Mermaids (Registered charity no.1160575) has been supporting transgender (trans), non-binary and gender-diverse children, young people up to the age of 19 (inclusive) and their families since 1995.
Mermaids is grateful for the opportunity to respond to this Inquiry within this context. Mermaids would welcome the opportunity to give oral evidence to this inquiry should that be of assistance to the Committee.
Provision of mental health support in schools
1.1. Currently, trans, non-binary and gender-diverse children and young people (from now ‘Trans young people’) experience disproportionately high levels of mental ill health, for example, statistics taken from Stonewall’s School Report 2017, showed that:
● 92% of trans young people have thought about taking their own life;
● 84% of trans young people have self-harmed; and
● 45% of trans young people have tried to take their own life.
1.2. Studies have shown that affirming and supporting Trans young people, both on an individual level, and in wider society, can play a role in reducing such mental ill health.
1.3. A recent study published this year discusses the vital need to improve the lives of Trans young people in schools, acknowledging that in schools where teachers were affirming of a Trans young person’s gender identity, ‘pupils experienced lower rates of bullying, had lower rates of school absenteeism, and higher rates of happiness and self-esteem’.
1.4. However, we hear from our service users that the reality in many schools for Trans young people is not always one of affirmation and support. We see first-hand that in-school victimisation, harassment and transphobic bullying negatively affects Trans young people’s mental wellbeing, and largely contributes to the high levels of depression, self-harm and suicidal ideation they experience. The following figures are illustrative of the often-hostile environments Trans young people are faced with in school (Stonewall 2017):
● 64 per cent of trans pupils are bullied for being trans at school;
● 1 in 10 trans pupils are subjected to death threats at school;
● Half of bullied LGBT pupils felt that homophobic, biphobic and transphobic bullying has had a negative effect on their plans for future education.
● 1 in 7 trans university students have considered dropping out or have dropped out of a higher education course because of experiencing harassment or discrimination from students and staff in the last year (Stonewall, 2018).
1.5. However, in our experience working with Trans young people, their wider families, as well as professionals, such as teachers, we have realised that a significant barrier to teachers and other authority figures within schools providing that support for Trans young people is that they themselves are not aware of how best to support Trans young people, and the hugely positive affect it can have on their mental wellbeing.
1.6. The Government Equalities Office (GEO) said, in July 2019, that the Equality and Human Rights Commission (EHRC) was developing guidance for schools on supporting trans pupils, which would replace their now outdated 2014 school guidance. Many local authorities and schools have removed their trans inclusion guidance following challenges by organisations and individuals who are decidedly unsupportive of Trans young people, and have instead decided to await the national EHRC guidance. However, we have recently been notified that the EHRC are no longer expected to produce such guidance.
1.7. We strongly recommend that the Department of Health and Social Care and the Department of Education convene a taskforce on trans mental health support in schools. This taskforce should, as a priority, produce national trans inclusion and wellbeing guidance for schools to educate and empower teachers and school staff on how best to support Trans young people. This will act to create an ‘affirming, trans-positive school environment’ which will act to improve Trans young people’s ‘mental health, wellbeing, self-esteem, school engagement, and sense of belonging’ (Horton 2020).
Addressing capacity and training issues in the mental health workforce and Improving access to mental health services
1.8. We have seen the average waiting times for Trans young people trying to access the gender-specialist medical support pathway, namely the Gender Identity Development Services (GIDS), increase significantly since 2016. The average waiting time has increased from between 14-18 months (in 2018), to an average of 24 months or more, prior to the pandemic. During the pandemic, the waiting times have increased to 33-36 months on average. The waiting times Trans young people are subject to are significantly higher than the maximum waiting times in England.
1.9. We see when working directly with our service users that without access to gender-affirmative care, which has been found to drastically reduce mental ill health for Trans young people, that such extensive waiting times simply elongate the mental distress felt by many Trans young people.
1.10. It is important to note that the GIDS service, although it does refer Trans young people to endocrinology clinics for gender-affirmative medical interventions, largely provides psycho-social support to young people facing issues around the development of their gender identity, offering them a ‘safe and supportive environment’ to explore their gender identity. Therefore, it provides psycho-social support which works to alleviate mental ill health. It also provides access to the above mentioned gender-affirmative medical interventions, for example, hormone blockers, which have been shown to have a hugely positive impact on Trans young people’s mental wellbeing.
