Earlier this year, a team of NHS researchers was asked to investigate why there has been such a huge rise in the number of adolescent biological girls seeking referrals to gender clinics.
The figures alone do seem remarkable.
According to a study commissioned by NHS England, 10 years ago there were just under 250 referrals, most of them boys, to the Gender Identity Development Service (Gids), run by the Tavistock and Portman NHS foundation trust in London.
Last year, there were more than 5,000, which was twice the number in the previous year. And the largest group, about two-thirds, now consisted of “birth-registered females first presenting in adolescence with gender-related distress”, the report said.
The review team is looking into the causes behind “the considerable increase in the number of referrals” and the changing case mix, but is not expected to publish any findings until next year.
Meanwhile, clinicians and parents are trying to make sense of it themselves.
Over recent months, the Guardian has interviewed 11 parents of gender-questioning adolescent biological girls (some of whom have transitioned to become trans boys), and six paediatricians and child psychiatrists, to discuss their views and experiences. For many of them, it has been a difficult and emotionally draining time.
Their testimony reflects the lack of consensus within the medical profession about how best to proceed if a child experiences gender dysphoria – and, in turn, how this confusion contributes to the central dilemma faced by concerned parents: how should they support their child during what may be the most challenging period of their lives?
Do they accept them changing their name, gender and pronouns at home and at school and investigating medical options, or should they try to help their child to accept their natal sex?
While some parents said they had embraced their child’s decision and welcomed the societal changes that had made this step possible, others felt confused by their child’s desire to change their body.
Several parents said they had been relaxed when their daughters initially began identifying as non-binary, but became uneasy when they said they wanted to take puberty blockers or cross-sex hormones and began binding their breasts.
Some spoke of their anxiety and uncertainty about how to respond, particularly when their child was unhappy.
The mother of one girl who came out as trans at the age of 12 said it was “very difficult to describe the feeling of being the parent of a trans-identified child”.
This mother feared they were heading towards medical intervention that might prove unnecessary. “As she got older … we had less control. Living with that fear is one of the toughest experiences I’ve had.”
(Her child, who recently started university, now describes herself as non-binary and uses a gender-neutral name, but is happy to be referred to as she, and is no longer seeking medical treatment.)
The uncertainty parents felt was compounded by the highly polarised debate – within the NHS, politics and the media – about how parents and professionals should respond to children who express distress about their gender.
“We were terrified of being accused of being bigoted,” said the woman, who asked to remain anonymous to protect her child’s privacy.
“We felt we were expected to accept her decision unhesitatingly. I felt so apologetic that I was questioning whether my miserable teenage daughter was genuinely a boy,” she said.
An ‘explosion’ in referrals
The rise in the number of biological girls seeking referrals to Gids was set out in an interim report by Dr Hilary Cass, the paediatrician commissioned to conduct a review of the services provided by the NHS to children and young people questioning their gender identity.
The trend was confirmed by clinicians who spoke to the Guardian.
“In the past few years it has become an explosion. Many of us feel confused by what has happened, and it’s often hard to talk about it to colleagues,” said a London-based psychiatrist working in a child and adolescent mental health unit, who has been a consultant for the past 17 years.
Like all NHS employees interviewed, she asked for anonymity due to the sensitivity of the subject.
“I might have seen one child with gender dysphoria once every two years when I started practising. It was very niche and rare.” Now, somewhere between 10% and 20% of her caseload is made up of adolescents registered as female at birth who identify as non-binary or trans, with just an occasional male-registered teenager who identifies as trans.
Another senior child psychiatrist said girls who wanted to transition made up about 5% of her caseload.
“In the last five to 10 years we’ve seen a huge surge in young women who, at the age of around 12 or 13, want to become boys. They’ve changed their name and they are pressing … to have hormones or puberty blockers”
The psychiatrist added: “Often those girls are children who are going through the normal identity and developmental problems of adolescence and finding a solution for themselves in this way.”
Greater awareness of trans issues is likely to be one common-sense explanation for the rise in requests for referrals.
“Left-handedness increased over time after we stopped punishing left-handed children in schools, because some children are naturally left-handed and were now able to express it,” said Cleo Madeleine, a spokesperson for the trans support group Gendered Intelligence.
