The care of transgender youth is often hampered by the fear that the child will ‘change their mind’, revert to their birth gender, make irreversible changes and then live to regret them. If we read this review article published in 2020 by the lead clinician for UK child services, Professor Gary Butler, we can start to understand why the UK may be so far behind other international centres of excellence in its approach.
In understanding the source of this misunderstanding, we need to unpick some basic terminology and the differences between some well-used descriptors.
I am a cisgender doctor, this is what I have learned from my patients about the following terminology:
Transgender is an umbrella term used to describe someone whose gender identity does not fit the sex they were assigned at birth.
Gender expression is how someone ‘wears’ their gender. How they live their gender and how that is reflected back by the world around them.
Gender identity is how people experience their innate gender, in their heart, mind, body and soul.
Gender nonconformity refers to how someones’s gender identity, role, or expression differs from the cultural norms that are perceived for people of a particular sex. (Institute of Medicine, 2011)
Gender incongruence has become the preferred term for the ‘medical diagnosis’ of what it means to be transgender (ICD-11). When your gender identity is at odds with the gender you were assigned at birth. When your primary (genitals) and secondary (pubertal changes) sex characteristics, and the associated cultural gender role, are different to what is expected based on society’s ‘norms’.
Gender dysphoria describes the distress, pain, anguish and discomfort that can be felt by the presence of this incongruence.
What I have learned through my work with the trans community over the years, first as a doctor and later as a firm advocate, is that not all people who experience gender nonconformity or gender incongruence will inevitably experience gender dysphoria. Just because there is a difference, doesn’t mean that it is a problem or a source of pain. That does not invalidate the incongruence, the nonconformity or their gender identity in any way. Just because it doesn’t hurt, doesn’t mean it isn’t real.
In his 2020 review, Professor Butler, who is considered the lead doctor for the UK NHS child and adolescent service, states: ‘Gender incongruence refers to an individual’s discontent with their assigned gender and the identiﬁcation with a gender other than that of their birth sex. The ‘dysphoria’ relates to the distress and unease experienced. It may present during early childhood, but most children will revert to their birth gender at puberty.’
I strongly disagree with this statement.
Gender incongruence does not automatically equate to feelings of discontent. Additionally, the suggestion made by Butler that ‘most children will revert to their birth gender at puberty’ is problematic in many ways. It is true that many children who experiment with their clothes and friends and playthings, and how they express their gender will not turn out to be transgender. This is because they never were transgender, or gender incongruent, in the first place. They were simply ‘trying on’ their gender to see what the best fit was.
People who are gender incongruent (transgender) do not necessarily feel distress or pain due to their incongruence. Rather it is the reaction, and action, of those around them that has the ability to cause such pain. Non-belief, non-acceptance, lack of access to support or care, inequality when it comes to human rights – these are so often the causes of the distress. In generations to come, transgender people will enjoy full acceptance and equality. Any required medical care will be affirming and supportive, starting from a position of belief.
Many children may experiment with their gender expression as they mature. That is part of their personal development and human identity. All children may indeed express gender nonconformity in their play and their life as they mature towards adulthood and beyond. That, in and of itself, does not make them trans.
Children who are transgender feel that their sex assigned at birth is different to their gender identity. To say that most of these children revert to their ‘birth gender’ is both wrong, disrespectful and harmful. Further it is clearly undermined by the mere existence of the many post pubescent people who have continued to identify as transgender after puberty.
Reducing gender incongruence to something people may simply ‘grow out of’ dismisses their experience, grossly undermining the depth of feeling and immense challenges that trans people face in their quest for acceptance and authenticity. Taken to its most extreme conclusion this out-dated approach has resulted in a healthcare system which is inadequate and deeply harmful.
The professionals that are guiding trans healthcare in the UK must understand the simple concept that some children are trans. If they do not, and instead they focus on using trans healthcare as a system to “filter out” confused cis children, rather than centering care around how best to help the individual to live in the world as trans, trans healthcare will never be fit for purpose.
Children who are gender incongruent, who feel that their gender is different to the one that they are assigned at birth, those that are clearly expressing distress at being forced to live in a social role that feels wrong, those who are aware that pubertal changes of the wrong type are looming, they are will not simply ‘grow out of it’. They are tomorrow’s trans adults and they need healthcare that meets their needs accordingly.
These young people must not be dismissed due to definitions which seek to deny the existence of trans children amongst those who are exploring the gender expression of childhood. This is what is hampering advances in the care for trans youth in the UK and urgent steps must be taken to improve the knowledge, skills and attitudes of those who hold such power in the very long-term outcomes of trans children.
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