Gender Identity Development Service Research Articles

Letter to the editor: Gender Identity Development Service

Letter to the editor: Gender Identity Development Service

Exploring navigation of gender in a sample of clinically referred young people attending the gender identity development service

BackgroundGender-diverse young people experience a cisnormative world and are subject to unique minority stressors, which have been found to contribute to adverse mental health. This research aims to understand the social and personal context unique to gender-diverse people that young people navigate prior to attending specialised services.MethodsThe baseline measure of a newly developed questionnaire, the GIDS Gender Questionnaire (GIDS-GQ), was sent to all young people (or caregivers for those aged under 12) attending the Gender Identity Development Service (GIDS). Eighty-four young people and caregivers completed the questionnaire, with eighty-one included in the final sample (M = 15.77 years, SD = 1.83, range = 9–17; assigned female at birth = 72, assigned male at birth = 9). Questionnaires were emailed to participants via an online survey between one and three appointments with the Service. Data were collected between April 2021 and February 2022.ResultsAll young people had initiated a social transition, with 75.3% categorised as fully socially transitioned. More young people reported experiencing transphobic bullying (64.2%) and a lack of acceptance of their gender identity (85.1%) in the past (lifetime) than in the 6 months prior to attending the service (transphobic bullying: 12.3%; non-acceptance: 49.4%). 94.5% of the sample reported disliked body parts, most commonly breasts (80.8%), genitals (37%), and hips (31.5%). Participants most commonly reported a decrease in their mood (61.25%) and most areas of social connectedness.ConclusionsThe majority of this sample had socially transitioned, were supported in their identification, and had experienced less transphobic bullying and non-acceptance prior to commencing services. However, young people continued to dislike their bodies, and experience low mood and social connectedness. Future research is needed to understand how clinical support can help reduce the impact of these external/distal minority stressors by promoting social connectedness, incorporating such learnings into clinical practice and subsequent policy in clinical work with gender-diverse young people.

Is Social Gender Transition Associated with Mental Health Status in Children and Adolescents with Gender Dysphoria?

Social gender transition is an increasingly accepted intervention for gender variant children and adolescents. To date, there is scant literature comparing the mental health of children and adolescents diagnosed with gender dysphoria who have socially transitioned versus those who are still living in their birth-assigned gender. We examined the mental health of children and adolescents referred to the Gender Identity Development Service (GIDS), a specialist clinic in London, UK, who had socially transitioned (i.e., were living in their affirmed gender and/or had changed their name) versus those who had not socially transitioned. Referrals to the GIDS were aged 4–17 years. We assessed mental health correlates of living in one’s affirmed gender among 288 children and adolescents (208 birth-assigned female; 210 socially transitioned) and of name change in 357 children and adolescents (253 birth-assigned female; 214 name change). The presence or absence of mood and anxiety difficulties and past suicide attempts were clinician rated. Living in role and name change were more prevalent in birth-assigned females versus birth-assigned males. Overall, there were no significant effects of social transition or name change on mental health status. These findings identify the need for more research to understand how social transition influences mental health, including longitudinal studies that allow for more confident inferences to be made regarding the relationship between social transition and mental health in young people with gender dysphoria.

Thinking Time, Shifting Goalposts and Ticking Time Bombs: Experiences of Waiting on the Gender Identity Development Service Waiting List.

LOGiC-Q is a prospective longitudinal qualitative study that explores the experiences of children and young people, and their families, who have been referred to the Gender Identity Development Service (GIDS) in the UK. This paper describes the experiences of children and young people and their parents while they are on the waiting list to be seen. Semi-structured interviews were undertaken with 39 families who had been referred to GIDS and were waiting for their first appointment with the service. Both parent and child/young person were interviewed. Analysis of the anonymised interview transcripts was informed by both narrative and thematic approaches, and three predominant narratives around waiting were identified: 1. Positive experiences attached to waiting; 2. Feelings of distress and stuckness; 3. Suggestions for support while waiting. Findings from this study indicate variations in how waiting is experienced depending on the age of the child, and how distressed their body makes them feel. Young people and their parents offered suggestions for how the service could support families on the waiting list. These suggestions related primarily to ways of checking in and providing reassurance that they were at least still on the list as well as ideas about how to make the wait less distressing, rather than necessarily making the wait shorter, which was more spoken about in terms of an ideal rather than a realistic option.

