Frequently Asked Questions
Gender dysphoria is the term used to describe the distress and discomfort experienced when a person feels their biological sex does not align with their internal sense of being male or female (or non-binary).
Gender dysphoria is the current diagnostic term for this sex-based distress, having previously been known as gender identity disorder. This was changed primarily to reduce the stigmatisation of being called a disorder.
The criteria for diagnosis is laid out in the DSM-V, a manual for the assessment and diagnosis of psychiatric disorders. There are separate criteria for Adults and Adolescents and Children.
Criteria: Gender Dysphoria in Children
A marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least six months, as manifested by at least six of the following (one of which must be the first criterion):
- A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
- In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
- 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
- In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
- A strong dislike of one’s sexual anatomy
- A strong desire for the physical sex characteristics that match one’s experienced gender
The condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Criteria: Gender Dysphoria in Adolescents and Adults
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, as manifested by at least two or more of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
As Dr David Bell phrased it in a recent interview for BBC Radio 4’s Woman’s Hour:
“There’s two different things: one is transgender, and the other is gender dysphoria. Gender dysphoria describes a discomfort, which may be mild to extremely severe, in the relationship between the self and the gendered or sexual body. That can have many, many determinations which need to be understood: individual, social, cultural, family; conscious and less conscious….Transgender is something quite different: that’s when a decision has been made that the way to manage this complex problem is to regard the child as being on a pathway to changing their gender.”
Talking about “trans children” makes the assumption that all children who are distressed about their gender will go on to happily and successfully transition, therefore becoming transgender adults. This is to deny the evidence from studies showing that in the past, for those expressing a cross-gender identity from early childhood, very few would continue their cross-sex identity into adulthood. Many would grow up to become gay, lesbian or bisexual adults, or perhaps gender non-conforming heterosexual adults. As we have no way of telling which child will develop into which adult, it is not accurate or helpful to call all these children ‘trans kids’.
The existing studies of persistence cannot easily be extrapolated to the cohort of childhood referrals to gender clinics we see today. With the change in presentation to mostly female, mostly teenage onset distress (from mostly male and pre-pubescent), we do not currently have any evidence on what will happen with these young people. It is very hard to say what their trajectories might be. We do not deny that adults who have transitioned exist, nor that they were once children. We cannot, however, reliably say that transition is the only pathway for distressed children, and that they will all become happily transitioned adults.
There are some who have suggested that ‘trans children’ can be identified, as they are insistent, consistent and persistent about their cross-gendered identity. Yet these terms could describe great swathes of children and adolescents and in particular those on the autism spectrum. This is why we advise caution over pursuing a medicalised pathway for our gender distressed children – none of us, not even the gender clinicians, have the ability to foretell the future.
What is important to remember as a parent is that each child should be treated as an individual within a social and familial context, and that any understanding of your child should take into consideration all the contributing factors, co-morbidities and risks, in order to maximise the likelihood of a positive and happy adulthood.
We just don’t know why some children, adolescents and young people develop these feelings of distress centred around their sex/gender. As parents, we may long to understand why this is happening and search for explanations, but there is very rarely a single reason that has prompted your child to explore a new identity.
Some children or adolescents may have a history of trauma or early experiences that have impacted on their development. Some have autism, ADHD or other neurodevelopmental disorders. Some may be struggling with their emerging sexuality, be that bisexual, lesbian or gay. Many have been subjected to bullying or physical or sexual assault.
And yet many others may well have experienced none of these things, but still come to make sense of themselves with a transgender identity. Just as there are many ways in which these feelings develop, we believe there are also many different pathways out of the distress they may cause.
It is not necessarily helpful to look at this as a ‘phase’, such as a period of time as a goth and wearing all black or being obsessed by the latest band. To your child, these feelings of confusion and doubt or the conviction that transition will help them are very real, and must not be dismissed as trivial or false.
We have no way of knowing which children who experience distress or confusion over their sexed bodies will go on to pursue transition in adulthood. It is important to be candid with your child about their feelings. Asking where your child thinks these thoughts might have come from, and what they think transition might do for them, can start an open dialogue through which you can understand more about your child’s internal world.
Acknowledge the pain/anxiety/fear they feel and let them know that you still love them and support them. Help your child to find their place in the world by exploring and encouraging their interests and abilities outside of a gendered lens. You may wish to consider finding a therapist who can help your child to work through their distress and explore their feelings and experiences (see our article on talking therapy).