1.11. In addition to GIDS waiting times, NHS Child and Adolescent Mental Health Services (CAMHS) itself has a long waiting list, and as found in January 2020, when one accounts for the great regional disparities across local CAMHS providers, the waiting time can be between ‘just 1 day to 6 months’.
1.12. Trans young people accessing general healthcare has been described as a ‘postcode lottery’, with many GPs unsupportive or unwilling to provide care for Trans young people or refer them to specialised services where they can receive that care. Stonewall (2018) found that 7 per cent of trans people said they had been refused care because they are LGBT, while trying to access healthcare services.
1.13. The consequence of these long waiting times, as the Children’s Rights Alliance England (2016) found, is that ‘whilst waiting for treatment [Trans] children said they often struggled with depression, self-harm and self-destructive behaviours and had nowhere to turn for support. Nearly 50% attempt suicide’.
Lack of Training
1.14. Reliance on mental health care, and healthcare more generally, for Trans young people outside of the gender-specialist medical pathway provided by GIDS continues to be unsuitable as many mental health care clinicians outside of the gender-specialist pathway lack the training to be supportive and inclusive of Trans young people as this training is still not mandatory.
1.15. Stonewall (2018) found that 41 per cent of trans people said that healthcare staff lacked understanding of specific trans health needs when accessing general healthcare services.
1.16. As a recent study has shown, CAMHS has often imposed outdated gender stereotypes on both trans binary and non-binary young people, in ways which act to undermine and dismiss these young people’s gender identity.
1.17. Many of the Trans young people we support have specifically sought our help, following the discrimination and prejudice they have faced from their GP or CAMHS. Examples of such conduct includes young trans people being misgendered, their incorrect name being used, and being told they are confused around their sexuality rather than their gender identity. These experiences show a lack of understanding of how to be supportive of Trans young people and can lead to a population of Trans young people feeling unable to seek help for any mental health concerns they may have, which negatively impacts their access to such care. Rather than supporting them in alleviating their mental ill health, their experiences of such services exacerbates mental ill health.
1.18. Our service users have told us that not only are CAMHS or GPs unable to provide the support Trans young people require, many GPs and CAMHS clinicians are unaware of the referral process to GIDS itself. Therefore, Trans young people and their families are shuttled back and forth between healthcare services, with neither seeming to understand how Trans young people can access the support they need.
1.19. Consequently, the lack of trans awareness training for general clinicians, both GPs and CAMHS clinicians, creates too heavy a reliance on the GIDS, which is already a hugely underfunded service. This is evident in GIDS’ waiting lists and times, and therefore, Trans young people are forced to suffer long periods of extreme ill mental health before they receive the medical care some so desperately need.
1.20. Unfortunately, as a recent study has shown, the GIDS service itself lacks awareness around young non-binary people’s experiences, with many young non-binary people saying they were fearful of presenting as themselves, and felt they had to present in a binary version of gender to access help. This illustrates the critical need for further training and awareness to be updated even amongst GIDS clinicians so that support is available for non-binary trans young people.
1.21. It is important to be mindful that those from lower socio-economic backgrounds are reliant on the NHS to access healthcare; those from more affluent socio-economic backgrounds can and do access private mental health and gender-affirmative care. Furthermore, we hear directly from our service users that there are regional disparities in accessing the GIDS particularly, which only has two main locations in the country, and therefore people have to travel to access treatment. Not everyone is able to travel long distances, or to afford the trips. These are but two examples of the ways in which intersectional inequalities can restrict a Trans young person’s access to mental health services.
1.22. We have outlined a summary of our recommendations in response to question 3 (para. 3.1).
2.1. As discussed above, healthcare professionals outside of the gender-specialist pathway lack the training to be supportive and inclusive of Trans young people, and this includes inpatient care medical professionals, who are not aware of how to be, or are sometimes unwilling to be, supportive of Trans young people.
2.2. We have heard directly from our service users, either who are in inpatient care themselves, or whose loved one’s are, that Trans young people’s gender identity is not supported and affirmed as it should be, and of cases where they have been discriminated against because of their gender identity. For example, Trans young people have been placed in wards which do not align with their gender identity, and they have been repeatedly misgendered and deadnamed. This can have a detrimental impact on a Trans young person’s mental wellbeing. For example, a study (2018) showed that using a Trans young person’s chosen name was linked to ‘reduced depressive symptoms, suicidal ideation and suicidal behaviour’. By deadnaming etc., Trans young people’s mental health deteriorates, which can exacerbate other mental health problems.
