Summary

Two clinicians at England's former national youth gender clinic (GIDS) looked back over 18 months of their own cases. They describe teenagers whose gender distress began in adolescence and who, after a longer assessment, no longer wanted puberty blockers (drugs that pause puberty) or hormones. They found 12 such young people out of 128 cases (9.4%). Most were girls, many were autistic, and many were self-harming or suicidal. Two case stories show how bullying, homophobia, family breakdown and distress about puberty came to be seen differently over time. The authors argue that assessment should allow unhurried exploration, while noting that many others do go on to medical treatment. It is a small case review by the treating clinicians, with no comparison group, no standard measurements and no long-term follow-up. It shows one path, but not how common it is or what caused the change.

Key findings

• The two authors reviewed all teenagers (aged 12 and up) they assessed at GIDS between October 2015 and April 2017: 156 cases, cut to 128 after some were excluded.
• 12 of the 128 (9.4%) had gender distress that began in their teens, asked for medical treatment at the start, and stopped wanting it during assessment.
• Of the 12, seven came to feel comfortable with their birth sex, while five still identified as trans but no longer wanted hormones.
• Most were girls (9 of 12), aged 12 to 16 (average 14). 7 had already been diagnosed with autism, 7 had recently thought about suicide, 7 had self-harmed and 2 had recently attempted suicide.
• Most had not socially transitioned (7 of 12), and most had no formal diagnosis of gender dysphoria from the person who referred them (9 of 12).
• Assessments were longer than the clinic's usual 3 to 6 sessions: on average 6.6 sessions over 9.6 months, mostly with family.
• Two case stories, a 14-year-old autistic boy and a 14-year-old autistic girl with a past eating disorder, describe distress coming to be understood in terms of bullying, homophobia, family breakdown and fear of puberty.
• The authors call for a full review of records across the clinic and for long-term research, and say medical treatment still helps some young people.

Abstract

As the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors' caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress. From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.

Conclusion

In conclusion, the adolescents included in this review met criteria for GD and initially requested medical interventions to resolve their difficulties. Over the course of the psychosocial assessment, they came to understand their distress and its alleviation (at that particular point in time) differently and eventually chose not take a medical (hormonal) pathway and/or identified their gender identity as broadly aligned with their biological sex. Of course, this is not the case for many other young people presenting to the service and it is important to hold onto the multiplicity of possible outcomes. The study highlights the need for the psychosocial assessment to nurture a space in between the internal and external worlds of these young people. Such an assessment would need to be properly located in a developmental framework which takes seriously the inescapable in between-ness of adolescence and joins with young people and their families to broaden the narratives available to them, to make sense of gender-based distress.