As parents, we are bombarded with advice that makes us feel as though we have failed if our offspring have not yet developed into well-rounded, stable, successful young people. These feelings of guilt are simply not helpful in building and maintaining positive family relationships. Take a look at this TED talk by Professor Yuko Munakata, explaining why, even with the best of intentions and the greatest of skills, our children may not turn out the way we’d expect.
Even if we have less of a role than we’d like in shaping our children’s futures, we can still take positive steps towards improving their mental health and wellbeing and central to this is developing effective communication. Take a look at our Top Ten Tips, and also our parenting resources for practical steps we can all take to bolster daily connections.
Therapist Sasha Ayad has written about how we may have lost confidence in our ability to parent. She advises:
“It is not easy to build up the confidence to stand strong in your role as a parent, especially if you’re dealing with a gender-questioning teen. But Hold on To Your Kids is an excellent book that can help restore your natural power to parent and guide your child.”
We have always been centrally placed to help our children when they are struggling. From their earliest years, we watch them grow and develop, taking daily steps towards independence and adulthood. We are there for the laughter and the tears, the joy and the fear. No one else takes such an active role in all aspects of a child’s development or knows a child quite so well. But when a child declares a transgender identity, we can be often be told we do not know our children at all, that they have been hiding this identity from us all along. Our perspectives on how this new identity may have arisen, its evolution from feelings of otherness, social ostracisation or traumatic experiences can often be ignored or dismissed, together with our parental intuition that something more complex might be going on.
We believe that parents take a central role in caring for their children, in supporting them and in ensuring they reach adulthood able to make the best decisions for themselves. Schools and healthcare settings rightly receive official guidance that working with parents is of the greatest benefit, and we agree.
Being able to talk with other parents who understand can also be of great benefit. Many of our parents express relief at finding others who share their concerns at being told to ignore and suppress their parental instincts. If you’d like to connect with other parents who are going through similar experiences, click here to join us.
We are all aware that the internet has as many negatives as positives. It has been suggested that some young people come to understand their adverse experiences of adolescence as being indicative of being ‘trans’. Parents have described periods of extreme immersion in online activities, prior to a child coming out as trans or non-binary.
Throughout history there have been many instances of psychological distress or physical illness spreading through social contagion, often affecting predominantly adolescent and young adult females. Lisa Littmann published a paper in 2018, in which parents reported entire peer groups declaring a cross-sex identity, calling this phenomenon ‘rapid onset gender dysphoria’.
Many parents and detransitioners, as well as some clinicians, are trying to raise awareness that peer influence may contribute to the exponential rise in young people declaring a transgender identity. One young woman, Helena, discusses the role of social media in the development of her trans identity. Whether or not this cohort of young, predominantly female, adolescents are emerging due to social inflence or not, it is concerning that very little research is going on into the reasons why this may be happening.
Setting limits on internet and social media use is not an unreasonable approach for the parent of any child or adolescent, and can help with other mental health difficulties too. Self-moderation is hard for children and teens, so setting age restrictions and reducing time spent unsupervised on the internet, as well as encouraging the pursuit of other activities will help your child increase their engagement in real life.
A quick Google search for ‘coming out letter’ will take you to many sites where template letters to parents can be found. Whilst not unusual (many kids can struggle to find the words to express what they feel) it can often have a contrived, forced feel to it if your child has not written it themselves.
Requests for changes of name and pronouns are often included and this letter can sometimes be the first indication that your child has been feeling like this. Many of our parents describe a ‘cut and paste’ feel to the letter, full of unfamiliar recollections of having ‘always felt like this’. It is not unusual for kids to be guided by others on the internet to write what will be most persuasive.
Rather than getting caught up with where the letter came from, use it as a starting point to open up a conversation about how they feel and why. Refer to the feel of the letter being unlike their natural language, and ask them to try and tell you in their own words what they are feeling. Express your appreciation that they have felt able to open up to you and that you’d like to learn more about how they have arrived at this conclusion.
This is one of the most common questions appearing on the Bayswater message boards, and there is no single correct answer. This is an especially challenging situation when teachers, therapists or other adult professionals have followed the child’s wishes.
Some of the solutions our families use include:
- Using given name and natal pronouns only
- Following your child’s wishes in the interest of family harmony
- Agreeing to use a childhood nickname, especially if it is more gender-neutral
- Using the child’s preferred name, but retaining natal pronouns
- Avoiding use of any names or pronouns through clever and often convoluted use of grammar or gender neutral language. For example using my child or my eldest instead of my son/daughter, or the use of gender neutral (they/them) pronouns
Having been largely abandoned in recent years, the early approaches to treating childhood gender identity disorder (as it was known then) were designed to reduce the distress experienced by children who had exhibited a cross-sex identity from early childhood by actively helping them to feel more at home in their own bodies and seeing an identity aligned with natal sex as the preferable outcome. The vast majority of children seen would grow up re-identifying as their natal sex.