“In the same way, increased visibility and acceptance of trans people has led to a gradual increase in young people who feel comfortable expressing their trans identity. The most important thing is to recognise that this is not a problem to be solved or a bad outcome to be avoided.”
The mother of a 17-year-old A-level student (who came out as trans at 13, leaving a handwritten letter for his parents on his bed) agreed: “It’s discussed so much more – on Facebook and on social media. It’s no longer a taboo.”
She is confident this was the right decision for her child. “I think I wondered if this was a phase, but I didn’t look to dissuade him. As he began to socially transition he was a different person. It has made him happier,” she said.
Her trans son has a weekend job to pay for his private testosterone prescription, because the NHS waiting list is too long, and the family is saving up for the £6,000 cost of breast removal.
“He would like to get it done as close to his 18th birthday as possible, so he can start afresh at university.”
Increased awareness may well be a factor. But most of the research in this field has been based on predominantly birth-registered males – not females.
The Cass report explained that relatively little was known about the causes of gender dysphoria in girls, or the outcomes for those who received treatment.
“At present, we have the least information for the largest group of patients – birth-registered females first presenting in early teen years,” it said.
“Since the rapid increase in this group began around 2015, they will not reach late 20s for another five-plus years, which would be the best time to assess longer-term wellbeing.”
The NHS review will help to shine some light on this issue – but it may be years before a clear picture emerges.
Silence, disagreement and polarisation
The dilemma for parents has hardly been helped by the confusing guidelines.
They are puzzled by the conflicting advice they get from doctors and trans rights groups about what their child may be going through.
Could it be a temporary exploration of gender identity, potentially the manifestation of other forms of distress? Or is it an innate experience for which treatment is required?
The definition of gender dysphoria is controversial in itself, and in England there is no consensus among clinicians over whether an adolescent’s desire to transition should be quickly affirmed or they should be encouraged to pause before changing their name and starting hormone treatment.
The Cass report revealed there was “a lack of agreement, and in many instances a lack of open discussion” about the best approach to take.
“The disagreement and polarisation is heightened when potentially irreversible treatments are given to children and young people, when the evidence base underlying the treatments is inconclusive,” it added.
Anyone looking for clarity from NHS England’s most recent draft guidelines on how to support under-18s experiencing what it calls “gender incongruence” may not find it helpful.
Published in October, the draft seems to put greater emphasis on the possibility that, for some, particularly pre-pubescent, children, this may be a “transient phase”.
It also suggests it is not a “neutral act” to help children transition socially (by using preferred names and pronouns) while they explore their gender identity, and stresses that more research is needed to “gather further evidence on the safety, potential benefits and harms” of puberty blockers.
In terms of practical advice, it does not go much beyond that.
Many of the parents who spoke to the Guardian admitted they struggled with the uncertainty involved, even in cases where they acknowledged that medical transition may be the correct outcome for some adolescent girls with gender dysphoria.
The Tavistock stresses that there is no set treatment pathway, and only about 20% of those referred to the service go on to be prescribed puberty blockers or cross-sex hormones on the NHS (although long waiting lists mean some people seek treatment in the private sector, or will receive treatment only when they have progressed to adult NHS services at 18). Parental confusion has been heightened by NHS England’s announcement in July that the Tavistock’s gender identity clinic would close next year and be replaced by new regional centres. This happened after the Cass review said the current model, with its long delays, was leaving young people “at considerable risk” of poor mental health and distress, and that having one clinic was not “a safe or viable long-term option”.
Parental anxiety: ‘We went from nothing to everything in three months’
With little research to draw upon, no consensus among clinicians and confusing guidelines, parents have differing explanations for what might have prompted their child’s desire to identify as male.
Some point to puberty, periods and unease with a changing body shape coinciding with the interest in becoming gender non-conforming.
Others have questioned whether their child’s autism might be a relevant factor. (The Cass report stated that approximately one-third of children and young people being referred to the Tavistock had autism or other types of neurodiversity.)
And others wonder if pre-existing signs of depression and mental health problems have been the cause or the result of gender uncertainty.
Possible influences they cite include childhood bullying, sexual harassment and abuse and the hyper-sexualisation of society, or a child’s early understanding of sexism, making them feel it may be easier to live as a man than as a woman.
