Reflections on Emerging Trends in Clinical Work with Gender Diverse Children and Adolescents

CCP0010.1177/1359104518812924Clinical Child Psychology and Psychiatryde Graaf and Carmichael 812924research-article2018

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Clinical Child Psychology and Psychiatry Reflections on emerging trends 1 –12 © The Author(s) 2018 in clinical work with gender Article reuse guidelines: sagepub.com/journals-permissions diverse children and adolescents https://doi.org/10.1177/1359104518812924DOI: 10.1177/1359104518812924 journals.sagepub.com/home/ccp

Nastasja M de Graaf and Polly Carmichael Gender Identity Development Service (GIDS), The Tavistock and Portman NHS Foundation Trust, UK

Abstract Gender is a fast-evolving and topical field which is often the centre of attention in the media and in public policy debates. The current cultural and social climate provides possibilities for young people to express themselves. Gender diverse young people are not only developing new ways of describing gender, but they are also shaping what is required of clinical interventions. Emerging cultural, social and clinical trends, such as increases in referrals, shifts in sex ratio and diversification in gender identification, illustrate that gender diverse individuals are not a homogeneous group. How do evolving concepts of gender impact the clinical care of gender diverse young people presenting to specialist gender clinics today?

Keywords Gender identity, gender diversity, children, adolescents, gender care, clinical management

Introduction The concept of gender identity was first formulated in the 1960s and was described as ‘a person’s fundamental sense of belonging to one sex [an awareness of being male or female and]; an over-all sense of identity’ (Stoller, 1964). The emergence of the concept of gender identity gave a way for people to describe their own experiences of gender identity, including experiences where the generally held assumption that gender identity followed physical markers of sex did not hold true. This was arguably important for bringing the issue into the vernacular. Some people who express a gender identity which is different from their birth-assigned gender do not seek physical treatment or even clinical attention. The possibility of expressing their gender identity in their chosen way (through name-changes, pronouns, clothing or lifestyle) may be sufficient. Others seek clinical attention and may request varying physical interventions to align the body to their experienced gender identity. In the United Kingdom, the first adult gender service was established in the 1966. It was not until the 1980s that the first few specialist child and adolescent gender services were established, in Amsterdam, London and Toronto. At that time, the diagnosis that described individuals who

Corresponding author: Nastasja M de Graaf, Gender Identity Development Service (GIDS), The Tavistock and Portman NHS Foundation Trust, 120 Belsize Lane, London NW3 5BA, UK. Email: [email protected] 2 Clinical Child Psychology and Psychiatry 00(0) experienced distress associated with an incongruence between their experienced gender identity and their birth-assigned gender was classified in Diagnostic and Statistical Manual of Mental Disorders (third edition; DSM-III) as ‘gender identity disorder’ (American Psychiatric Association (APA), 1987). The few young people who sought clinical help most often identified with the ‘opposite gender’. Terms such as non-binary or gender queer were not yet in common usage and rarely if ever heard in gender services for children and adolescents. Young people rarely made a social transition before presenting to specialist gender services and hormone-blocking treatment in the early stages of puberty was not available. Over the past decade, the gender field has developed exponentially. The dimensionality and diversity of gender identity have received increasing attention in the literature (Fausto-Sterling, 2000). Although epidemiological studies on the prevalence of gender dysphoria (GD) are lacking, it is suggested that 1.3% of minors identify as transgender and that this number is increasing (Connolly, Zervos, Barone, Johnson, & Joseph, 2016; Zucker, 2017). It is evident that more clinics have opened up in Europe and around the world. The scope of standards of care and clinical guidelines has been expanded to accommodate gender identification across the gender spectrum. Importantly, diverse gender identities are conceptualised as variations of human experience and not as a mental health disorder. In line with this development, the diagnosis changed from ‘gender identity disorder’ to ‘gender dysphoria (GD)’ (APA, 2013; Drescher, 2013). With the emergence of physical treatment to arrest puberty in its early stages, there is more of a focus on a physical pathway for younger adolescents. These developments do not go without debate. There has been an increase in both media coverage and public policy debates. It is apparent that many factors contribute to what may be seen as a challenge for gender health services and what constitutes appropriate care. This article will highlight some cultural, social and clinical factors that illustrate the changing context and reflect on how these have impacted the clinical care of gender diverse young people who attend specialist gender clinics from a UK perspective.