Watchful waiting – When this approach is taken, no intervention is made to guide the child toward or away from a particular gender identity, but rather the child’s emerging identity is allowed to take its natural course. This was the approach followed for many years, and there is evidence to say that most children who followed this pathway returned to identifying as their biological sex by adulthood.
Affirmative approach – this is where the child’s assertion that they are of the opposite sex, or none (non-binary), is supported and affirmed by those around the child (family, healthcare practitioners, staff in educational settings). Changes of name and pronouns are encouraged, and the child is treated in all circumstances as if they were the sex they identify as, regardless of their age, developmental stage or the presence of other mental health or neurodevelopmental conditions. This has become the standard approach, certainly in most UK settings including the NHS and is advocated for by almost all transgender and LGBT charities and lobby groups. However, from the affirmative approach there is a natural progression to medicalisation. This was brought about by the introduction of the Dutch Protocol; the use of puberty blockers followed by cross-sex hormones. Ken Zucker has hypothesised that children who are affirmed in their identity from childhood are more likely to persist in their identity through adolescence and into adulthood. Indeed, for those children who begin puberty blockers nearly 100% will continue on to cross-sex hormones. From this data, it has been suggested that there is some feature of the affirmative/medicalised pathway that increases the persistence of a cross-sex identity. (For more on the affirmative approach, read this article from Stephanie Davies-Arai)
The Gender Exploratory model – this therapeutic approach, variations of which have been described by Anastassis Spiliadis and others, looks at the child or young person in the context of their developmental stage, and sensitively explores the meaning and the evolution of their cross-sex identity. There is no predetermined or preferred outcome for the child, and this model allows for careful exploration of identity formation and the associated co-morbidities and contributing factors. It is not yet known how effective this approach is at alleviating distress, or what outcomes it achieves, as it is not yet widely adopted.
Any thoughts of suicide or self-harm must be taken extremely seriously.
If you think your child has thoughts of suicide or self-harm, contact your GP or local Child and Adolescent Mental Health Service (CAMHS) team. If it is an emergency, seek help from your nearest Accident and Emergency (A&E) room.
From the GIDS website:
“The majority of the children and young people we see do not self-harm, nor do they make attempts to end their own life. Although there is a higher rate of self-harm in the young people who are seen at GIDS compared to all teenagers, it is a similar rate to that seen in local Child and Adolescent Mental Health Services (CAMHS).”
What GIDS is highlighting here is the equivalent levels of self-harming behaviour across the young people accessing CAMHS services. There are several mental health conditions where the rates of suicidal behaviour and self-harm are even higher than in the gender distressed population. This is certainly not to say that your child should not be taken seriously if they express a wish to hurt themselves. They should always be assessed by a suitably qualified mental health professional.
In some instances, the rate of suicidal behaviour has been used to put pressure on parents, teachers and professionals, or to justify the pursuit of medical interventions. “I’d rather a live son than a dead daughter” is a phrase often used when parents unfalteringly affirm their child. As the Samaritans and other suicide prevention charities tirelessly point out, there are strict guidelines on reporting around suicide due to its highly contagious nature. Telling young people they are more likely to attempt to take their own lives if they have gender dysphoria may make the general public sympathetic to their struggles, but it is also likely to increase the likelihood that a young person would take such action.
You can read more about suicide and self-harm in gender dysphoria, and how it has been used in an exploitative manner, here.
“The available evidence suggests that most prepubescent children with gender dysphoria will have a different outcome in adulthood,” Carmichael says: “The most common would be one around sexuality, rather than gender identity.”In her experience, therefore, they are more likely to be LGB than T. It is important to note that whilst the current evidence does not suggest that all children and adolescents who experience gender dysphoria will end up same-sex attracted as adults, a significant number will. Many detransitioners have described the role their same-sex attraction played in their desire to transition, but there are growing numbers of heterosexual detransitioners, too. It is important to remember throughout, that there is no single reason for developing a trans identity. Be open with your child in age-appropriate discussions of romantic and sexual attraction and reassure them that you love and support them, regardless of their emerging sexual orientation.
There are several conditions that have been shown to occur with greater incidence in those who express a cross-sex identity, including depression, anxiety and eating disorders. Many parents report that their child’s other difficulties predate the trans identity, often by a significant length of time.