Gender dysphoria: An overview for orthodontists.

Among non-gender conforming populations, there is a subgroup of individuals who experience significant distress associated with their gender incongruity, commonly referred to as gender dysphoria (GD). In the UK, there is a recognised pathway for individuals experiencing GD. This has traditionally been initiated by a referral to the Gender Identity Development Service (GIDS) for children and adolescents or to a Gender Identity Clinic (GIC) for adults. This pathway can potentially involve several specialties and treatment modalities, including the prescription of various hormones. It is important for orthodontists to have an understanding of this field, as well as the potential treatment modalities, so that they can support this often marginalised patient group. Inherent differences between male and female facial features may also lead patients with GD to present to orthodontists, wishing to change their facial appearance. This article highlights the current national pathway for GD and the orthodontic considerations for these individuals.

The interim report of the Cass review into the NHS gender identity development service: a discussion

Professor Bryan McIntosh and Ellie Koseda provide an overview of the review into the NHS's only gender identity development service, led by Dr Hilary Cass, following the publication of the interim report in February 2022. Key issues in this complex and developing field are discussed.

Trajectories of transgender adolescents referred for endocrine intervention in England

ObjectivesSome gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then...

Discharge outcome analysis of 1089 transgender young people referred to paediatric endocrine clinics in England 2008–2021

IntroductionThe destination of transgender and gender variant young people referred by the National Health Service (NHS) Gender Identity Development Service (GIDS) to, and discharged from the two English paediatric endocrine...

Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy

Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population. The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender. Gender expression in trans binary youths and non-binary youths. The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019-June 2021. The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants' experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants. These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender. This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy. The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;19:1035-1048.

Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory, ideas and practice.

The Gender Identity Development Service (GIDS) supports gender diverse young people, and their families but currently does not provide weekly psychological therapy as part of its core work. In addition, local Child and Adolescent Mental Health Services (CAMHS), may feel deskilled in providing support for this population. We, a group of three Clinical Psychologists, aim to share some common themes and observations gained from our work in GIDS. We talk about how existing Cognitive Behavioural Therapy (CBT) models can be relevant and helpful for the challenges facing gender diverse young people, without pathologising, or aiming to change a young person's gender identity. An illustrative case study is presented, based on an amalgamation of young people we have worked with highlighting how third-wave cognitive behavioural theory, ideas and practice can be used to support young people to manage gender-related distress. Further reflections on the broader socio-political context, and implications for clinical practice and future research are discussed.

Shifts in demographics and mental health co-morbidities among gender dysphoric youth referred to a specialist gender dysphoria service.

Past research has identified shifts in the demographics and co-occurring mental health issues of youth referred to certain gender dysphoria services. The present study examined shifts in demographics (age, sex and social transition status), social adversity (bullying experiences and abuse) and psychological functioning (mood, anxiety, suicidality and autism spectrum disorder) at time of referral (of both children and adolescents) to the Gender Identity Development Service, London between the years of 2012 and 2015. Patients were 782 children and adolescents (M = 13.94, SD = 2.94, range 4-17; 63.8% assigned female at birth). Little change in sex ratio or age was observed between these two time points. However, we observed greater rates of depression and anxiety of birth-assigned females (but not birth-assigned males) in the more recent cohort, at the same time that reported social adversity (bullying and abuse) was falling. Also, of interest, the proportion of young people who had partially or fully socially transitioned prior to contact with the service had increased overtime. We discuss potential factors driving these shifts and their implications for supporting recent cohorts of gender diverse young people.

