Executive Summary
I am the parent of two gender variant teenage children, one of whom continues to suffer from significant gender dysphoria and potentially dangerous low mood.
Neither we nor our children had any prior education or understanding of transgender and non-binary people and the potential issues they might encounter.
While professionals we have encountered have been largely helpful and sympathetic, schools and the GP service appear to have little understanding of gender variant children, and schools may be unaware of their responsibilities.
The referral process from GP to specialist mental health and gender services is rather complex and lengthy. The delays have caused severe distress to one of our children and potentially could limit the effectiveness of treatments such as hormone blockers.
Recommendations focusing on the needs of young people:
- Mandatory education for primary and secondary students, parents and teachers
- Mandatory education for GPs and A&E departments
- Simplified and accelerated referral process to allow rapid (< 1 week) parallel referral to CAHMS and gender specialists.
- More resources to allow rapid and effective assessment (and treatment) of young people which will lead to long term cost savings in reduced need for long term mental health care.
- Simplification of bureaucratic processes to allow transgender people to gain legal recognition without seeing a doctor or needing medical treatment.
- Public sector organisations to lead the way by providing “non-specified” and “non-binary” gender options on official paperwork and by promoting non gender-specific toilets.
- Care should be taken to ensure that non-governmental support organisations can continue to provide essential assistance to families and individuals on a long-term basis.
Background
I am writing as the parent of two teenage gender variant children and I am submitting this evidence to describe our experience, the consequences of this experience and to make suggestions about changes that could improve the situation of young trans people.
One of our children has been out to family and friends as a trans boy since October 2014 and our other child has recently identified as gender non-binary. Our trans son has just completed the initial series of assessments at the London Tavistock NHS Gender Unit and we have recently begun the process of referral in the case of our non-binary child.
Until October 2014 we had no indication that either of our children was gender variant. Other than occasional references in the media we had had very little experience of transgender issues and our children had not received any information about gender identity issues at either primary or secondary school.
During 2014 we started to notice that our trans son (then still identifying as a girl) was losing self-confidence in social and school situations. From October 2014 he started to experience increasingly severe panic attacks and signs of low mood at which point we approached our GP. We now know these to be the symptoms of severe gender dysphoria. Following referral to the London Tavistock service and CAHMS locally it became clear that he was potentially suicidal and after a number of CAHMS sessions he was prescribed anti-depressive medication which has stabilised the situation somewhat. At Tavistock we expect the next step to be a course of hormone blockers prior to eventual cross-hormone treatment.
Our second child fortunately does not yet appear to have experienced such severe symptoms of although the signs of dysphoria are there. However, in contrast to the case of clearly binary trans children, the optimum way forward for non-binary young people are less clear.
We have received significant and invaluable support and advice from charities such as Mermaids and GIRES. However these were found by chance through a newspaper article and not through any official channel.
Current Situation and Recent Experience
2.1 Public response to trans people
In recent times a number of well-publicised media cases have raised the profile of trans people. I feel that in general these have been helpful and that public acceptance of LGBTQ people has improved a little as a result. It also appears that the increasing number of referrals of young people (and early intervention) may be due to a higher profile, with many not waiting until adulthood before realising that they are gender variant. However there remains some confusion in the public mind between sexuality and gender identity and there is still next to no understanding of non-binary gender identity. Thankfully in our case we have met a positive reaction from family and friends when we have informed them about the situation of our children. It is ironic in this age of information that as parents we received the first reliable information about our children’s condition and potential options as a result of their own independent internet searches and not through any formal education or public information programme.
2.2 Education: Teachers and Schools
Our experience with our children’s school has been positive at an individual level. It appears that the school knew in general terms of its responsibilities under the equalities act. The teachers whom we are dealing with have listened to us and our child and have put effective plans in place for our trans son. However it is also clear that the teachers had previously received no specific training in how to deal with gender variant students and the school had no contingencies in place for e.g. provision of male toilets in an all girls (state, academy status) school.
Because of panic attacks, severe distress and low moods, our son attended school progressively less frequently over the 2014-2015 school year (then year 10, i.e. one year before GCSE). As he had previously been at A*/A level for all GCSE subjects this was clearly a concern. Fortunately in our region it was possible for his original school to enrol him also into a Community Special (Medical) school where, following medication it has been possible for him to resume most of his studies in an informal small-group setting, where he can identify as male. While still not fully engaging socially Plans are now being put into place for him to return to his original school where he has expressed the wish to identify as male and use the correct pronoun and a new name. We expect this to be quite challenging for him and the school and we do not yet know whether for instance staff and students will be educated about gender variance.
Education: Students and Parents
Both the close friends of our children and their parents have been accepting of our children’s situation but it is clear that in general children are not informed about gender variance at primary or secondary level in e.g. PHSE lessons. Increased education in schools would increase not only the acceptance amongst fellow students and their parents and could potentially enable allow trans children to identify at an earlier age. This would have the benefit of avoiding the extreme trauma, distress of coming out as a teenager or adult and would potentially minimise costly and prolonged mental health intervention.
GP Services
Our GP has been both helpful and open in respect of our children’s situation. However it was clear that she had next to no prior experience or knowledge of transgender issues. With the support of Mermaids we were able to discover the potential pathway of CAHMS/Tavistock intervention and had to provide her with this information.
CAHMS
The process to obtain the first CAHMS appointment was a very slow one (our impression is that this is due to financial or resource constraints) and was fraught with administrative mistakes. This delay caused a significant amount of anguish at a time when our son was suffering very low mood and potentially suicidal. After a tricky start our experience with the nurse and the specialist at CAHMS has been constructive during consultations and they appeared to understand gender variance issues and have communicated with Tavistock.