Some conditions, particularly eating or food issues, can be triggered after the trans identity. Some girls read online that having a larger BMI will help them pass as male, or conversely that being thinner will stop their periods. Boys and young men may try to lose weight to reduce their overall body mass, feeling this will help them to appear more feminine. What starts as pure dietary control can quickly escalate into more serious issues. Seek professional advice if you have any concerns over weight loss or the eating habits of your child.
In the young people presenting to gender identity clinics neurodevelopmental conditions, such as autism and ADHD are found in much higher percentages than occur in the general population (for autism this is between 7-26%). Try to ensure that these other conditions are dealt with – not through the lens of gender – but independently of it, and before the gender issues are addressed.
Studies suggest that the more psychologically unstable the individual, the less well they may fare with transition in the long term. If your child ultimately pursues transition as an adult, they need to be in the best possible mental health and this starts with tackling issues arising in adolescence. For further advice, take a look at our Top Ten Tips and our Mental Health resources.
The honest answer is – we just don’t know, and there are several reasons for this.
Firstly, if we look at the studies that were published prior to 2012, they largely come to the same conclusion: most children (60-85%) who declare a cross-sex identity, do not grow up to be transgender (see James Cantor’s review of the studies and critiques here). Despite this evidence, many clinics and charities claim the desistance rate is around 1-2%.
Stonewall claims 1% as the rate of desistance, based on a single study that is unlikely to be representative of the true number. The method used to generate such a low number, and one that runs contrary to all the previously published research, was to review the notes of current patients at a gender identity clinic and scan them for specific words and phrases referring to detransition or regret. It is made clear by many detransitoners that once they decided to detransition they did not return to the clinic, this method is therefore likely to miss a large number of those who may come to regret transitioning or reidentify as their natal sex. Similarly low rates have been found by looking at clinic notes from gender-reassignment surgeons, again missing those they wish to capture but not realising (or ignoring) that detransitoners would not necessarily return to the source of their treatment if they experienced regret.
We could claim the 60-80% desistance rate from earlier studies is more likely to be accurate for today’s young people, but there are compelling reasons why this also may not be the case. Aside from issues of numbers and methodology that complicate the current claims for low rates of regret and desistance, the most significant confounding factor is the change in demographics of the children and young people currently being referred to gender clinics, together with changes in the approach to treatment.
The early generation of children treated at gender clinics were predominantly boys who had experienced gender dysphoria from early childhood, with very little or no other mental health diagnoses, who underwent a watchful waiting approach. Two thirds of the current cohort are girls who have experienced a ‘gender uncontentious’ childhood, presenting in adolescence but with alarming rates of comorbid psychiatric conditions and who are likely to have socially transitioned before even reaching the clinic. This population has not been followed up or studied comprehensively, let alone for anywhere near long enough for any conclusions to be drawn. In fact, it has taken the gender clinics a long time to even acknowledge the shift in presentation, and some clinics and charities still do not agree there has been a change, or explain it away as due to increased awareness.
There is a growing concern not only about the number of detransitioners, but the provision of care for them. Thankfully, researchers are now looking at this population and their needs, that we might provide better healthcare for them and perhaps discover more about the factors that contributed to their cross-sex identity.
As parents, we often like practical solutions to any problems our child may be facing. But providing your child with a barrage of information that contradicts any deeply held beliefs about themselves is only likely to make them withdraw from you, and further cement their feelings.
Cognitive dissonance is the term used to describe the discomfort of trying to hold two opposing beliefs at the same time and occurs when we are presented with new information that contradicts our strongly held ideas.
We will try and take action to reduce the discomfort, giving us several options: to agree with the new information and change our original beliefs (“You’re right, these interventions have very little evidence base and may be harmful”), to trivialise the belief (“I may wish to change my body, but it’s no big deal”), or to modify the belief to incorporate, or explain away, the new information (“Detransitioners who regret their changes were never trans anyway; I am true trans so it will not happen to me”).
The first of these options, changing the belief, can be extremely difficult and often requires a lot of courage and maturity. Unfortunately, the last option, to explain away the new information, is often the most common pathway to restoring psychological equilibrium.
Many of our parents have found out, after the fact, that giving too much information to contradict their child’s perspective drove themto hold to their belief all the more strongly. Waiting – either for a greater degree of maturity, or until the initial emotionally charged conversations are over – has enabled some parents to later present, slowly and sensitively, the lack of evidence for medical interventions and have this information received by their child with a more open mind .
