Children may show an interest in clothes or toys that society tells us are more often associated with the opposite gender. They may be unhappy with their physical sex characteristics. However, this type of behaviour is reasonably common in childhood and is part of growing up. It does not mean that all children behaving this way have gender dysphoria or other gender identity issues. Most children who seem confused about their gender identity when young will not continue to feel the same way beyond puberty. Role playing is not unusual in young children.
A small number of children may feel lasting and severe distress, which gets worse as they get older. This often happens around puberty, when young people might feel that their physical appearance does not match their gender identity.
This feeling can continue into adulthood with some people having a strong desire to change parts of their physical appearance, such as facial hair or breasts. As Christians, we know that God created us and that being male or female is an important part of what it means to be created in the image of God (Genesis 1:27). We know that God doesn't make mistakes when he creates an individual (Psalm 139:13-16).
- Over the past few years, there has been a significant increase in the numbers of children presenting with gender dysphoria or questioning their gender identity (bit.ly/3idL1pL).
- In particular, there has been a very significant increase in the numbers of girls with no childhood history of gender dysphoria presenting as trans or as non-binary in their teens (bit.ly/3xizj04). The reasons for this increase are as yet poorly understood. There are often clusters within friendship groups in schools.
- Evidence shows that gender dysphoria will only persist in around 16 per cent of those presenting in childhood (bit.ly/3jvqg4F). For the majority, the feelings of gender dysphoria will discontinue as they go through puberty, with many of these people being same-sex attracted (bit.ly/3KGr26S). For those who develop gender dysphoria in adolescence, the persistence rates are unknown.
- There is a high incidence of comorbid mental health problems among those with gender dysphoria.
- There is also a high prevalence of autistic spectrum disorders (or traits) in those suffering from gender dysphoria (bit.ly/3E7rVa2).
- Increasingly children and young people self-identify as transgender and socially transition before seeing a medical professional and receiving any assessment or diagnosis. Social transition is a powerful intervention that often doesn't decrease the person's distress in the long term and may increase the likelihood of trans identification persisting (bit.ly/38CwhKs).
- There is currently much debate about treatment pathways for children suffering from gender dysphoria. Little evidence is available to help clinicians reach an agreed approach. Recent NICE evidence reviews looked at the use of puberty blockers and cross-sex hormones. They found that the evidence base to support their use in children was very poor (bit.ly/3EsQAOJ).
- The latest NHSE guidance states: 'Healthcare decisions always involve weighing up the potential benefits and risks of treatment. For hormone blockers, that includes reflecting on the limited scientific evidence base for their use in this context (see NICE evidence review). This underlines the importance of patients, their families or carers, and clinicians having full information when making decisions and in ensuring the Gender Identity Development Service (GIDS) follows a safe and robust clinical process' (bit.ly/3EsQiOJ).
- Puberty blockers were introduced as a way to put a pause on puberty to hopefully reduce distress and allow time to properly assess a child and explore their difficulties. However, almost all children who go onto puberty blockers progress to cross-sex hormones. They do not, therefore, appear to be the reversible pause that was intended. This is particularly problematic because puberty itself often brings about resolution of the gender identity difficulties. (bit.ly/3MS9rhL).
- Puberty blockers and cross-sex hormones have several adverse effects - loss of fertility, loss of sexual function, reduced bone density, vaginal atrophy and the need for hysterectomy (biological females) and lack of penile development (biological males). Some of these are irreversible, while others can make reassignment surgery more complicated if the young person chooses that pathway at a later date.
- The issue of consent has been raised and is being debated in the court arena. At the time of writing, Bell v Tavistock is awaiting an appeal to the Supreme Court. Medical treatment and surgical procedures for gender dysphoria in children are experimental, and due to the effects on sexual function and fertility, there are big questions over a child's or young person's ability to meaningfully consent to such experimental treatments with lifelong consequences, especially when in the midst of such distress.
- Increasing numbers of people are coming forward about their decision to stop transitioning and live once more as their biological sex. Some regret the treatment they have been given; others don't but wish to return to living as their biological sex (bit.ly/3JAFyzx). This growing cohort of 'detransitioners' is another reason to be cautious when discussing transition in the first place. There is an increasing likelihood of some detransitioners taking legal action in the future, who may justifiably feel that a gender-affirming approach was taken too easily when they were at a particularly vulnerable period of their lives.
- As healthcare professionals, it is always our duty to act in the best interests of our patients, based on the best available evidence and considering implications for the future.
What can I do?
- Listen to the patient - allow them time and space to share what they feel comfortable sharing. There may be many reasons or other issues underlying their questioning of gender.
- Consider the need for referral to mental health services to address co-existing mental health problems.
- As always, do not make inappropriate promises around confidentiality (basic safeguarding principle).
- If the patient is a child or young person:
- Encourage communication between them and their parents
- Normalise uncertainty and understand that puberty and adolescence can be a time of great turmoil for many young people
- Ensure that they and their parents have access to good quality information around gender dysphoria. This may involve you checking resources or local groups first.
- Consider whether a referral to CAMHS may be appropriate if there may be co-occurring mental health issues.