On one occasion our son experienced severely low mood and self-referred to hospital A&E out of hours (as recommended by CAHMS). Unfortunately the hospital was completely unequipped to deal with his situation which caused further severe distress.
2.6 Tavistock and Portman NHS Trust
Our experience with the individual specialists at the Tavistock clinic has been generally positive and open. We have taken part in individual and family group sessions. As with CAHMS, the parallel delay in getting the first Tavistock appointment caused considerable anguish to our child and to ourselves as parents. Once in the system, whilst individual discussions have been positive we have the impression that specialists are not encouraged to complete the assessment process quickly. While understanding that they do not want to rush into a decision that may be “wrong”, it is equally important to understand the negative impact of delays on the young person to whom it seems nothing is happening for several months.
2.7 Support Organisations
As mentioned, charities such as Mermaids and GIRES and organisations such as Gendered Intelligence provide outstanding support in the form of information, guidance, contacts and events. Most of our information on gender variance and options for treatment has been gained from these channels rather than from NHS sources. As young people are now identifying earlier it is certain that demand for this support will increase and it is unclear whether these organisations will have the resources to cope. In practice these organisations are relieving some of the burden on state services. One only has to look at the recent example of Kids Company to see how dangerous it is to rely on under-resourced charities to deliver what are effectively front-line services.
2.8 Bureaucracy
While it might seem a trivial matter, the business of officialdom and form-filling can cause unnecessary distress to trans young people. Every time that the wrong name, pronoun or gender has to be used has the potential to enhance the feelings of dysphoria. There is for example no easy process to change names and gender officially and quickly, or to use preferred rather than official names, and most forms require a gender to be entered, even if specifying a gender serves no purpose, and the options of “rather not say” or of leaving blank the box for gender are not permitted.
This is an example where simple changes could be brought in (e.g. in allowing free choice or a choice of unspecified gender, choice of preferred pronoun and name in forms for schools, dentists, travel, driving licenses, university or college applications and other government services) that would have no negative impact for the majority of the population while having a huge benefit for trans and non-binary people of all ages. It would be possible for government services to take a positive lead in this matter (and in matters such as the provision of non gender-specific toilets) which would raise public awareness without requiring legislation.
Recommendations for Action
3.1 Education
All schools should be required to include explanation and discussion of gender variance and gender diversity within PHSE education at primary and secondary level. It would be a straightforward and cost-effective matter to put together information packs and online material. In fact much of this information is already available from the charities mentioned and potentially those charities could provide speakers - including trans young people - to come to speak to classes. Sessions for parents could also be held. Obviously such discussion would need to be age-appropriate and at primary level could be “light touch”. The benefit of such a programme would be to normalise gender variance and to reduce the potential incidence of transphobia amongst parents and children. There should be no reason for allowing parents to opt the children out of these sessions. The programme would have the benefit of allowing gender variant children to identify earlier and thus reduce the possibility of severe dysphoria, panic attacks and depression later, i.e. around the time of puberty. The potential knock-on benefit of a reduced need for costly and prolonged mental intervention is obvious.
In parallel to this all schools should be required to ensure that staff have received a basic level of training in gender variance, the consequences and symptoms of dysphoria, as well as an understanding of potential options open to gender variant children.
Healthcare Services
GPs are the frontline service that most parents turn to first in this situation. It is essential that GPs are provided with adequate training so that they can answer initial questions, assess the severity of dysphoria, refer the child promptly to specialist services and provide families with basic factuial information and details of support organisations. Training sessions do not need to be long or onerous but they should be obligatory and as the science and understanding of gender variance is progressing at a rapid rate they should be repeated on a regular basis. A&E departments should also be trained and instructed by CAHMS as they may well receive out of hours referrals.
Following referral to specialist services every effort should be made to ensure that initial consultations with e.g. CAHMS and the Tavistock clinic take place extremely quickly and efficiently. This is particularly important when dysphoria and depression are believed to be severe. A quick intervention could potentially save lives and reduce the extent (and costs) of mental health treatment further down the line. Additionally in the case of teenagers going through puberty the time window for effective treatment with hormone blockers is very short – every week counts!
It is also apparent that an increased referral rate has led to pressure on specialist services so additional resources should be put into these with urgency. Clearly this will lead to increased costs in the short term but, as explained, earlier and more rapid intervention will reduce costly treatment at a later date.
Bureaucracy
At the heart of this issue is the right to allow trans people to self-define their gender without going through a lengthy, costly and humiliating process. The UK government e-petitions site currently lists a petition (https://petition.parliament.uk/petitions/104639) which summarises the situation well and recommends an act equivalent to the recent Irish Gender Recognition Act, as well as including provision for gender non-binary people. The Irish Act (and other legislation in Europe and elsewhere) allows transgender people to gain legal recognition without seeing a doctor or needing medical treatment. Such an Act would simplify and accelerate the process, reduce cost and distress to trans people while at the same time causing no problem or inconvenience to the rest of society.
Even before such legislation were passed, it would be relatively easy to bring in changes to official procedures to remove the requirement to specify gender (or to provide “rather not say” and “non-binary” categories in government and public sector paperwork). At the same private sector organisations could be encouraged to follow suit and encouragement given to introduce non gender-specific toilets.
3.4 Support Organisations
The ability of support organisations such as Mermaids, GIRES and Gendered Intelligence, to provide invaluable assistance to families and individuals should not be left to chance. While they cannot be expected to deliver frontline services they have immense expertise and should continue to play an important role with information, contacts and events. Education and healthcare services should be encouraged to forge links with these organisations. Furthermore their ongoing governance and finances should be reviewed to ensure that there is no risk of essential support being lost suddenly.
13 August 2015