A gender identity development service

We work in the UK service based at the Tavistock Centre in London, offering assessment and intervention for children and adolescents experiencing difficulties with their gender identity development. In addition, we work with children with a transgendered parent. The multidisciplinary team includes clinical psychologists, psychiatrists, social workers and child psychotherapists, working in association with two consultant paediatric and adolescent endocrinologists at UCLH who provide regular adolescent liaison clinics. Our assessments consider the holistic context of such a presentation, including the history of the gender dysphoria, the family history and young person’s developmental and medical history, the attitudes of the family and school, and sources of stress and supports. We particularly focus on areas of gender identity such as the young person’s identity statements, cross-dressing, toy and role-play, peer relations, mannerisms and voice, anatomic dysphoria, and rough-and-tumble play (Zucker &?Bradley, 1995). We also include risk assessments around any self-harm and possible suicidal ideation and, with the family’s permission, liaise with any local services and the school. The service operates a network model of care, and team members regularly convene and attend local meetings to discuss the needs of the young person in relation to their gender identity development, and agree roles with all involved professionals. Following our assessment, we might recommend family and/or individual work to monitor the gender dysphoria and address associated difficulties, such as low mood and distress and problems with bullying and stigma in the family, local community or school. We also work closely with schools and local services in order to reduce shame and secrecy, consider the boundaries between what is public and private with regard to information sharing and to manage risk and promote support and coping. Our interventions involve a staged model of care, which include: Stage 1: Following assessment, further therapeutic exploration of the nature of gender identity. In adolescents, reversible physical interventions are considered if their gender identity disorder (GID) persists and shows a high level of consistency. Stage 2: Includes wholly reversible intervention to produce a state of biological neutrality – known as hormone-blocking treatment. This occurs alongside continued psychological exploration, support and physical monitoring by a consultant paediatric endocrinologist.I Stage 3: Is considered if the GID persists during Stage 2. Includes partially reversible interventions, e.g. the administration of cross-sex hormone that masculinises or feminises the body. Stage 4: Includes irreversible interventions, such as surgical procedures. This is not considered before the age of 18, and so the Gender Identity Development Service would facilitate a smooth transition to the adult Gender Identity Service who are able to provide these interventions. Transfer to adult services would usually happen prior to the introduction of cross-sex hormones. The figures usually quoted suggest that for individuals presenting with GID prior to adolescence about 80 per cent do not persist and find a solution other than gender transition. The most common outcome in this group is homosexuality and bisexuality. Conversely for those who present to the service in adolescence the figures are reversed and about 80 per cent pursue physical sex re-assignment. The recent newspaper articles assume that allowing the young person to live in a role of their perceived identity necessarily leads to gender reassignment. Our experience shows that some young people who lived in role from the age of nine or ten changed during their pubertal development. There is currently much debate around the timing of physical interventions. In a number of countries in Europe and America the hormone blocker is being offered in earlier stages of puberty. If the young person decides not to pursue physical gender reassignment the blocker is stopped, and their own sex hormones resume. But the debate revolves around the reversibility of this intervention – physical and also psychological, in terms of the possible influence of sex hormones on brain and identity development. Zucker, K.J. & Bradley, S.J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Plenum Press

Seeing the child in context: Supporting gender diverse children and their families in multiple ways – An introduction to this special edition

This Special Issue of Clinical Child Psychology and Psychiatry includes a group of papers that originated in the work of the Gender Identity Development Service (GIDS), which is the nationally designated National Health Service (NHS) in the United Kingdom to work with children and adolescents experiencing significant concern and distress about their gender. This short introduction to those papers aims to set the context and explain why certain areas have been given a focus

Psychological functioning in adolescents referred to specialist gender identity clinics across Europe : a clinical comparison study between four clinics

Adolescents seeking professional help with their gender identity development often present with psychological difficulties. Existing literature on psychological functioning of gender diverse young people is limited and mostly bound to national chart reviews. This study examined the prevalence of psychological functioning and peer relationship problems in adolescents across four European specialist gender services (The Netherlands, Belgium, the UK, and Switzerland), using the Child Behavioural Checklist (CBCL) and the Youth Self-Report (YSR). Differences in psychological functioning and peer relationships were found in gender diverse adolescents across Europe. Overall, emotional and behavioural problems and peer relationship problems were most prevalent in adolescents from the UK, followed by Switzerland and Belgium. The least behavioural and emotional problems and peer relationship problems were reported by adolescents from The Netherlands. Across the four clinics, a similar pattern of gender differences was found. Birth-assigned girls showed more behavioural problems and externalising problems in the clinical range, as reported by their parents. According to self-report, internalising problems in the clinical range were more prevalent in adolescent birth-assigned boys. More research is needed to gain a better understanding of the difference in clinical presentations in gender diverse adolescents and to investigate what contextual factors that may contribute to this

