The care and treatment of children and adolescents in relation to their gender identity in the UK
Section 4: Approaches to care and treatment
The current approach to care and treatment in the UK is based on the World Professional Association for Transgender Health (WPATH) guidelines. It focuses on providing psychological and psychosocial support to patients and families and, if there are persistent signs of gender dysphoria upon reaching puberty, making a referral to a paediatric endocrine clinic for puberty suppression with the option of receiving cross-sex hormones to masculinise or feminise the body from the age of 16.
The purpose of puberty blockers
One of the current dilemmas in treatment decisions relates to the purpose of puberty blockers: whether it is to give young people time for reflection and exploration before proceeding with further, irreversible treatment, or whether it is intended as the first step towards other treatment and designed to facilitate more straightforward transition with cross-sex hormones and later surgical interventions.
There is also a broader question about whether the provision of puberty blockers at a young age opens up or closes down future choices, for example, whether it leaves room for gender identity to fluctuate or evolve over time, or whether it determines or fixes a particular identity which excludes exploration of other options. Evidence on the number of children and adolescents with profound and longstanding gender dysphoria who persist in their gender identities, and on those who desist and do not become transgender adults, illustrates the complexity of the situation.
8. What should be the purpose of puberty blockers? Does this match up with how they are used in practice?
The gender affirmative approach
One current approach to care and treatment of children and young people is often referred to as the ‘gender affirmative’ approach. It seeks to affirm the gender identity expressed by young people without questioning it. This approach complements the idea that gender is innate, sometimes expressed as the view that gender diverse and gender incongruent young people are ‘born this way’. According to the gender affirmative approach, refusing to acknowledge and affirm gender identity, or attempting to ‘cure’ gender dysphoria, would be an attack on the identity and dignity of children and young people.
Others note evidence that a number of young people will desist from questioning their gender identity and will not become transgender adults. They also note evidence that suggests the majority of gender-questioning young people later identify as homosexual or bisexual adults, and worry that it is not always easy for children or clinicians to distinguish early questions and feelings about gender identity from early questions and feelings about sexuality. On this basis, they question whether the presence of gender non-conforming feelings and behaviour provides sufficient basis to endorse, unquestioningly, a child’s view of their gender.
Those who view gender dysphoria as a symptom of broader mental health or social problems may advocate psychological and therapeutic approaches which adopt a more enquiring approach to a young person’s expressed gender identity. Finally, the high rates of autism spectrum disorders (ASD) and mental health conditions in gender diverse and gender incongruent children and adolescents, and whether they are interrelated or simply co-existing, may also influence views on the most appropriate approach.
9. What is the best way to respond to a child or adolescent who expresses unhappiness or discomfort with their gender identity?
Another approach to gender dysphoria is to support young people to live in accordance with their chosen gender identity, through choice of dress, changing names or pronouns - known as social transition. Some encourage early social transition as a way of exploring and expressing gender without the need for medical intervention, and note that it can help to reduce signs of distress and dysphoria. Recent trends in referrals indicate that a growing number of young people presenting to specialist gender clinics do so having already made a social transition.
Others have argued that social transition makes it difficult for young people to change their minds, and in fact increases the likelihood of later medical transition. Some raise concerns about external pressure to socially transition, perhaps from parents, mentors, or peers. They question whether social transition opens up or closes down future options. Some note that young people who later desist from identifying as trans may find this difficult it they have socially transitioned.
10. Should children and adolescents with gender dysphoria be encouraged or supported to transition socially? When should this occur?