The changing context Although cultural and contextual factors are not commonly described in the literature, it is likely that the perception of gender or gender identity is conceptualised in different ways cross-culturally (see de Graaf, Manjra, Zitz, & Hames, this issue). Traditionally, the understanding of gender and gender roles was often based on expectations of male and female gender stereotypes, which were common in Western societies (Oakley, 2015). While these views remain dominant in many spheres of society, alternative perspectives on traditional beliefs about gender have gained increasing support in the 21st century (Nanda, 2014). One of the most significant directions in which conceptualisations of gender have ‘moved on’ is the emergence of new theoretical frameworks such as post-modernism, feminism and transgender theory (Davies, 2004; Koyama, 2003). The emergence of such frameworks has challenged the existing gender role stereotypes and contributed to acceptance of diversity (McRobbie, 2009). One of the factors that supported this development was the movement for transgender civil rights. Over the past decades, trans inclusion has become a focus of lesbian, gay, bisexual and transgender (LGBT) civil rights organisations and parliamentary committees in the United Kingdom (most recently, the Women and Equalities Committee). This shift contributed to the emergence of the Gender Recognition Act 2004 and the Equalities Act 2010, passed by the UK government, which recognises the rights of transgender people in law in the United Kingdom. In line with these political movements, the World Professional Association for Transgender Health (WPATH) has recently updated their Gender Identity Recognition Statement (2017) which de Graaf and Carmichael 3 advocates that persons must be able to freely express their gender identity, whether or not that identity conforms to the expectations of others. Not only is gender something that is more spoken of, the ways in which this is communicated has changed as well. The use and familiarity with communications, media and digital technologies is one of the biggest influential factors that society has witnessed in the past decade. Although to date there has been little attention devoted to the impact of social media and the Internet, without doubt it has impacted the gender field in many ways. The online social network provides a space for individuals to construct and express themselves in their preferred gender identity. On Facebook, for example, there are currently 71 options to describe one’s gender identity (Telegraph, 2014). Motives for using social network sites, such as peer group communication, may give young people feelings of collective self-esteem and a sense of belonging (Barker, 2009). Young people often use online forums to talk to other young people who are in the same situation, or share detailed information about how to access treatment, either through health care providers or directly from pharmaceutical websites. The validation and possibility of constructing gender outside the binary has also had its impact on media coverage, on TV and in magazines. Representations of gender in the modern media are more complex and less stereotyped than in the past. Seeing trans individuals or characters on tel- evision is often cited as important for young people in identifying their own feelings about their gender. In Gauntlett’s (2008) work on media, gender and identity, it is suggested that media representations play a role in the way individuals construct a narrative of the self, which is modified by the individual’s social experiences and interactions. Gauntlett (2008) argues that mass media of the current era can provide tools for individuals which can be used to construct their own narrative. Although for some young people media may validate their experience, it is also important to be mindful that for others media may direct or confuse their feelings (Barker, 2009; Gauntlett, 2008). The influence of Internet and social media on gender identity development in young people is currently under debate and concerns have been raised that some young people may too quickly come to conceptualise difficulties as relating to gender with a focus on a physical treatment pathway to resolve them (Marchiano, 2017).

Emerging clinical trends While the gender field is evolving at a rapid pace, the aetiology of GD remains unclear. It seems most likely that gender involves ‘an interweaving of biology, development and socialization, and culture and context, with all three bearing on any individuals’ gender self’ (Hidalgo et al., 2013). In the absence of a reliable evidence base, social and cultural factors are currently more in the forefront and arguably more influential in driving change in gender health care. With the changes described on the wider contextual level, new clinical presentations and expectations have emerged in children and young people referred to specialist gender services across the world.