3.1. As we have discussed in detail in our response to question 1, extensive changes are needed in the system as a whole, and the changes we would recommend are as follows:
● Schools need to be provided with training to enable them to feel confident in their ability to provide appropriate support for Trans young people, which can have a hugely positive impact on their mental health.
● Generalised mental health service professionals, with emphasis on GPs and CAMHS clinicians, need appropriate and comprehensive training to ensure they are aware of how to support Trans young people, so that Trans young people are not overly reliant on gender-specialised care which is often inaccessible.
● Further training and awareness of non-binary trans identities needs to be given to all medical professionals that support Trans young people, to avoid perpetuating harmful gender stereotypes that act as a detrimental barrier from Trans young people obtaining the support they need.
● NHS mental health services must receive better funding from the government to ensure they have the means to meet the demands from service users to a high standard and reduce waiting lists.
3.2. A study published last year found that Trans young people who access gender-affirmative care and support at ‘earlier ages’, for example during early puberty, are likely to have ‘fewer mental health concerns’. This is in contrast to Trans young people who access such support at an older age and later pubertal stage who are more associated with ‘increased rates of mental health problems (depression and anxiety)’.
3.3. Trans young people’s access to gender-affirmative care and support for mental ill health at an early age is a crucial factor in reducing the high levels of mental ill health amongst Trans youth. However, with the combination of extensive waiting times, gatekeeping, lack of alternative care outside of specialist pathways, and a lack of training amongst both general and specialist clinicians, Trans young people are often unable to access the support they need until years after such care becomes necessary.
3.4. We believe that the above recommendations (para. 3.1) would ensure that early intervention in Trans young people’s mental health is possible.
4.1. As we have illustrated in paragraph 1.1, Trans young people experience extremely high rates of self-harm, suicidal ideation and suicide. We have outlined above the ways in which the current healthcare system is not adequate in addressing and alleviating Trans young people’s mental ill health.
4.2. We have also discussed the hugely influential and positive role schools can have on Trans young people’s mental wellbeing when they are educated and empowered, with the support of trans inclusion guidance, to support, protect and affirm Trans young people.
4.3. It is important to note that access to gender-affirmative medical care and interventions, for example in the form of hormone blockers, have also been shown to reduce mental ill health for Trans young people, especially with regard to reducing suicidal ideation and suicide amongst this demographic of young people. However, because of the difficulties of accessing of gender-affirmative medical care, many Trans young people cannot access hormone blockers at the recommended early stages of puberty, and therefore, as explained above (paragraph 3.2), are only able to access such care at later stages, which is shown to be not as effective in reducing mental ill health.
4.4. Those from lower socio-economic backgrounds who are unable to access private care; those with unsupportive GPs who struggle to find the support they need or who struggle to be referred to such support; or those who are unable to commute to the few GIDS clinics, are more unlikely to be unable to access gender-affirmative care, and therefore, their rate of experiencing self-harm, suicidal ideation and suicide is increased.
4.5. Finally, in the last year or so, we have seen an extremely hostile discourse taking place within the UK media and in wider society more generally around trans healthcare, specifically in relation to Trans young people. We have also seen the way this hostility has greatly exacerbated Trans young people’s mental ill health. The Trevor Project in their National Survey (2020) found that “86% of LGBTQ youth said that recent politics have negatively impacted their well-being”.
4.6. This open hostility in the media acts to influence wider society, and as we can see from a study published in 2018, Trans young people who are exposed to transphobic discrimination, either by an individual, or witnessed in the media, often exhibit negative mental health outcomes, which can in turn cause internalised transphobic, aggravating such mental ill health.
4.7. In addition, due to the pandemic, Trans young people have been isolated from physical interaction with supportive friends or family members, and often rely on social media for interaction. However, much of this transphobia plays out on social media platforms, leaving Trans young people even more isolated and unable to find the support they need. If they are also living in an unsupportive, or even hostile household, the transphobic content they see in the media or on social media, can have an even more detrimental effect on their mental health.
4.8. As discussed throughout, there is a large evidence base supporting affirmation of Trans young people, which clearly indicates that those who are accepted and supported in their gender identity often have reduced mental ill health.