Caring for Transgender Kids: Is Clinical Practice Outpacing the Science?

Becky McCall, BSc, MSc; Lisa Nainggolan

Disclosures

August 28, 2018

In the year leading up to March 2018, the Tavistock Centre—the United Kingdom's only National Health Service (NHS)–funded clinic to treat gender dysphoria in children—received a record number of referrals: 2500, a 25% increase from the previous year and a 50-fold increase from 12 years ago.[1]

Managing issues related to transition between the sexes is central to the work of the Gender Identity Development Service (GIDS) at the Tavistock Centre, where a striking and intriguing change has occurred in both the volume and type of patients being referred.

This vast expansion in referral numbers serves as a barometer of the changes going on in society today. Once the subjects of prejudice and rejection, people with gender dysphoria are experiencing an astonishing shift in recent years in societal attitudes toward gender identity issues.

Not intervening is not an option, and saying that we can't do anything until we have the data means we will never do anything and never have the data.

However, the demand for care still far outstrips the evidence-based medicine to support it, stirring debate around blocking puberty and altering fertility. Similarly, the surge in number of patients far exceeds the number of endocrinologists who possess the ability and confidence to manage them.

Indeed, the Tavistock Centre treads a fine line between those who feel that more should be done for people with gender dysphoria and those who object to any intervention that alters birth gender.

Gender Dysphoria Sits at a Complex Crossroads

Sarah Davidson, PhD, is a consultant clinical psychologist who has worked at the Centre for 12 years. She says that gender dysphoria lies at the intersection of a patient's relationship with his or her family, the sociocultural context, and the implications of gender identity in child development, including physical and mental health. "Gender has always had huge implications for power, expression, and sociocultural norms, hence its importance."

In managing gender dysphoria, Davidson emphasizes that in the balance lies the individuals' happiness with their gender identity and mental health, as well as complex medical and delicate social issues around preventing natural puberty and making life-changing decisions regarding fertility.

Reflecting on these issues and the paucity of data, leading US pediatric endocrinologist Stephen Rosenthal, MD, from the University of California San Francisco, says, "Not intervening is not an option, and saying that we can't do anything until we have the data means we will never do anything and never have the data.

"On the one hand, it's important to do the best we can with the information available. On the other, it is the responsibility of academic centers to conduct progressive research to discover what is best for our patients."

Surge in Referrals and Switch to Majority Trans-Males

The statistics alone tell an intriguing tale of how the number of referrals is rising and how the patient demographic has and is continuing to transform, although no concrete reasons exist to explain why this is happening.

Davidson points out that if "we make something into a phenomenon, then naturally we might recognize it in ourselves or our children. People are seeing this in places where it was not seen previously."

More fascinating still is the dramatic switch in natal gender being referred. Natal female referrals for gender dysphoria have grown from 42% of the total in 2009-2010 to 72% in 2017-2018.[1,2]

"It has absolutely shifted," says Davidson. "In the under-11-years referral group, the split is still 50/50 boy-girl referral. But there has been a change in the adolescent population." Now, the majority of teens they see are trans-males (female-to-male transition).

She also highlights the diversity of referrals, pointing out that some people decide they would rather be nonbinary and not transition, or be homosexual.

Approximately 11% of referred adolescents use labels such as "gender neutral" or "gender fluid," and, in general, referrals are an increasingly heterogeneous group that includes those who would not have previously presented at gender services.

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