Increase in referrals Internationally, many specialist gender services have witnessed an increase in referrals of young people seeking help with gender identity development (Aitken et al., 2015; de Graaf, Carmichael, Steensma & Zucker, 2018; Wiepjes et al., 2018). Factors associated with this rapid rise in referrals are very likely to be associated with increased attention in society and media, which contribute to greater awareness and availability of information regarding treatment. In the United Kingdom, the rise in referrals can be understood in light of some specific factors. First, the Gender Identity Development Service (GIDS) in the United Kingdom was nationally commissioned in 2009, which improved access to care. Second, one of the main aims of the GIDS has been to work on equitable 4 Clinical Child Psychology and Psychiatry 00(0) access to the service by promoting recognition, acceptance and support around GD. By using The Network Model (Davidson & Eracleous, 2009), GIDS facilitates awareness and understanding of gender identity development and support for this in local Child and Adolescent Mental Health Services (CAMHS) and educational settings around the country with the aim of ensuring all aspects of a young person’s development are supported.

Shift in sex ratio One of the most recent and striking emerging trends is the reported shift in sex ratio in referrals to specialist gender services. While historically more birth-assigned males attended services (Cohen- Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003; Di Ceglie, Freedman, McPherson, & Richardson, 2002), the current referrals favour birth-assigned females. This trend has been reported by a number of centres in Europe and North America (Aitken et al., 2015; de Graaf, Giovanardi, Zitz & Carmichael, 2018; de Graaf et al., 2017; Steensma, Cohen-Kettenis, & Zucker, 2018; Wood et al., 2013). There are polarised debates around potential explanations for this inversion in the sex ratio of referrals. One speculation about the sudden increase in birth-assigned females suggests that it may be easier, or more acceptable, for birth-assigned females to present themselves in their preferred gender than it is for birth-assigned males (de Vries, Steensma, Cohen-Kettenis, VanderLaan, & Zucker, 2016; Shiffman et al., 2016). More contentiously, the over-representation of birth-assigned females has prompted discussion from radical feminists, sometimes referred to as TERF’s (Trans Exclusionary Radical Feminists), and lesbian groups about the experience of young women growing up in present society. One argument put forward is that a trans identity may be an expression of emerging sexuality or an expression of discomfort with the female body (Marchiano, 2017; Williams, 2016). Another movement, mainly led by concerned families or parents, suggests that social and peer contagion have an impact on the number of young people identifying as trans, particularly in adolescent girls, and often in the context of co-occurring autism (autism spectrum disorder (ASD)) (Littman, 2018; Marchiano, 2017). In addition, contextual factors, such as the digitalisation of the ways in which young people and society communicate, should not be underestimated. Social media is increasingly used as a platform to seek peer group belonging and support, especially by adolescent girls (Barker, 2009). In the current context, influences of socially constructed views of ‘femininity’ and ‘masculinity’ and the way these are being displayed on social media are more often being discussed in clinical sessions with young people. Whatever the reasons, the evident over-representation of birth-assigned females does raise some important questions about what it means to be male or female in current society

Diversification of gender identity and expression Gender diverse young people are identifying in a range of ways across the gender spectrum (see Twist & de Graaf, this issue). Whereas pre-pubertal children most often identify according to a binary model of gender and more often than not present in ways stereotypical of their preferred gender, adolescents are increasingly reporting identities which fall outside the gender binary, such as non-binary, gender queer or gender fluid. Similarly, some young people are purposefully challenging stereotypical expectations around gender expression. Along with diverse identities and preferences around gender expression, some young people are seeking different outcomes from treatment and thereby challenging a binary based model of clinical care. For example, increasingly more birth-assigned females want to achieve ‘some’ rather than ‘full’ masculinisation. At present, the language of gender is being contested, owned and refined by gender diverse individuals. In relation to health care, there is an emphasis on depathologisation, self-definition de Graaf and Carmichael 5 and self-determination. For example, the preferred description for ‘biological sex’ became natal gender and more recently birth-assigned gender. This acknowledges that a gender is given at birth and may later differ from the gender as experienced by the individual. Similarly, there is an ongo- ing debate about diagnostic terms and whether GD should be placed in a mental health framework (Beek, Cohen-Kettenis, & Kreukels, 2016). Currently, the diagnosis is held within a mental health framework in both the DSM of the APA and International Classification of Diseases and Health Related Problems (ICD) of the World Health Organization (WHO). In recognition of the debate, the conceptualisation of GD has changed considerably over time (Beek et al., 2016). The newest version of DSM sought to depathologise, changing the diagnostic label ‘gender identity disorder’ to GD. While ICD 10 still refers to gender identity disorder, it is currently under review and there is a strong lobby for the diagnosis to be changed to gender incongruence. In addition, there is a call for the diagnosis to be moved to a new chapter named Conditions Related to Sexual Health and for it to be removed from a mental health framework by employing non-pathologising Z Codes (Winter, De Cuypere, Green, Kane, & Knudson, 2016). In the literature, there have been efforts to find terms which ‘normalise’ rather than ‘pathologise’, such as gender variant, and increasingly gender diverse. Such terms seek to describe the reality that people experience gender differently and by no means all decide to attend gender services. The choices made by those that do attend specialist gender services are varied and assumptions cannot be made about the outcome of gender identity or what choices those who follow a physical pathway will make.

