When speaking to professionals who work with trans children I was shocked to discover that the diagnostic tool used is sexist, outdated and, in my view, only serves to reinforce gender stereotypes.
I was told that if I wanted to have my child diagnosed with gender incongruence the psychologists would be looking for evidence of my child exhibiting six out of the following eight criteria, and that these behaviours must have been ongoing for longer than six months:
- A strong desire to be of the other gender or an insistence that one is the other gender
- A strong preference for wearing clothes typical of the opposite gender
- A strong preference for cross-gender roles in make-believe play or fantasy play
- A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
- A strong preference for playmates of the other gender
- A strong rejection of toys, games and activities typical of one’s assigned gender
- A strong dislike of one’s sexual anatomy
- A strong desire for the physical sex characteristics that match one’s experienced gender
As well as this, children must show, “an associated significant distress or impairment in function, lasting at least six months.”
The International standard diagnostic tool from WHO, ICD-11 HA61 Gender incongruence of childhood, takes it even further, stating that “The incongruence must have persisted for about 2 years.”
While some of the criteria are reasonable, others are, I believe, dangerous.
Number two is “A strong preference for wearing clothes typical of the opposite gender”, this condition ‘genders’ clothing and reinforces the idea that girls should only wear one type of clothing and boys another. This leaves very little space for individuality, further segregates and encourages gender stereotypes, and thus stigmaitises people who fall outside of those stereotypes. It also begs the question, is it appropriate for the WHO to be perpetuating gender stereotypes and stigmatising those who choose to dress differently, like girls who wear black trousers instead of pink dresses?
Sinead* is the mother of a trans teen living in County Kildare in Ireland. Sinead says that one of her daughter’s team was a psychiatrist who, when her daughter was 14, “Criticised her because her makeup wasn’t very good and her clothes didn’t match.”
“We were shocked, and my husband told the psychiatrist that he thought every kid at that age probably didn’t know how to put makeup on and wasn’t very good at it.”
The danger of including such gendered stereotypes in the diagnostic criteria is that it opens the door for professionals to judge the femininity or masculinity of a transgender individual, like a psychiatrist expecting a 14 year old girl to demonstrate femininity by being good at makeup. Not all 14 year old cis girls wear makeup but Sinead’s trans daughter was not only expected to; she was critisied for not being good enough at it.
Criteria number four is, “A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender”
I have been a parent for over 20 years, as well as being a feminist, this has made me mindful of not gendering the toys my children play with or the books they read. I don’t believe children’s games and activities should be gendered, I think play of all types should be available to all children and that it should be left to them, to decide what they enjoy.
My children, who are of various genders, cis and trans, all have varied interests. My trans daughter loves Marvel, lego and medieval weaponry. When I read this criteria I wonder why these passions should bar her from being acknowledged in her clear self-identity as a girl?
Sinead’s daughter had a similar experience to my child, and Sinead said that when she herself was a child she had no interest in dolls or “girly” things,
“My daughter doesn’t conform to gender stereotypes at all, She was never a child who played with dolls. She played with lego and Thomas the Tank Engine when she was little but she didn’t mention that during her assessments as she was worried about having a black mark against her.”
Sinead said that her daughter told her she knew she had to pretend to be more “girly” for professionals, in order to be accepted as a girl.
“My daughter was 12 when we went to CAMHS and we had to fill out a questionnaire and she told me she felt she needed to change her answers in order to be accepted as trans.”
Criteria number five is, “A strong preference for playmates of the other gender”
My trans daughter has had a group of best friends who are boys all the way through school. Her male friends are still her closest group of friends, even though she has been socially transitioned for over two years at this stage.
Why is the gender of the people children spend time with a factor in a diagnosis? The idea that gender-affirming support or intervention could be withheld because the gender of the company we keep isn’t uniform enough, seems an absurdity. My daughter is no less a girl because she spends time with boys, just as I am no less a woman because I spend time with my male friends.
Sinead says the process was an uphill struggle to get healthcare providers to accept her daughter as trans and that they regularly encountered sexism from their multidisciplinary team. “One of them said to me ‘How can she know she’s a trans girl if she hasn’t had sex as a boy yet?’ It was all so damaging.”
Some parts of the diagnostic criteria punish children who don’t adhere to outdated sexist, gender stereotypes. Aspects of it read like a 1950’s parenting manual. It is not reflective of the world we live in and it leaves no space for people to express their gender in ways that are authentic for them.
Trans people and people who have lived as trans children must be central to any changes made to the diagnostic tool, their voices and experiences should be heard and they should be involved in writing new criteria.
As it stands, trans children are making efforts to jump through hoops created for them by cis people, they know what is expected of them and perform it for professionals, for just long enough to get the support they need. I can think of no other healthcare that can be denied on the basis of who the patient spends time with and how they dress.
Sinead describes hers and her daughter’s experience of trying to access trans healthcare as “antiquated, biased and transphobic.”
“You always felt you had to answer correctly rather than truthfully or they would tell you that she wasn’t a girl.”
At GenderGP we have taken our experience of working with hundreds of trans individuals and their loved ones, over the past five years, to create what we believe is a more realistic set of criteria. We would like to use this to start a conversation with the community to come to a point where we have something which is community led and actually fit for purpose. Below is the criteria used by GenderGP, we’d love to hear from trans people, and especially people who were or are trans children, about what they think the international criteria should be.
- The child or adolescent is expressing that their gender is different to the one they were assigned at birth.
- This feeling of gender incongruence has been with them for at least six months, regardless of the date of disclosure.
- The expression may be that their gender is opposite to the gender assigned at birth, or that they do not fit into a binary gender classification.
- There is no reason to believe that this expression is for any other reason than as a true self-identification of gender.
- The young person has had the opportunity to explore their gender identity in a free way and with appropriate support, as required.
- The prospect of developing secondary sex characteristics which would be characterised by a different gender to their gender identification causes distress.
- They wish to live in a role that is in keeping with their self-identified gender rather than their birth-assigned gender.
*Name has been changed to protect anonymity
If you want to know more about how GenderGP works to support transgender adults and youth, our approach and services, please get in touch using our Contact Page.