Gender incongruence in children, adolescents, and adults

Full text

More individuals are requesting medical
assistance for gender uncertainty or dysphoria
and provision of adult NHS gender identity
services (GIS) is changing.1 Despite minimal
medical input to polarised debates, several
issues are potentially concerning: reports of
poor care; rapid rises in referrals of children
and young people to GIS;2 public conflation
of biological sex with socially influenced
gender roles; and extensive uncertainty in the
evidence base to guide practice.3
Medical practice should happen within
robust human rights frameworks where
individual patients always have their concerns
heard. Generalists, with expertise in whole-
person care, handling uncertainty and
complexity, have a key role when consulted
by identity-questioning and transgender
individuals for routine care, gender identity
concerns, treatments recommended by
private or NHS services, or for referral.
Presentations with prior emotional trauma,
co-existing mental or neurodevelopmental
issues, or ‘bridging hormones’ requests may
make primary care professionals uneasy.
Without a considered approach to practice,
high-quality evidence and guidance, a policy
of active ‘affirmation’ and ‘treat or refer’
may lead to more people receiving medical
interventions with uncertain outcomes.
CHANGING THE LANDSCAPE
The characteristics of those seeking help are
changing. In the past these were predominantly
for male to female medical transition.
Contemporarily, many younger people identify
with a range of gender types (such as, trans,
fluid, non-binary, gender-queer) and there
is greater difficulty distinguishing overlaps
with imaginative processes. The majority
presenting before puberty desist. Some, but
not all, seek interventions with uncertain long-
term outcomes. There is growing demand for
GPs to prescribe cross-sex hormones before
specialist assessments but GMC and BMA
positions differ.4,5 More definitive knowledge is
needed about: the causes of rapid increased
referrals, especially girls and young females;2
the outcomes of interventions or ‘wait and see’
policies in this new demographic; and how
to practice and organise services, especially
anticipating long-term health implications.
The planned recommissioning of adult GIS
in England provides an opportunity to develop
best practice through integrated programmes
of training, research, and service redesign.
Multidisciplinary approaches used within
child and adolescent services might ensure
that adults now being referred also receive
whole-person comprehensive support.
UNDERSTANDING RISE IN REFERRALS
No robust analysis explains why referrals
have risen so fast. While some individuals feel
able to disclose earlier in a less stigmatised
context, it is possible that gender identity
uncertainty and dysphoria may be generated
or exacerbated by societal and psychological
factors, particularly during puberty. A study of
concerned US parents reported their trans-
identifying children had previously identified as
gay, had mental health or neurodevelopmental
problems, recent onset dysphoria, or were in
friendship groups with other trans-identifying
individuals.6 The paper drew intense criticism
despite acknowledging limitations including
distinguishing cause and effect. Likely, the
rise is multifactorial: 35% of those seen in the
Tavistock service have autism traits;1 some
females may favour traditional male roles;
current female stereotypes and appearances
may be rejected; some young females who
are attracted to other females may initially
believe they are transmen, but later identify as
lesbians. While sexual orientation and gender
identity are distinct, such confusion is now not
uncommon.
INTERVENTION OUTCOMES
While a low-quality observational study of
mainly older male-to-female full transitions
has shown high levels of satisfaction,7 there
are no robust contemporary cohort studies
of younger female-to-male outcomes,1 nor
of supportive, non-invasive interventions.
Adolescents, who previously may have come to
terms naturally with the emotional difficulties
of pubescent bodies or with emergent
homosexuality, may consider themselves to
be ‘trans’ and be offered puberty-blocking
drugs prior to psychoactive steroid hormones
and irreversible surgery. We lack information
whether these improve outcome, including
reproductive consequences. Improved mental
wellbeing is the main rationale for intervention
though one study shows high rates of suicide
after surgery.8 This could be due to ineffective
treatment, ongoing prejudice, or co-existent
mental illness. Rates of persistence, benefits
and complications, regret, and detransition,
are unclear. Practitioners have been sued
for not providing sufficient assessment or
information.9
PATHWAYS TO MEDICAL INTERVENTIONS
Gender-questioning individuals need
protection from discrimination, high quality
services, and clear information. Professionals
should be able to refer to bodies of evidence
and guidelines, but there is no UK guidance
designed for generalists. Some international
guidelines advocate ‘affirming’ an individual’s
expressed gender. The 2017 UK Memorandum
Gender incongruence in children,
adolescents, and adults
Editorials
170 British Journal of General Practice, April 2019
Box 1. Medical uncertainties and our response to gender dysphoria
Medical uncertainties Response
What are the causes of The causes of feeling uncomfortable with one’s biological sex are unclear
gender dysphoria? but likely to be multifactorial and include society’s expectations of gender
roles.
Is there a biological basis for Humans are sexually dimorphic, with rare intersex conditions being
the concept of ‘being born in anomalous developments of dimorphic sexual classes. It is not possible to
the wrong body’? change biological sex. There is no agreed scientific basis for someone
having the mind of someone from the opposite sex or being born in the
wrong body.
How should a child or young Questioning is a normal part of growing up, as is discomfort during
person questioning their puberty. Young people should be encouraged to talk about their worries as
they may not have other people they can trust outside of peer groups.
What do shared decision Generalists should feel confident and supported to explore the potential
making look like in the links between gender questioning, emotions and cognitions, and the
absence of evidence? cultural context. Differences in views are likely to occur and provide the
basis for each party to shift position.
How should we advise patients Medical practitioners should be open and clear that, while satisfaction has
about the outcomes of been high for previous cohorts, we know little about the impact on physical
medical treatments given the (for example, fertility), emotional, and social (future intimate relationships)
paucity of evidence? outcomes for the current younger and mainly female group presenting.