Early social transition Social transition usually involves making significant changes in the way young people express their gender identity, for example, changing their name and pronouns, cutting or growing hair and choosing clothes or a style that expresses their preferred gender. In the past, young people were more likely to live in their preferred role at home, but not in school, or conversely, to gradually make changes apparent with their peers or at school, but not at home. It was very rare for younger service users to make a ‘full’ social transition, presenting and living in their preferred gender full time. Most often, if a ‘full’ social transition was made by younger service users, it was prompted by the move to secondary school. However, if this became public, there was a risk of sensationalist and generally unsympathetic front page headlines. Over the past decade, and with the emergence of hormone blocking treatment for young people in the early stages of puberty, increasingly more young people are presenting to specialist gender services already having made a social transition (Steensma & Cohen-Kettenis, 2011). This trend seems likely to be associated with the emergence of the ‘affirmative approach’, which encourages parents to advocate for their children with the goal of creating a safe space for their gender noncon- forming child (Hill & Menvielle, 2009). The affirmative stance urges parents to unconditionally value their child, validate their gender wishes and avoid criticism of the child’s choices (Ehrensaft, Giammattei, Storck, Tishelman, & Keo-Meier, 2018; Hidalgo et al., 2013; Hill, Menvielle, Sica, & Johnson, 2010). Anecdotal reports from parents suggest that young people are significantly happier having made a transition (Olson, Durwood, DeMeules, & McLaughlin, 2016). In contrast, critics of the gender affirmative approach argue that hurrying to transition reinforces the traditional expectations of masculinity or femininity that are held by society (Brunskell-Evans & Moore, 2018). Furthermore, it is debated whether earlier social transition increases the likelihood of pro- gressing onto physical pathways. While the impact of models of care and timing of treatment in pre- and peri-pubertal children is one of the most topical issues in current debates, to date, there has been almost no research that explores the impact of early social transition on gender identity 6 Clinical Child Psychology and Psychiatry 00(0) development and longer term outcomes both in terms of the choices made in relation to gender and general well-being (Vrouenraets, Fredriks, Hannema, Cohen-Kettenis, & de Vries, 2015). The UK specialist gender service is seeing increasingly younger children who have made a full social transition. Parents and social networks frequently report that these young people appear happier. Clinically, however, it is apparent that early social transition can bring its own challenges. For example, early social transition is increasingly associated with living ‘in stealth’, that is, the choice not to share gender history outside the home. While young people have reported that openness may compromise acceptance in their preferred gender, secrecy can be a burden and there is a potential for internalised shame. Some young people who are living in their preferred gender may find it difficult and distressing to acknowledge that their body is not in line with the way they present and are identified. This appears to be more of an issue for young people with co-occurring ASD and can bring implications for informed consent if physical treatment is considered at a later stage. Furthermore, it is notable that younger children referred to the United Kingdom almost without exception identify as the ‘opposite gender’ to their assigned gender and that their gender expression conforms to sex-normed stereotypes. Whether this reflects stage of development or that younger gender diverse children represent a specific group is unclear and what this implies for early social transitioning has yet to be explored.

