Gender Identity Development Service Research Articles

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.

'Taking the lid off the box': The value of extended clinical assessment for adolescents presenting with gender identity difficulties.

As the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress. From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.

The UK gender identity clinic for young people

The Gender Identity Development Service (GIDS) in London—the only one of its kind in the UK—started out from small beginnings at St George's Hospital nearly 30 years ago. Its founder, the child and adolescent psychiatrist Domenico di Ceglie, was inspired to start the service after seeing a teenage patient who claimed she was a boy in a female body. “She wondered why [her parents] had not sought help for her when she was a child”, di Ceglie subsequently wrote. “Her thoughts made me wonder why there was no service for children with these rare and unusual experiences. This planted in me the seed for the creation of such a service.”

Thinking about ethnicity and gender diversity in children and young people.

Little is known about how social and cultural variants interact with gender identity development. This article aims to identify the ethnicities of children and young people referred to the United Kingdom's national Gender Identity Development Service (GIDS), and compare the ethnicity data with the UK child population and referrals to Child and Adolescent Mental Health Services (CAMHS). GIDS referrals made between April 2012 and April 2015 for children and young people were retrieved. Ethnicity data were obtained by the '16 + 1' ethnicity list. Chi-square and t-tests were performed on the demographics. Less than 10% of the 995 referrals at GIDS were from Black and minority ethnic (BME) groups - an underrepresentation as compared with both the national population and CAMHS figures. No significant differences in ethnic representation were found between the demographic birth-assigned sexes, across age groups, or year of referral. Hypotheses proposed for this underrepresentation take into account both the potential barriers to accessing services and the possibility of cross-cultural variations in the conceptualisations of gender, gender roles and gender diversity. Ethnicity, culture and religion, and their overlapping relationship with gender need further exploration.

Gender diversity and non-binary presentations in young people attending the United Kingdom's National Gender Identity Development Service.

There has been a recent rise in the number of people who hold a non-binary gender identity. However, the proportion of young people attending gender services who identify as non-binary has not yet been investigated. This article presents the findings from a pilot study of newly designed questionnaire, the Gender Diversity Questionnaire, which included questions about gender identity and gender expression. Responses from 251 adolescents attending the United Kingdom's National Gender Identity Development Service between June 2016 and February 2017 are reported here. The majority, 56.9%, of young people identified as trans, 29.3% identified as a binary gender (male or female), 11% identified as non-binary and 1.2% as agender. There were no significant differences in self-defined identities based on assigned gender or age. However, once young people were separated into these groups, some of them were very small; thus, a larger sample is required. In terms of aspects of gender expression that were important to the young people, the data formed five themes - name and pronouns, external appearance, the body, intrinsic factors and 'other'. Strengths and weaknesses of the research are discussed as well as future work that will be conducted.

A therapeutic group for young people with diverse gender identifications.

Young people are presenting to specialist gender services in higher numbers than before and many with significant psychosocial difficulties. Negative experiences of stigma, difficult peer relationships and discrimination exacerbate distress and psychological difficulties, negatively impacting wellbeing and resilience. Social support is advocated as a means of supporting young people with diverse gender identifications, such as through peer support groups. This article describes the establishment of a young persons' group in 2011 within the United Kingdom's Gender Identity Development Service (GIDS), for those attending the service as a means of enabling their coping with difficult experiences and facilitating their wellbeing and resilience through effective social support. The group was evaluated using qualitative and quantitative measures and has subsequently run each year. Now in its sixth year, the authors reflect on their learning and experiences.

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.

Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017)

IntroductionThe prevalence of gender dysphoria in children is not known; however, there are some data on the sex ratio of children referred to specialized gender identity clinics. AimWe sought to examine the sex ratio of children, and some associated factors (age at referral and year of referral), referred to the Gender Identity Development Service in the United Kingdom, the largest such clinic in the world. MethodsThe sex ratio of children (N = 1,215) referred to the Gender Identity Development Service between 2000–2017 was examined, along with year of referral, age-related patterns, and age at referral. Main Outcome MeasureSex ratio of birth-assigned boys vs birth-assigned girls. ResultsThe sex ratio significantly favored birth-assigned boys over birth-assigned girls (1.27:1), but there were also age and year of referral effects. The sex ratio favored birth-assigned boys at younger ages (3–9 years), but favored birth-assigned girls at older ages (10–12 years). The percentage of referred birth-assigned boys significantly decreased when 2 cohorts were compared (2000–2006 vs 2007–2017). On average, birth-assigned boys were referred at a younger age than birth-assigned girls. Clinical ImplicationsThe evidence for a change in the sex ratio of children referred for gender dysphoria, particularly in recent years, matches a similar change in the sex ratio of adolescents referred for gender dysphoria. The reasons for this remain understudied. Strength & LimitationsThe United Kingdom data showed both similarities and differences when compared to data from 2 other gender identity clinics for children (Toronto, Ontario, Canada, and Amsterdam, The Netherlands). Such data need to be studied in more gender identity clinics for children, perhaps with the establishment of an international registry. ConclusionFurther study of the correlates of the sex ratio for children referred for gender dysphoria will be useful in clinical care and management.de Graaf NM, Carmichael P, Steensma TD, et al. Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017). J Sex Med 2018;15:1381–1383.