Time trends in referrals to child and adolescent gender identity services : a study in four Nordic countries and in the UK

Purpose: To explore whether the increase observed in referrals to child and adolescent gender identity services (GIDSs) has been similar in four Nordic countries and in the UK. Materials and methods: Numbers of referrals per year in 2011–2017 were obtained from all GIDS in Denmark, Finland, Norway, Sweden and the UK and related to population aged <18. Results: A similar pattern of increase in referral rates was observed across countries, resulting in comparable population adjusted rates in 2017. In children, male:female birth sex ratio was even; in adolescents, a preponderance of females (birth sex) was observed, particularly in Finland. Conclusions: The demand for GIDSs has evolved similarly across Nordic countries and the UK. The reasons for the increase are not known but increased awareness of gender identity issues, service availability, destigmatization as well as social and media influences may play a role

Longitudinal Outcomes of Gender Identity in Children (LOGIC): protocol for a prospective longitudinal cohort study of children referred to the UK gender identity development service.

INTRODUCTION: Gender identity development services (GIDS) worldwide have seen a significant increase in referrals in recent years. Many of these referrals consist of children and young people (CYP) who experience gender-related distress. This study aims to improve understanding of outcomes of CYP referred to the UK GIDS, specifically regarding gender identity, mental health, physical health and quality of life. The impact of factors such as co-occurring autism and early social transition on outcomes over time will be explored. METHODS AND ANALYSIS: This is a prospective cohort study of CYP aged 3-14 years when referred to the UK GIDS. Eligible participants will be ≤14 years at the time their referral was accepted and will be on the waitlist for the service when baseline measures are completed. Children aged under 12 years will complete the measures in an interview format with a researcher, while young people aged 12 years and over and their parents/caregivers will complete online or paper-based questionnaires. Participants will complete follow-up measures 12 months and 24 months later. The final sample size is expected to be approximately 500. Logistic regression models will be used to explore associations between prespecified explanatory variables and gender dysphoria. Appropriate regression models will also be used to investigate explanatory variables for other outcomes. Subgroup analyses based on birth-assigned gender, age at referral and co-occurring autistic traits will be explored. ETHICS AND DISSEMINATION: The study has been approved by the Health Research Authority and London - Hampstead Research Ethics Committee (reference: 19/LO/0857). The study findings will be published in peer-reviewed journals and presented at both conferences and stakeholder events. Findings will be used to inform clinical practice

Longitudinal Outcomes of Gender Identity in Children (LOGIC): study protocol for a retrospective analysis of the characteristics and outcomes of children referred to specialist gender services in the UK and the Netherlands.

INTRODUCTION: Specialist gender services for children and young people (CYP) worldwide have experienced a significant increase in referrals in recent years. As rates of referrals increase, it is important to understand the characteristics and profile of CYP attending these services in order to inform treatment pathways and to ensure optimal outcomes. METHODS AND ANALYSIS: A retrospective observational study of clinical health records from specialist gender services for CYP in the UK and the Netherlands. The retrospective analysis will examine routinely collected clinical and outcome measures data including demographic, clinical, gender identity-related and healthcare resource use information. Data will be reported for each service and also compared between services. This study forms part of a wider programme of research investigating outcomes of gender identity in children (the Longitudinal Outcomes of Gender Identity in Children study). ETHICS AND DISSEMINATION: The proposed study has been approved by the Health Research Authority and London-Hampstead Research Ethics Committee as application 19/LO/0181. The study findings will be published in peer-reviewed journals and presented at both conferences and stakeholder events

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

A child without a gender challenges our preconceptions about sex

The Canadian health card issued to baby Searyl Atli marked with a U for gender highlights the increased need in society to recognise and accommodate diversity in gender identities and expression. Whether this U stands for unknown, undisclosed or unidentified is not clear. But a binary definition of gender and the assumptions and expectations that go along with this are problematic for those who do not feel they fit into this construct. And that binary model of gender is being challenged, with many young people conceptualising it in terms of a spectrum...Click on official URL to continue readin

To treat or not to treat: Puberty suppression in childhood-onset gender dysphoria

Puberty suppression using gonadotropin-releasing-hormone analogues (GnRHa) has become increasingly accepted as an intervention during the early stages of puberty (Tanner stage 2-3) in individuals with clear signs of childhood-onset gender dysphoria. However, lowering the age threshold for using medical intervention for children with gender dysphoria is still a matter of contention, and is more controversial than treating the condition in adolescents and adults, as children with gender dysphoria are more likely to express an unstable pattern of gender variance. Furthermore, concerns have been expressed regarding the risks of puberty suppression, which are poorly understood, and the child's ability to make decisions and provide informed consent. However, even if the limited data available mean that it is not possible to make a conclusive treatment recommendation, some safety criteria for puberty suppression can be identified and applied