The child transgender patient in primary care: practical advice for a 10-minute consultation

Background

Children and adults with gender identity concerns are increasingly presenting for treatment, with referrals to specialist clinics rapidly rising. The percentage of children with gender identity disorder that self-harm or attempt suicide is estimated at 50%, so it is essential that it is recognised early and managed appropriately.¹

Gender identity disorder of childhood usually manifests before puberty. The child typically experiences distress resulting from an incongruence between their current gender identity (sense of themselves as ‘male’, ‘female’, or otherwise), and their gender assigned at birth. Behaviour and activities of the child may stereotypically be associated with that of the opposite gender and the child may be preoccupied with wanting to change their name and gender pronoun (‘she’, ‘he’). Depending on the age, they may also have a strong desire to acquire secondary sexual characteristics of the opposite gender. This may cause significant distress and can impact their performance and experiences at school or at home. Six months of persistent gender non-conforming behaviour has been proposed as an indicator that this is more than ‘a phase’, which is common and not necessarily pathological for many individuals in childhood.

Example case

Tom is 13 years old and has come with his mother to see you. She tells you he becomes distressed when people address him as Tom, and asks to be called Kelly. He hates wearing boys’ clothes, and most of his friends at school are girls, leading to teasing about him being ‘gay’. Recently, his mother found a skirt in his room, which he eventually admitted to having stolen from a friend’s house. He has asked his mother if he can ‘become a girl’, and seems so preoccupied with this idea that he is struggling to complete his school homework. Today Tom’s mother wants to know what to do.

What needs to be ascertained?

Actions advised

• Depending on the level of distress, a referral to both the local CAMHS service and specialist gender identity development service (GIDS) should be urgent. If Tom is suicidal, self-harming, or extremely distressed, an urgent referral is warranted. If the child is not suicidal, then a routine referral to CAMHS is warranted as ongoing psychological support will be required.

• Assess whether Tom is ‘Gillick competent’. There is a question about consent in this age group, particularly about potentially complex treatment decisions such as gender reassignment. For the majority of children, gender identity concerns will resolve before adulthood (roughly 75%).⁴ However, when the distress does not resolve, the benefits of treatment before puberty might be enormous, and would avoid the need for later surgical procedures (with associated risks) aimed at reversing secondary sexual characteristics. Due to the difficult nature of these questions, cases should be considered on an individual basis. Involvement of an ethics committee is recommended for particularly difficult cases.⁵

• Determine the attitudes of the parents or guardians regarding referral to specialist gender services.

• Refer to GIDS if appropriate; where further decisions about management and intervention can be made (see Box 1). In general, GIDS will only accept referrals for patients with identified risk behaviours if there is already local CAMHS support or a CAMHS referral.

• Discuss the importance of the school and its ability to provide an advocate, as support in the school environment is key.²–³

Long-term follow-up

Specialists will guide this. However, GPs may play a role in performing baseline and monitoring bloods (under specialist advice). Ongoing psychological input may be required; the mental health specialists, within CAMHS, usually direct this. Providing support and acting in a role of advocacy for the child and their family remains a key role for the GP, throughout a process which is likely to be challenging for them all.⁶