Increase in complexity Clinically, it seems that along with the increase in number has come an increase in the complexity of young people referred to specialist gender services. It is well-documented that compared to the general population, gender diverse young people often experience more psychological difficulties (de Vries et al., 2016; Steensma et al., 2014; Zucker et al., 2012). In the past, more birth-assigned males than birth-assigned females tended to present with internalising problems, such as anxiety and low mood. However, more recent research has shown that increasingly more birth-assigned females are experiencing psychopathology, such as internalising and externalising problems and increased risk of self-harming thoughts and behaviours (de Graaf et al., 2017; Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, 2015; see Mann, Taylor, Wren, & de Graaf, this issue). Research and commentary around psychological well-being have tended to focus only on the outcomes for young people who undertake physical treatments. Early outcome studies from the Dutch specialist gender service suggested that the mental health of gender diverse adolescents improves after puberty suppression treatment and following affirming hormone therapy (de Vries et al. 2014; de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011). Some researchers suggest that associated difficulties are secondary to GD and therefore resolve when physical treatment is started (Spack et al., 2012). Other research papers have identified social factors which could have a mediating impact on disadvantageous mental health outcomes, such as peer relations, prejudice, stigma, transphobia, discrimination and violence (de Graaf et al., 2017; de Vries et al., 2016; Lombardi, 2009; Shiffman et al., 2016; Testa, Habarth, Peta, Balsam, & Bockting, 2015). Recently, some researchers have tried to define young people referred to gender services by making differentiations between early-onset and late-onset GD and how this may relate to the emergence of psychopathology (Kaltiala-Heino et al., 2015). In line with this distinction, in the UK specialist gender service, it is recognised that there is a group of ‘early presenters’ who have embarked on physical treatment in the early stages of puberty and are generally doing well. However, the majority of referrals to the specialist gender identity service in the United Kingdom consist of older adolescents who present after having gone through puberty (Butler, de Graaf, Wren, & Carmichael, 2018; de Graaf, Giovanardi, Zitz & Carmichael, 2018). Compared to the early presenters, these ‘late presenters’ represent a more heterogeneous group and are more likely to identify in various ways across de Graaf and Carmichael 7 the gender spectrum. A proportion may present with some difficulties; however, the majority report significant psychopathology and broader identity confusion than gender identity issues alone (de Graaf et al., 2017; Kaltiala-Heino et al., 2015). The increase in the complexity of young people referred to specialist gender services is an ongo- ing phenomenon. Although there are many factors that could have an impact on mental health, it is important to keep in mind that physical treatments are not always associated with a resolution in mental health difficulties. In some cases, mental health problems can emerge while on physical treatment. This highlights the importance of following young people’s trajectories to better understand the changing clinical presentations in gender diverse children and adolescents and to monitor the influence of social and cultural factors that impact on their psychological well-being.

Gender and autism In line with increased complexity and associated difficulties, a topical subject in the gender field is the growing awareness of the association between GD and autism (ASD). It has been observed that there is a higher prevalence of autistic traits in clinically referred gender diverse young people than in the general adolescent population (Van der Miesen, de Vries, Steensma, & Hartman, 2017). In the Dutch gender identity service, 9.4% of referred adolescents presented with ASD, whereas in Finland, 26% of adolescents were diagnosed to be on the ASD spectrum. There are various hypotheses put forward in the literature that try to explain the co-occurrence between gender and autism. Some offer a biological explanation suggesting that prenatal exposure to high levels of testosterone is involved in the development of both conditions (GD and ASD), especially for birth-assigned females with ASD, but this leaves the comorbidity in birth-assigned males unexplained (Jones et al., 2012). Others hypothesise that several subdomains of ASD may moderate the co-occurrence of GD and ASD. Several authors have suggested that there is a link between GD and unusual interests or pre-occupations (VanderLaan et al., 2015). As such, unusual interests or preoccupations for cross-dressing or cross-gender behaviour might resemble features of GD while they are actually part of the ASD. Others have hypothesised that the GD and ASD overlap relates to deficits in social communication (Strang et al., 2014). GD may cause social difficulties by, for example, people with GD being subject to a high level of bullying (Holt, Skagerberg, & Dunsford, 2015; Skagerberg, Di Ceglie, & Carmichael, 2015). In the most recent study on this topic, Van der Miesen et al. (2018) concluded that the association between GD and ASD is unlikely to be attributed to solely one subdomain of the ASD spectrum. In the gender identity service in the United Kingdom, numerous young people are presenting with features of ASD. An emerging clinical picture, particularly in pre-pubertal young people, is that younger service users frequently present as being dissociated from their body, which makes talking about or naming specific primary and secondary bodily sex characteristics almost impos- sible, as to do so causes severe distress and withdrawal. This highlights the importance of consider- ing the implications of models of care that could arise for young people with ASD who are uncomfortable with dealing with change or who need support with communication difficulties. More tools and guidelines are needed to support young people with ASD making informed decisions about their treatment pathway.