Gender Dysphoria in looked-after and adopted young people in a gender identity development service.

This research investigated the prevalence of looked-after and adopted young people within a case file review of 185 young people referred to a UK gender identity development service over a 2-year period (1 April 2009 to 1 April 2011). Data were extracted from referral letters, clinical notes and clinician letters. Looked-after young people were found to represent 4.9% of referrals in this cohort, which is significantly higher than within the English general population (0.58%). Adopted young people represented 3.8% of referrals. In addition, the findings showed that looked-after young people were less likely to receive a diagnosis of gender dysphoria compared with young people living within their birth family. There were no statistically significant differences in the gender ratio or age of first gender dysphoric experience between groups. Looked-after and adopted young people were also not found to be experiencing greater impairment in overall functioning compared to other young people referred to the gender identity development service. In conclusion, there are a substantial proportion of referrals pertaining to looked-after or adopted young people, and it appears the referral route and process through the service may be distinct, particularly for looked-after young people. This may be understood by considering the possible complexities in the presentation of these groups, alongside the established higher levels of complexity generally for those experiencing feelings of gender dysphoria.

Assessment and support of children and adolescents with gender dysphoria

There has been a large increase in the number of children and adolescents who question conventional gender expectations and seek recognition and acceptance of their gender diversity, wishing to develop...

Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service

This paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings. Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to. To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.

The use of metaphors in understanding atypical gender identity development and its psychosocial impact

Over the years I have found a number of metaphors which have helped me to deal with particular dynamics in therapeutic work or with group and institutional conflicts involving the Gender Identity Development Service at the Tavistock Centre. This nationwide service, which is for young people with atypical gender identity development and their families, was established in 1989. In this paper I describe some of these metaphors in relation to the particular problems or conflicts which had stimulated their appearance in my mind. The emergence of these metaphors links the vicissitudes of atypical gender identity development to issues regarding symbolisation or symbolic thinking. Metaphors such as ‘working at the edge’ or ‘navigating between Scylla and Charybdis’ allow the professional to hold on to multiple perspectives and to maintain a certain degree of ambiguity in situations in which the interpersonal dynamics can be experienced as rigid and deterministic. The emergence of metaphors can then be perceived by the professional with a sense of relief and freedom of thinking. In this paper, metaphors are linked to: the model of care developed; the therapeutic stance; and the aims, risks and pressures experienced by the professional in this area of work. The association between gender dysphoria in some young people and autistic spectrum features is explored. The paper emphasises the importance of responding flexibly to individual differences and of recognising complexity.

014-Information Provision for Young People Referred to the Northern Gender Identity Development Service

Background: The Leeds Teaching Hospitals Northern Gender Identity Development Clinic is a supra regional centre for young people with a diagnosis of gender dysphoria. The service is jointly run with the Tavistock and Portman NHS Foundation Trust and University College London Hospital NHS Foundation Trust. We provide a highly specialised service for young people (up to 18 years of age) who are experiencing gender dysphoria and who have major concerns about their physical development through puberty. The young people are referred to the endocrine service following extensive assessments undertaken by the Tavistock Team. Since 2009 referral rates have increased 50% year on year with a 100% increase in 2016. Purpose: With increased referrals and waiting list pressures, we felt that the original model of practice did not meet the needs of the young people and their families. Furthermore, due to the physical interventions offered by the service it was felt a strong public health approach was required in order for the young people to be able to make informed decisions about their care. Methods: The original care pathway involved an initial 40-minute appointment with a paediatric endocrinologist followed by a two month nurse led telephone consultation prior to commencing any medical treatment. The aim was to change the model of practice in order to provide a better quality of care through a strategic public health approach. We aimed to implement and evaluate a new model where the clinical nurse specialists ran an education session alongside some clinical tests as the initial appointment. This was followed by a two-month review with a paediatric endocrinologist to discuss results and the young person's eligibility to commence hormone blocker treatment. Results: The new pathway of care is being positively evaluated by both the young person and the parent/caregiver. Post session questionnaires demonstrate that they feel more knowledgeable about the hormone blocker and also have a better understanding of the implications of any treatment on their fertility. Clinical Implications: From a clinical perspective it has reduced waiting lists, enabling the consultants to see the increasing number of review patients. From the clinical nurse specialist perspective it has allowed us to provide a more holistic model of care, utilising the highly specialised skills of the GID clinical nurse specialists. It is anticipated that the nurse led education session will support young people to make better informed decision about their ongoing care.