Shapes of gender identity: three stories with impact

The paper describes three stories of children and adolescents with atypical gender identity development followed in psychotherapy. These cases have already been published, but are revisited here to show how these experiences contributed to the creation of the therapeutic intervention model of the Gender Identity Development Service originally established in 1989 at St George’s Hospital, London. The service transferred to the Tavistock Centre in 1996. The first case shows the gradual recognition of dealing with the development of an atypical gender identity rather than a psychiatric condition. Reflection on this case led to the definition of possible therapeutic goals. The second case illustrates the difference between solid and fluid identities, an important distinction in the decision to consider the possibility of physical intervention. The third case shows the network management model and addresses issues concerning autonomy.

Puberty blockers in gender dysphoria: an international perspective

Keira Bell, a patient who started to take puberty blockers at the age of 16 years for gender dysphoria (GD), recently won a legal battle against the Tavistock and Portman...

A Backwards-step for Gillick: Trans Children's Inability to Consent to Treatment for Gender Dysphoria-Quincy Bell & Mrs A v The Tavistock and Portman NHS Foundation Trust and Ors [2020] EWHC 3274 (Admin).

The case of Quincy Bell & Mrs A v The Tavistock and Portman NHS Foundation Trust and Ors is a judicial review into the treatment practices of the Gender Identity Development Service (GIDS) run by Tavistock and Portman NHS Foundation Trust (Tavistock). The Divisional Court considered whether children and young people with Gender Dysphoria (GD) can ever be Gillick competent to consent to treatment with Puberty Blockers (PBs), and if so whether GIDS provided sufficient information to support an informed consent. This commentary examines the six key areas of the judgment: the nature of GD and its treatment with PBs; the categorisation of PBs as experimental treatment; the high bar set to achieve Gillick competence; the convergence of information provision and competence; the role of parental consent; and finally the protective jurisdiction of the court. The conclusion of the court that transgender children aged under 16 years will find 'enormous difficulties' in reaching the Gillick threshold to be able to consent to PBs, and that even 16- to 17-year olds would benefit from a 'best interests determination' from the court, signals judicial thinking which is markedly protectionist. Considering the broad contemporary stance in healthcare of facilitating competence, valuing patient participation, and respecting rights, I argue that this judgment is out of step. It has implications not only for transgender children, but it may also be a worrying signal of a greater general retreat from Gillick and a corresponding advance in emphasis on judicially determined best interests.

The Violence of Postmodern "Gender Identity" Medicine

The medical “transition” of children with “gender dysphoria” is increasingly normalized in North America, Western Europe, Australia, New Zealand, and the United Kingdom. Although each country has specific national gender identity development services, the rationale for prescribing hormone treatment is broadly similar. A minority rights paradigm underpinned by postmodern theory has gained traction in the past 10 years and has been successful in influencing public policy, the education of pediatricians, endocrinologists, and mental health professionals. In this view, any response other than an affirmation of the child’s claim to be the opposite sex or “born in the wrong body” is understood as a denial of their human rights to have their “outer” body match their authentic “inner” self. The postmodern paradigm has brought about a concomitant shift in the classification of the patient from a child who suffers “gender dysphoria” to a child who is “transgender”. Yet the practice of putting children on a medical pathway brings severe, life-long consequences including bone/skeletal impairment, cardiovascular and surgical complications, reduced sexual functioning, and infertility. Examination of postmodern “transgender” health care reveals it is rarely expert, evidenced-based or objective but on the contrary, is highly politicized and controversial. Although the High Court in the United Kingdom has ruled those children 16 years and under cannot consent to hormone treatment, several lobby groups, as well as the NHS Tavistock and Portman Hospital Trust Gender Identity Development Service (GIDS), have been granted legal permission to challenge the ruling. With the example of the United Kingdom, I demonstrate that if the appeal is successful, children’s rights to protection from bodily and psychological harm will continue to be abused by the postmodern social justice paradigm which, in the very name of upholding children’s rights, violates them.