Health care in an evolving context In a recent special issue devoted to gender, the front page of National Geographic referred to a Gender Revolution, highlighting that conceptualisations of gender are shifting rapidly and radi- cally. Changing social and contextual factors have undoubtedly contributed to a more widely held 8 Clinical Child Psychology and Psychiatry 00(0) awareness that gender is not a binary given. An increasing number of young people are presenting in a range of ways across the gender spectrum and are seeking help from specialist gender services in supporting them through this process. Gender diverse individuals are shaping the way their experiences are described by health services and advocating for models of trans health care which support self-definition and individualised requirements for physical treatments. How and whether these aspirations can be translated into the development of appropriate care pathways for developing young people is not clear. While it is positive that there is greater awareness and that young people are more able to express diverse gender identities, there are strongly held competing views about how best to support young people experiencing GD (Vrouenraets et al., 2015). There are contradictions in the way the field is developing, which is putting immense pressure on young people, their carers and those working in the field who strive to retain a balanced and thoughtful approach. For example, while there is greater awareness and tolerance of gender diversity, supported by the Equalities Act (Legislation.gov.uk, 2010), many service users present with increased complexity and more young people are choosing to live in stealth. The narrative around young people experiencing GD is often negative with an emphasis on self-harm (see Mann et al., this issue). In particular, a causal connec- tion between mental health and the urgent need for physical intervention is emphasised, together with well-established dominant treatment pathways. The intense desire to change the body to one that feels right for the experienced gender can make it difficult for young people to fully explore their options and make informed choices about possible treatments. It is apparent that young people seeking help through specialist gender services are a heterogeneous group. While for some a physical treatment pathway resolves dysphoria, this is not the case for all and outcomes are diverse. It is challenging to find a balance between diametrically opposing views about the nature of GD in young people and how best to provide care. On one hand, there is a push for earlier physical treatment, and on the other hand, there is a view that for some young people what they are experiencing is not best resolved in this way. For this reason, it is essential that careful exploration precedes any action and that a range of pathways are established and accepted as appropriate responses to GD. It is exceedingly challenging not only for families but also for professionals within the field, to be affirmative while remaining open to the possibility of a range of outcomes or developmental trajectories in relation to gender. This is made all the more difficult by the current heated debates, often media based, around care for gender diverse young people which tend to polarise views and position contributors as either ‘gender affirmative’ or ‘gender critical’. Such debates quickly become self-referencing around these positions and academic publications and evidence are too frequently accepted or rejected on the basis of ideology rather than appraisal. It is increasingly difficult to find ways of remaining curious and countenance different points of view without being positioned. It seems likely that these different views reflect the heterogeneity of gender diverse young people rather than competing frameworks into which all gender dysphoric young people will fit. It is clear that individual experiences of gender differ and that a broader understanding of what may influence gender development and the decisions young people make around this is required. It can only be positive that cultural and social expectations around gender are being challenged, as this may provide a context in which self-definition can meaningfully emerge and inform the development of gender services moving forward. In this contradictory climate, how can specialist gender services provide best care? Although evidence is slowly starting to unpick the emerging complexity, there are still many unknowns around understanding the development of gender diverse outcomes (Hidalgo et al., 2013). Research is urgently needed to follow young people who attend gender services, not just those who take a physical treatment pathway. Care pathways need to be evaluated in terms of how they open up de Graaf and Carmichael 9 possibilities for young people to take different routes and make their own choices, rather than a one-size-fits-all approach. Specialist services are not necessarily helpful for all gender diverse young people and support groups may play an important role in supporting young people find their own path as well as supporting parents and carers to maintain the delicate balance between acceptance and affirmation and ensuring there is space for an individual outcome to emerge. There is still much to learn about the trajectories of young people experiencing distress around their assigned gender and how best to support them. The needs of young people referred to specialist gender services are changing, reflecting wider social and cultural shifts in thinking about gender. How should we respond to this? Certainly with respect and acceptance, but also with curiosity and care. Gender identity development in young people is complex and while the evidence base remains poor we need to proceed with caution, taking a case-by-case approach to understand the individual’s context and to think of each child in their own developmental framework.

Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publi- cation of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship and/or publica- tion of this article.

ORCID iD Nastasja M de Graaf https://orcid.org/0000-0003-2478-5626

References Aitken, M., Steensma, T., Blanchard, R., VanderLaan, D., Wood, H., Fuentes, A., & Zucker, K. (2015). Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. Journal of Sexual Medicine, 12, 756–763. American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd rev. ed.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th rev. ed.). Washington, DC: Author. Barker, V. (2009). Older adolescents’ motivations for social network site use: The influence of gender, group identity, and collective self-esteem. Cyberpsychology & Behavior, 12, 209–213. Beek, T. F., Cohen-Kettenis, P. T., & Kreukels, B. P. (2016). Gender incongruence/gender dysphoria and its classification history. International Review of Psychiatry, 28 , 5–12. Brunskell-Evans, H., & Moore, M. (Eds.). (2018). Transgender children and young people: Born in your own body, 244. Newcastle upon Tyne, UK: Cambridge Scholars Publishing. Butler, G., de Graaf, N. M., Wren, B., & Carmichael, P. (2017). The assessment and support of children and adolescents with gender dysphoria. Archives of Disease in Childhood, 103, 631–636. doi:10.1136/ archdischild-2018-314992 Cohen-Kettenis, P. T., Owen, A., Kaijser, V. G., Bradley, S. J., & Zucker, K. J. (2003). Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: A cross- national, cross-clinic comparative analysis. Journal of Abnormal Child Psychology, 31, 41–53. Connolly, M. D., Zervos, M. J., Barone, I. I. C. J., Johnson, C. C., & Joseph, C. L. (2016). The mental health of transgender youth: Advances in understanding. Journal of Adolescent Health, 59 , 489–495. Davidson, S., & Eracleous, H. (2009). The gender identity development service: Examples of multi-agency working. Clinical Psychology Forum, 201, 46–50. 10 Clinical Child Psychology and Psychiatry 00(0)