Some believe the extended isolation children experienced during Covid is relevant (for example, Google searches for “top surgery”, double mastectomies, soared during this period).
Many are aware of online content that has educated their children about gender, and of the influence of YouTubers, Tumblr accounts and TikTok personalities where individuals’ medical transitions are documented in detail (footage of recoveries from double mastectomies and phalloplasty, or “bottom surgery”, has been watched by hundreds of thousands).
A 20-year-old medical student who came out as a trans boy at 16, having told his parents the year before that he was a lesbian, and who spent £8,000 on private breast removal earlier this year, said the realisation was “a lightbulb moment”. He had watched a lot of YouTube content on LGBTQ+ issues.
“From watching that I was able to educate myself. I’d always felt that something was not right. Everything made much more sense afterwards,” he said. His parents were “incredibly supportive”.
But some parents have been frustrated by the speed with which schools have adopted their child’s new identity, without parental consent, uncertain about the implications.
One father, whose child came out as a trans boy three years ago at the age of 11, with the approval of his estranged wife, said he had initially supported the decision. However, had become increasingly sceptical about whether it was helping his child. He said he felt disconcerted by the school’s readiness to adopt the child’s male identity before any specialist assessment had occurred.
“We went from nothing to everything in three months. I know now that a lot of the explanations of what they were feeling came from an internet script. All my concerns were minimised,” he said. “Everyone told me it was a totally benign step to change names, and pronouns.
“The school’s position was: ‘If you say you are a boy, you’re a boy,’” he said. “At the time I was shocked, but I trusted them that it was a good idea.”
He struggles with the new pronouns but agreed to the new male name, and reluctantly bought, at the 11-year-old’s request, a crocheted penis and testicles to wear inside their underwear.
“I’ve said no to a chest binder and puberty blockers. I kept asking: ‘What’s wrong with being a girl? What problem are we trying to fix?’” He said he believes the decision was triggered by severe bullying in primary school, undiagnosed autism and a few influential YouTubers.
“She’s interested in boys now and describes herself as a gay boy. None of this has made her happier.”
One mother of an adolescent who came out as a lesbian aged 13 three years ago, and came out as a trans boy nine months later, said she and her husband had wanted to be supportive.
“We said: ‘OK, no matter what, we love you,’ and tried to be very neutral about it. She told me she wanted to go to the GP to get a referral to the Tavistock, so we went and we were referred. I was absolutely fine with gender non-conformity.”
But her views on social, medical and surgical transition evolved as she did more research. She said no when her child asked to speed up the process by going private, which would have allowed them to start puberty blockers.
“My daughter has barely spoken to me for three years because I haven’t continued with the referral process. Parents are in a very difficult position.”
Two years ago, a grassroots support group started campaigning for “evidence-based care”. Called Bayswater Support, it now represents the parents of about 500 trans-identified adolescents – and its membership is growing rapidly.
The group says around 70% of the children it represents were registered as female at birth; 80% experienced bullying prior to identifying as trans and more than 50% had come out as lesbian, gay or bisexual.
A spokesperson said: “Our members commonly describe their child’s trans identity as overshadowing factors such as poor mental health, neurodevelopmental conditions like autism and ADHD, social factors like bullying and not fitting in with their peer group, emerging same-sex attraction, serious safeguarding issues – and often puberty itself.”
‘Trans kids weren’t as hotly debated then, it was much less politicised’
There is one thing that all sides on this debate would probably agree on: the increased scrutiny of the subject has made life much harder for trans adolescents and their families.
A 29-year-old charity worker who transitioned 13 years ago, in the summer after sitting GCSEs, told the Guardian: “Trans kids weren’t as hotly debated then, it was much less politicised. Trans people didn’t have that level of visibility – and that might be seen as a negative, but it also meant that trans people were left alone.”
He said he now tried to avoid reading newspaper reports, and was suspicious of the research into what might be causing an increase in the number of biological girls wanting to identify as boys.
“I would guess it’s because trans people are more able to find other trans people. Research into the cause of a marginalised identity can make you feel nervous. It makes me wonder: why would you want to ask that question?”