Bone density and body composition in post-pubertal adolescents treated with GnRH analogues in a gender identity development service

Bone density and body composition in post-pubertal adolescents treated with GnRH analogues in a gender identity development service

Pushing at the edges in uncertain places: Jos Twist in conversation with Bernadette Wren

Bernadette Wren is a Consultant Clinical Psychologist, Systemic Psychotherapist and Trust-wide Head of Psychology, working at the Gender Identity Development Service (GIDS) at the Tavistock & Portman NHS Foundation Trust. Bernadette first worked at the Tavistock GIDS back in the 1990s before leaving to work in a more ‘general’ clinical team and to teach therapists and researchers. Bernadette has also worked at Great Ormond Street hospital with young people with eating problems. Bernadette returned to the GIDS in 2011. The following is an edited version of a conversation between Bernadette and Jos Twist who is also a Clinical Psychologist at the Gender Identity Development Service.

Longitudinal changes in bone density and body composition in post-pubertal adolescents treated with GnRH analogues in a Gender Identity Development Service

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Young people with features of gender dysphoria: Demographics and associated difficulties.

This article presents the findings from a cross-sectional study on demographic variables and associated difficulties in 218 children and adolescents (Mean age = 14 years, SD = 3.08, range = 5-17 years), with features of gender dysphoria, referred to the Gender Identity Development Service (GIDS) in London during a 1-year period (1 January 2012-31 December 2012). Data were extracted from patient files (i.e. referral letters, clinical notes and clinician reports). The most commonly reported associated difficulties were bullying, low mood/depression and self-harming. There was a gender difference on some of the associated difficulties with reports of self-harm being significantly more common in the natal females and autism spectrum conditions being significantly more common in the natal males. The findings also showed that many of the difficulties increased with age. Findings regarding demographic variables, gender dysphoria, sexual orientation and family features are reported, and limitations and implications of the cross-sectional study are discussed. In conclusion, young people with gender dysphoria often present with a wide range of associated difficulties which clinicians need to take into account, and our article highlights the often complex presentations of these young people.

Empathising and Systemising in Adolescents with Gender Dysphoria

Background: Recent studies have highlighted the co-occurrence of gender dysphoria (GD) in adolescence and Autistic Spectrum Conditions (ASC). Systemising and empathising are two psychological dimensions linked to ASC. People with ASC score below average on the Empathy Quotient (EQ) and average or above average on the Systemising Quotient (SQ). Based on the results of previous studies we predicted that if the young people with GD shared aspects of the ‘broader autism phenotype’, their EQ would be lower, and their SQ would be the same or higher, compared to controls of their natal gender. Methods: This preliminary study examined systemising and empathising in adolescents with GD using parent report questionnaires. 35 parents of adolescents with GD aged 12-18 attending the Gender Identity Development Service (London) took part. Parents of 156 typically developing adolescents aged 12-18 were used as a control group. The parents were asked to complete the Adolescent EQ and SQ. Results: The mean EQ score of both the female-to-male, and male-to-female GD group was found to be significantly lower than typically developing females, but similar to that of control males. There was no significant difference on the SQ between the gender dysphoric groups and either female or male controls. Conclusion: This study shows that on average adolescents with GD, specifically those who are female-to-male, have lower empathy than controls. For this group of adolescents it may be helpful to offer psychological interventions that improve their communication skills and their ability to take on board other people’s views, to support their development. This may enable them to make better informed decisions regarding treatment and physical intervention options during adolescence and beyond.

Internalizing and Externalizing Behaviors in a Group of Young People with Gender Dysphoria

ABSTRACT The aim of the current paper was to examine externalizing and internalizing behaviors in adolescents with gender dysphoria. One hundred forty-one young people (84 natal females and 57 natal males, M age = 15.13, SD = 1.70) attending the Gender Identity Development Service in London completed the Youth Self Report form at the end of the assessment period (4 to 6 sessions). The main findings indicated that, overall, the adolescents showed significantly more internalizing than externalizing behaviors. Using cutoff points provided by Achenbach and Rescorla (2001), the mean internalizing score fell within the clinical range and the mean externalizing score within the normal range. There was also a significant positive relationship between these two behaviors both in the natal females and the natal males. The natal males presented with significantly more internalizing behaviors than the natal females; however, no significant difference was observed between the genders in terms of the number of externalizing behaviors and total problems. We discuss the implications of these findings with regard to clinical work.

Self-Harming Thoughts and Behaviors in a Group of Children and Adolescents with Gender Dysphoria

ABSTRACT This article presents the findings from an audit on self-harm in 125 children and adolescents referred to the Gender Identity Development Service in London. Data concerning self-harming thoughts and behaviors before attending the service were extracted from documents in the patient files and from clinician reports. The findings indicated that suicide attempts and self-harming were more common over the age of 12. Overall, thoughts of self-harm were more common in the natal males whereas actual self-harm was more common in the natal females. The number of suicide attempts did not differ significantly between the two genders. The implications of these findings are discussed. Limitations of the study are also discussed which include that the data was only collected over an 8-month period and that it was extracted from patient files and from clinician reports.