of Understanding on Conversion Therapy,10
signed by the RCGP (but not the Royal College
of Psychiatrists), rejects formal ‘conversion
therapy’, but also states that actions which
contribute to a change to gender identity could
be seen as ‘covert’ conversion. So practitioners
might infer they should not explore wider
issues or discuss harms of interventions.
This would be counter to consultation models
which encourage evidence sharing and leave
room for differing views.
Paradoxically, calls for medical intervention
refer to mental distress and suicide risk, while
psychiatric assessment is often rejected. This
is worrying as there are no objective tests
for gender dysphoria, which has no agreed
physical basis and is assessed by interview.
It may be effected by social and cultural
context and has the potential to change over
time. In contrast to previous debates about
depathologisation of sexual orientation, which
led to demedicalisation, the opposite may
occur here; while helping some, interventions
can result in ongoing side effects and medical
dependency. Medical intervention may, in
effect, become another form of ‘conversion,’
whereby some children who would otherwise
have grown up gay or lesbian receive ‘gender
affirming’ cross-sex treatments instead.
Much patient information does not
fully express the known uncertainties of
interventions. Many healthcare organisations
and schools have been educated by charities
and non-NHS groups using inaccurate
information, including exaggerated risks of
suicide.11 NHS material contains concepts
that biological sex is assigned at birth (rather
than observed) and that surgery can change
sex. The wide range of treatment experiences
and outcomes including desistance need to
be included.
For children and young people, an
individualised age-and-developmental-stage
approach is required. The facts in each case
will influence consultation style, for example,
where does the child live, and with whom?
Who are the key carers? Is the child in
education or employment? What are prior
family values and current concerns? Are there
conflicts or safety issues? Practitioners can
draw on a variety of familiar consultation
skills, such as seeing the child alone and
together with family or trusted friends,
gradually gaining insight, allowing the ‘test
of time’. In general, GPs will want to include
parents and/or guardians in consultations,
aiming for all parties to find common ground
in their legal obligations under the Children’s
Act 1989 using the best interests test.
A number of consultation approaches may
be considered: use clear, respectful language
and the patient’s preferred form of address;
take a non-judgemental person-centred
approach; reflect on personal biases; allow
a few appointments to explore issues and
the time frame of gender-related distress,
whether the individual is questioning or has
firm beliefs, and how feelings of gender relate
to sexuality; assess associated mental health
issues such as self harm, anxiety, or body
dysmorphia, as well as autism traits; enquire
about relationships with family, friends,
intimate partners, and online groups, and how
these relate to the patient’s views and wishes;
remember sex is biological and fixed while
gender relates to social roles; allow respectful
space for differing views; share understanding
of the uncertainties of long-term treatment;
and share literature from a variety of sources
to discuss at future meetings (Box 1).
IMMEDIATE ACTION AND RESEARCH
Immediate action could include: examination
of NHS literature on evidence and uncertainty;
creation of coherent guidance for practitioners
not specialising in gender identity; a national
survey of doctors to understand views and
concerns, and development of training to
ensure practitioners are competent and
understand the evidence.
Well-funded, independent, long-term
research is required to ensure doctors meet
their ethical duties to ‘first do no harm’
and fulfil good medical practice. Research
could include: exploration of the interplays
between gender dysphoria, mental health
problems, autism spectrum disorders, sexual
orientation, autogynephilia, and unpalatable
societal gender roles; and exploration of the
different assessment and diagnosis models;
trials of different strategies, including wait-
and-see versus intervention for young people,
puberty-blocking, hormonal, and surgical
treatments.
National reconfiguration of services
is a chance to integrate research, service
redesign, and training, with the creation of
ongoing cohorts to monitor immediate and
longer-term outcomes for all those referred
and receiving different interventions.
Susan Bewley,
Professor Emeritus of Obstetrics and Women’s
Health, Department of Women and Children’s Health,
St Thomas’ Hospital, London.
Damian Clifford,
Consultant Psychiatrist, Cornwall Partnership NHS
Foundation Trust, Bodmin, Cornwall.
Margaret McCartney,
GP, Fulton Street Medical Practice, Glasgow.
Richard Byng,
GP and Academic, Community and Primary Care
Research Group, Faculty of Medicine and Dentistry,
University of Plymouth, Plymouth.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
DOI: https://doi.org/10.3399/bjgp19X701909
ADDRESS FOR CORRESPONDENCE
Susan Bewley
Department of Women and Children’s Health, Kings
College London, 10th Floor North Wing, St Thomas’
Hospital, Westminster Bridge Road, London SE1 7EH,
UK.
Email: susan.bewley@kcl.ac.uk
British Journal of General Practice, April 2019 171
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