Gender Identity Development Service on BBC Radio 4’s Woman’s Hour

11 April 2016

Why has there been such a substantial rise in the number of referrals over the past few years?

The answer to this question is not straightforward or clear cut. There are a number of possible reasons why this rise is occurring.

In recent years there has been significant progress towards the acceptance and recognition of transgender and gender variant people in our society. These issues are now discussed as a matter of course as part of debates on human rights and equality at the highest levels of government. Across the mainstream media, the experiences of transgender and gender variant people are becoming more visible. As a social group transgender people are gaining a stronger voice.

One result of society becoming both more tolerant and aware is that more space is created for young people to freely explore their gender identity and consider the different options available to them. There is greater knowledge about specialist gender clinics and the pathways into them, and an increased awareness of the possibilities around physical treatments for young adolescents.  All these factors contribute to increased referral numbers.

The rise of social media also plays a part as it sponsors a fast developing shared language around gender identity and expression. We are seeing that young people now have a wider and more varied vocabulary for articulating their experience of their gender identity, and often have more confidence in putting their experience into words.  

Our work at GIDS is to support young people to explore their experiences of gender, sexuality and the body, and to consider very carefully their options and the implications of any decisions they make around their gender expression, including social transition and physical treatments.

What kinds of children and young people use the service?

All young people referred to the service are experiencing issues around their gender identity. Most often referrals are for young people who feel there is a mismatch between their biological sex at birth and the gender they identify with psychologically and emotionally. These children and young people are often unhappy and may experience strong feelings of being very different and isolated from their peers. Rejection and bullying are not infrequent and relationships can be negatively affected. In puberty feelings of distress frequently increase as the body develops in a way that does not feel right for their gender identification.

But the stats show clearly that more natal females than males are being referred to the service - is this because girls struggle more with puberty and with their bodies?

An increase in distress at the time of puberty is typical in both natal males and natal females experiencing gender dysphoria. It is not possible to say with any confidence why the number of natal females referred to the service has increased in recent years.  It is likely that the reason is multifactorial involving individual, social and cultural factors.

This trend is a relatively recent phenomenon.  Prior to 2009 there was a fairly even split and we were seeing roughly three natal males to one natal female. Since around 2011 there has been quite a shift in the ratio of referrals. While there is no concrete evidence to explain this, research suggests this trend is occurring worldwide and is not exclusive to the UK.

It could be argued that we live in a society where there is a disproportionate emphasis on physical appearance and huge pressure to attain an ideal body type. In this context it may be disproportionately young women who hate their bodies if they feel that cannot attain these ideals, and who wish to act on their bodies in some way, for example  through restrictive dieting and body modification.  However it would be speculative and simplistic – and from our point of view premature -  to suggest that this is the main reason for the increase in referrals of natal females to our service. Gender dysphoria, body dysmorphia and eating disorders are each complex predicaments in their own right and should not be recklessly conflated.

Perhaps this is a question that society as whole should be asking.  In today’s social landscape no one really understands the complexity of gender identity development and the extent to which biological and social factors work together to shape how we see ourselves.  In our social world too there is more respect paid to the right of individuals to self-define and more attention paid to people having more of a say in decisions about their medical treatment. As technology advances people have greater freedom to alter their bodies - this is becoming an accepted part of modern culture.  This faces a service like GIDS with questions that appear moral as much as medical or psychological - requiring both a grasp of theory and the scientific evidence base, as well as an engaged moral awareness and imagination.  As a society we have to consider carefully the moral assumptions we make about the 'care' and support that is owing to gender nonconforming and gender dysphoric children and adolescents.

How does what is going in the UK compare to what is happening globally? Is there any significant international research?

There has been some research looking at this phenomenon. Recent papers[1] have identified it in Finland, the Netherlands and Canada. So it seems that the increase in referrals for natal females is happening in other countries and not just the UK. There however no identified cause for this trend.

Have you seen young women who have anxiety about going through puberty but do not necessarily want to be male?

Very rarely would such young natal women present to GIDS.  Some young people in puberty (natal males and natal females) are radically uncertain about how to go forward - whether to go on struggling to adjust to the body they have and to establish a gender role and gender expression that feels right for them, without physical intervention. Some are especially troubled by the expectations that they should be becoming a sexual being when they would prefer to be a-sexual.  There are always young people, even those with pronounced gender dysphoria, who fear their developing adult bodies and just want to stop the clock. The source of anxiety may be the fact of not having control over their lives or bodies, and such anxiety needs a sensitive and thoughtful response.

Not all the young people we see go down the route of physical intervention or make a decision to transition. Our job is to help to make life as bearable as possible for the young person while they explore their feelings and options. However there is always lots of pressure to resolve things quickly.

Do you see different attitudes between natal males and natal females referred to the clinic?

Natal males and females have in common the experience of gender dysphoria. There do not seem to be any simple and marked differences in ‘attitudes’. Each young person referred potentially has concerns about a physical body that feels incongruent with their gender identity, each experiences their own particular degree and quality of mental anguish and physical discomfort, their own worries about openness and privacy.  They may differ too in how far they are curious about their own gender and sexual identity development, the impact of stereotypical gender roles and expectations, how ready they are to explore this with family, partners or clinicians, and to what extent their hopes are pinned on physical intervention as part, or all, of the solution, now or in adulthood.  Such characteristics do not align in any simple way with their original assigned gender.

There is a question mark around whether fewer young people would be experiencing these problems and being referred to the clinic if we lived in a less binary or gendered world, and if we were more open to the fact there is a gender continuum.

Could it just be that natal males are under-represented in the figures?

This seems very unlikely.  There is no obvious obstacle that is holding back natal males from accessing our service.

Does it concern the service that there is an increase in the number of natal female referrals?

It’s not a concern for us as such. It is a notable trend that requires thought and research.

Referrals are up by 100% - is the service able to cope?

It would be difficult for any service to plan for such a large and unexpected increase in referrals over a short period of time. We are actively employing more staff, however it is a very specialist service which needs an interdisciplinary approach and recruitment and training at this level takes time.

[1] Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Child and adolescent psychiatry and mental health, 9(1), 9.

Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria. Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A et al (2015) Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria.

Journal of Sexual Medicine 2:756–763