He said his mother was very supportive of his decisions, and they had attended a summer residential camp organised by the charity Mermaids. She paid for a private referral and supported him through medical transition, including cross-sex hormones, a hysterectomy and double mastectomy.
“Initially she was confused. She was obviously concerned about what I would go through. She had, I suppose, the normal feelings that any parent would have when suddenly their child tells them: ‘Actually, I’m a boy and I don’t feel comfortable in my body, and I want to go through these processes.’ I imagine it’s a very helpless feeling.
“Now she talks to other parents to help them understand that if your child comes out as trans, their life will be fine with the right support. I have a flat, a partner, a good job – it is not all doom and gloom. Trans kids turn into trans adults, and that’s fine. Of course there’s anxiety because it’s an unknown, but keep talking.”
He said that now he barely thinks about the process of transitioning, and does not have an easy answer to what it means to be a man.
“I can’t tell you, and I think if you asked my [male] partner, he wouldn’t know either. I’m very comfortable living as a guy, I’ve done that for 15 years.”
A 20-year-old student who describes herself as trans-adjacent spent five years living as a boy, from the age of 13. She hadn’t had many close friends at primary school and had been diagnosed with autism when she was 12. She spent a lot of time on Tumblr following trans groups and became close to a friend at her girls’ school who also came out as trans. Shortly after she came out as trans, a third person in the year also came out; the two others have subsequently medically transitioned, but she has decided not to.
“I don’t know how much of it is because I am autistic. I felt I didn’t fit in with any of the girls,” said the student, who now uses a gender-neutral name but said she was happy to be described using she/her pronouns. She didn’t initially want to tell her mother she was trans because of a misunderstanding they had when she came out as gay at the age of 12.
“My mum said: ‘That’s fine, but you’re too young to know.’ I think now what she was trying to say was: ‘No matter what, we will accept you, but you’re really young, you don’t need to worry about what box you’re in.’
“I think then I took it much too literally. So I didn’t talk to her about being trans at the start.
“I was really struggling in secondary school. I think being a girl is hard for a lot of people when you are going through puberty and you are really unhappy. It’s quite easy to want to escape from that.”
She was on antidepressants. Her parents began the process of a referral to the Tavistock, but decided against pursuing it.
“I started binding with duct tape because I didn’t have access to a breast binder. I wanted my chest to be flat. I slept with it. It helped me alleviate a lot of my distress. I still have pain in my ribs. I identified as trans masculine, as a trans man.
“I wasn’t so obsessed with being referred to as male but I did want the school to use he pronouns.”
When she moved to a sixth-form college to do A-levels, she became more interested in her work and less interested in her identity. She is still known by her new name but is no longer thinking about transitioning.
She said: “I think there might be people who identify as trans, who were like me, who were just unhappy, and there are others who are just trans. There are people who have medically transitioned and for whom that is completely the right option. Trans people have existed for a very long time.”
The mother of a 20-year-old trans student said the process had been stressful but, on balance, she believed her child had become happier.
“My son, who was then my daughter, came out as a lesbian at 13 or 14. After they turned 15 my husband and I were called into school by my child’s year head, and it turned out to be for an announcement that my daughter was now my son. I think the meeting was done that way because my son was concerned particularly about how his dad would react, and he needed there to be other people there. His dad’s reaction was quite hostile. He said that, for one thing, my son was being ridiculous, and for another thing, about to ruin his life.
“I didn’t understand everything, but I wanted to support him. I didn’t feel I should interfere in my son’s treatment. Instead I got involved in helping him with the practicalities of getting his name changed, speaking to the school about toilets and changing rooms. He went on testosterone at 18. I don’t think he will have surgery; the thought of it makes him quite anxious so I’m not sure how actively he wants to pursue it. In any case he has passed as male for quite some time now.”
She said the increased awareness of trans issues via the media made it easier for children who might be trans to communicate with others. “In the 90s, when trans people began to be presented in the media it was very much done for shock value. Things have changed since then.”
She said the process had been stressful. “But in the end I realised that people make all sorts of decisions in their lives that have long-term, knock-on effects that can’t be imagined at the time the decision is made. I think transitioning has been a positive step for my son. His mental health is much improved – he socialises now rather than just hiding away.”