A Longitudinal Study of Features Associated with Autism Spectrum in Clinic Referred, Gender Diverse Adolescents Accessing Puberty Suppression Treatment.

Literature has documented inflated rates of features associated with autism spectrum (AS) in clinic referred, gender diverse young people. This study examined scores on the Social Responsiveness Scale, Second Edition (SRS-2) over time in a group of clinic referred, gender diverse adolescents accessing gonadotropin-releasing hormone analogues (GnRHa) to supress puberty. Primary caregivers of 95 adolescents presenting to the Gender Identity Development Service (GIDS) completed the SRS-2 prior to receiving endocrine input (mean age: 13.6 ± SEM: 0.11) and after approximately one year of accessing GnRHa (mean age: 14.6 ± SEM: 0.13). No significant differences in SRS-2 scores over time and between birth assigned sex were found. No interactions between time and birth assigned sex were established for SRS-2 subscales or total scores.

No matter what pronoun: reading on gender and humanity

The UK's Gender Identity Development Service places an emphasis on context—on assessing the wider context of the lives of young people referred to the clinic: their relationships, peer groups, cognitive development, and family dynamics. Considering questions and concerns around gender identity, one useful context to enrich understanding and empathy can come through reading novels: well-written ones that create whole worlds in which we meet and eventually understand individual characters.

Co-ordinating meaning within a gender identity development service: What can the theory of the co-ordinated management of meaning offer clinicians working with young people, and their families, exploring their gender identities.

Working with young people who present with diverse gender identifications and their families requires consideration and acknowledgement of a range of contexts (including relationship, family, social and cultural) as well as the influences of prior experience and language. Family members often present with diverse understandings and hopes from their referral to the Gender Identity Development Service and look to us to meet these. This article considers the contribution of Cronen and Pearce who introduced the theory of the co-ordinated management of meaning (CMM). We focus on their ideas about communication, the complexities of communication, meaning, context and multiple perspectives. This article relates to our practice as well as considers useful ways to work with families and young people, within a highly contested field. Clinical examples are used to illustrate how we have made use of the theory and models of CMM to facilitate engagement, build therapeutic rapport, facilitate understanding and support those we see in a way which takes into account the many contexts of their lives.

Ethical issues arising in the provision of medical interventions for gender diverse children and adolescents.

The care of children and adolescents whose experience of the body is at odds with their gender feelings raises a number of questions that are as much ethical as medical or psychological. In this article I highlight some areas of ethical concern from the point of view of a senior clinician at the nationally commissioned UK Gender Identity Development Service (GIDS). I make the assumption that ethical deliberation is relational and grounded in the natural, social, political and institutional worlds in which the ethical questions arise. I try to show how matters of empirical fact, alongside an appreciation of broad social contexts, and historic and current power relations, provide an essential framework for the ways that ethical choices are framed by key groups of people as they take up different, sometimes opposing, ethical positions. I argue that practising ethically in such a service is not helpfully reduced to a single event, a treatment decision aimed at achieving the morally 'right' outcome, but an extended process in time. In the charged debate surrounding the recognition of these young people's needs, we must do more to promote responsible debate about the scope of sound ethical practice.

Reflections on 'Thinking an Ethics of Gender Exploration: Against Delaying Transition for Transgender and Gender Variant Youth'.

In this short article are offered some brief reflections on the commissioned response to my article on ethical issues arising in the provision of medical interventions for gender diverse children. Ashley argues for the importance of 'an ethics of exploration' which prioritises making opportunities for fluid, open-ended reflection by gender diverse children and young people, operating through and alongside, rather than prior to, social and medical transition. While noting significant areas of shared outlook between Ashley and myself, I correct some assumptions that Ashley may be making about the range of young people seen at the UK Gender Identity Development Service (GIDS) and the way we work clinically within a developmental framework. I highlight my reasons for thinking that there are particular concerns arising in the care of the very young. Finally, I reiterate my view that professionals cannot so easily abandon altogether an 'ethic of prediction' and surrender their responsibilities and accountabilities in this area of clinical practice.