with the exploitation of children by adults for their own sexual gratification. It is a form of child abuse, which has certain well-recognised elements, including befriending, giving favours, and, importantly, encouraging a child to keep secrets and isolating him or her from their parents. Groomers exert control by encouraging the child to see them as the child’s true ally whilst portraying their parents as being abusive.
Many parents of trans-identified children have vividly described the ways in which they have been estranged from their children if they did not agree to “affirm” the new gender identity, as a step along the pathway of social transition. (Bayswater Support Group). They say that this has prevented them from being able to protect their children from the consequence of decisions which are being facilitated by other adults, external to the family, who have established influence over their children, and alienated them from their parents. (PHSE Brighton)
During the child sexual exploitation scandals in Rochdale and elsewhere in the UK, there was, for many years, a widespread set of assumptions, across professions, including social care, the police and healthcare. Those professionals asserted that the child victims were making “lifestyle choices”. They were seen as mini-adults, competent to make informed choices to comply with what some powerful adults were demanding of them. Their supposed decision-making was, however, based not on true autonomy but upon a form of coercion disguised as friendship, even love. This is now widely accepted, so that the former presumptions are thoroughly discredited, and the statutory agencies are judged to have catastrophically failed those children.
Many desperate parents spoke out then; their voices originally largely fell upon deaf ears, but they are now being listened to, by both professional practitioners and policy-makers.
Perhaps there are still lessons to be learned from those events, and the assumptions that were made at that time, assumptions about children and the balance between their autonomy and their continuing need to be kept safe and well by responsible adults. Listening to the child can sometimes mean that we are hearing someone else’s script, and not necessarily the child’s own words.
Younger children, as we have seen, with their limited experience and their still-developing cognitive capacity to appraise the meaning and motives of adult influence, can be readily manipulated or coerced to conform with adult desires and wishes. Teenagers, girls in particular, can be pulled into conforming with whatever the peer group happens to be promoting, especially via electronic media, and sometimes with the blessing of official sources of mental health support from adults.
Others propose that such fears constitute “transphobia”, referencing historical, homophobia-driven opposition to teaching children about homosexuality, as a comparator, citing the infamous “Section 28”. This argument rests on acceptance of the proposition that there is an equivalence between the issues or consequences for young people in schools from discussion of same sex attraction as there are for unscientific notions around transgender identities.
Media sources have recently suggested that the UK Government’s long-awaited Guidelines for teachers on trans-identified children in schools are likely to recommend a “presumption against” social transition. It appears that there have been debates within the Government on related legal issues; these have been commented on elsewhere.
Teachers urgently need informed, evidence-based and detailed guidance, which should include attention to relevant clinical issues, and which takes into account that social transition is not a neutral act, and that it may have profound consequences for children.
2 replies on “What is ‘Social Transition’ and why is it important?”
Thank you Dr Jane Martin.
Brilliant article. Says it all!