Each child is different and each family has its own set of circumstances, relationships and perspectives. Only you can judge what level of information your child can understand, and when, but we advise that you do not try to ‘fact check’ them out of their identity.
When your child is going through a distressing time, conversations might not always go as well as you’d like. Here are our tips on talking to teens:
- If you find conversations at home don’t go well, try talking when you are out, such as on a car journey or out for a walk. Sometimes a neutral environment can help, as can talking side by side rather than face to face.
- Ask your child if they rather write down what they want to say. Perhaps a shared notebook, or an email exchange might help take the emotion out of a conversation, as questions and responses can be thought about in advance
- Don’t bombard them with an overwhelming amount of your own opinions; this can make them feel like you haven’t listened, despite how tempting it might be to give them all the reasons you transitioning may not be the solution. They will not take kindly, or process any information that contradicts how they feel. Patience is required, as there may well come a time when your child will be more receptive to what you have to say.
- Ask lots of questions, and allow them to fully describe their experience to you. Expressing your desire to understand where they are coming from and to learn more can open up a conversation. Comment, but don’t judge. Sentences that start with ‘why…’ rather than ‘I…’ will be more likely to get the conversation going.
- If your child makes requests that you are not comfortable with, defer decisions to a later time. Phrases such as ‘I’m not sure/I don’t know enough about that, can I go away and read up, and give you my answer another time?’ can be a good way for you to be able to step back from a potential confrontation. But remember, do go back and give them your answer – keep to your word to maintain trust.
- Sometimes agreeing to an information exchange can be helpful. Ask your child if they would be prepared to watch a video/read an article/listen to a podcast that explains your position, in exchange for watching a source of information they feel expresses their perspective. Sometimes information from trans people, such as Blaire White or Buck Angel can help them to see that not everyone agrees with every idea, even within the trans community.
- Make sure ‘trans’ is not the only topic you talk to them about. Once your child comes out to you as trans, it often becomes the only topic of conversation. If they can talk to you freely about other things, they are more likely to open up to you about their developing identity.
- Acknowledge the difficulty they have in expressing this to you. These are some of the deepest, most profound ideas your child has about themselves, and although they may change over time, let your child know that you are pleased they have been able to tell you.
Maybe your child’s declaration has come out of the blue, with no prior hint of what was to come. Or perhaps you had your suspicions that there might be something going on in your child’s life. Either way, you need to be able to deal with your own emotions effectively in order to adequately support your child.
Try to remember that you are the parent and your child will likely look to you for help, support and guidance, no matter how old or young they are. Keeping a calm head is essential, despite how emotionally charged the situation may feel. It is also important to take time for yourself to address your own mental health – parenting teens can be hard at the best of times. Perhaps even consider undertaking talking therapy to help clarify your own thoughts and feelings.
Take some practical steps towards addressing this new situation you find yourself in. Read through our Top Ten Tips for some useful advice. Remember to ask questions, and listen to what your child is telling you, without passing immediate comment or judgment. Perhaps read up on how teen brains work (clue: not quite like everyone else’s!), in order to understand how to effectively communicate with the adolescent or young adult in your life. Further information can be found in our parenting resources.
Some young people who identify as trans are beginning to use ‘sex is a spectrum’ as an argument to support their desire to transition. This seems to go against the widely understood and almost universally held perspective that in humans there are two sexes, male and female.
Many well known media and science outlets have run articles supporting this notion about the nature of biological sex. Nature ran a feature in 2015, and in 2017 Scientific American published an often cited article which utilised intersex conditions and an attractive infographic to explain why sex may be more complex and less discrete than we might currently understand. The New York Times also printed Anne Fausto Sterling’s explanation of why ‘Sex is not Binary’.
As we have said before, sometimes there is very little point in producing counter-evidence to our children’s assertions that they are actually the opposite sex, or why they feel they way they do. But if you wish to understand both perspectives in this debate, in order to be able to have an open conversation about the issues encountered, we would suggest you read evolutionary biologist Colin Wright’s rebuttal of the arguments against binary sex in this article, and again with Emma Hilton here. Psychiatrist and genetics expert Dave Curtis also covers this subject well here, as does science editor Tom Chivers and this article here.
Heather Heying, an evolutionary biologist based in the US, puts it very succinctly:
“Males produce tiny zippy gametes (sperm). Females produce large, sessile gametes (eggs). And it’s been that way for a very long time.”
At Bayswater Support Group, we can put you in touch with other UK-based parents who understand the ups and downs of parenting a child with a cross-sex, trans or non-binary identity. As a peer support group, we are well placed to help you navigate this complex world, so why not join us?