Davies, E. (2004). Finding ourselves: Postmodern identities and the transgender movement. In S. Gillis, G. Howie, & R. Munford (Eds.), Third wave Feminism (pp. 110–121). Hoboken, NJ: Palgrave Macmillan. de Graaf, N. M., Carmichael, P., Steensma, T. D., & Zucker, K. J. (2018). Evidence for a change in the sex ratio of children referred for gender dysphoria: Data from the gender identity development service in London (2000–2017). Journal of Sexual Medicine, 15, 1381–1383. doi:10.1016/j.jsxm.2018.08.002 de Graaf, N. M., Cohen-Kettenis, P. T., Carmichael, P., de Vries, A. L., Dhondt, K., Laridaen, J., & Steensma, T. D. (2017). Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: A clinical comparison study between four clinics. European Child & Adolescent Psychiatry, 27, 909–919. de Graaf, N. M., Giovanardi, G., Zitz, C., & Carmichael, P. (2018). Sex ratio in children and adolescents referred to the GIDS in the UK. Archives of Sexual Behavior, 147, 1301–1304. de Graaf, N. M., Manjra, I. I., Zitz, C., & Hames, A. (IN PRESS). Thinking of ethnicity gender diversity. Clinical Child Psychology Psychiatry. de Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134, 696–704. de Vries, A. L., Steensma, T. D., Cohen-Kettenis, P. T., VanderLaan, D. P., & Zucker, K. J. (2016). Poor peer relations predict parent-and self-reported behavioral and emotional problems of adolescents with gender dysphoria: A cross-national, cross-clinic comparative analysis. European Child & Adolescent Psychiatry, 25, 579–588. de Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. The Journal of Sexual Medicine, 8 , 2276–2283. Di Ceglie, D., Freedman, D., McPherson, S., & Richardson, P. (2002). Children and adolescents referred to a specialist gender identity development service: Clinical features and demographic characteristics. International Journal of Transgenderism, 5(4). Drescher, J. (2013). Gender identity diagnoses: History and controversies. In B.P.C. Kreukels, T.D.Steensma, & A.L.C. de Vries (Eds.), Gender dysphoria and disorders of sex development: Progress in care and knowledge (pp. 137–150). New York, NY: Springer. Ehrensaft, D., Giammattei, S. V., Storck, K., Tishelman, A. C., & Keo-Meier, C. (2018). Prepubertal social gender transitions: What we know; what we can learn – A view from a gender affirmative lens. International Journal of Transgenderism, 19 , 251–268. Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexuality. New York, NY: Basic Books. Gauntlett, D. (2008). Media, gender and identity: An introduction. New York, NY: Routledge. Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., & Olson, J. (2013). The gender affirmative model: What we know and what we aim to learn. Human Development, 56, 285–290. Hill, D. B., & Menvielle, E. (2009). ‘You have to give them a place where they feel protected and safe and loved’: The views of parents who have gender-variant children and adolescents. Journal of LGBT Youth, 6, 243–271. Hill, D. B., Menvielle, E., Sica, K. M., & Johnson, A. (2010). An affirmative intervention for families with gender variant children: Parental ratings of child mental health and gender. Journal of Sex & Marital Therapy, 36, 6–23. Holt, V., Skagerberg, E., & Dunsford, M. (2015). Young people with features of gender dysphoria: Demographics and associated difficulties. Clinical Child Psychology and Psychiatry, 21, 108–118. Jones, R. M., Wheelwright, S., Farrell, K., Martin, E., Green, R., Di Ceglie, D., & Baron-Cohen, S. (2012). Brief report: Female-to-male transsexual people and autistic traits. Journal of Autism and Development Disorders, 42, 301–306. Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9 , 9. doi:10.1186/s13034-015-0042-y de Graaf and Carmichael 11

Koyama, E. (2003). The transfeminist manifesto. In R. Dicker, & A. Piepmeier (Eds.), Catching a wave: Reclaiming feminism for the 21st century (pp. 244–259). Boston: Northeastern University Press Legislation.gov.uk. (2010). Equality act 2010. Retrieved from https://www.legislation.gov.uk/ukpga/2010/15/ contents. Littman, L. (2018). Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PloS One, 13(8), e0202330. Lombardi, E. (2009). Varieties of transgender/transsexual lives and their relationship with transphobia. Journal of Homosexuality, 56, 977–992. Mann, G., Taylor, A., Wren, B., & de Graaf, N. M. (IN PRESS). Review of the literature on self-injuri- ous thoughts and behaviours in gender-diverse children and young people in the UK. Clinical Child Psychology and Psychiatry. Marchiano, L. (2017). Outbreak: On transgender teens and psychic epidemics. Psychological Perspectives, 60, 345–366. McRobbie, A. (2009). The aftermath of feminism: Gender, culture and social change. London, England: Sage. Nanda, S. (2014). Gender diversity: Crosscultural variations. Long Grove, IL: Waveland Press. Oakley, A. (2015). Sex, gender and society. Farnham, UK: Ashgate. Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics. Retrieved from http://pediatrics.aappublications .org/content/137/3/e20153223 Shiffman, M., VanderLaan, D. P., Wood, H., Hughes, S. K., Owen-Anderson, A., Lumley, M. M., & Zucker, K. J. (2016). Behavioral and emotional problems as a function of peer relationships in adolescents with gender dysphoria: A comparison with clinical and nonclinical controls. Psychology of Sexual Orientation and Gender Diversity, 3, 27–36. Skagerberg, E., Di Ceglie, D., & Carmichael, P. (2015). Brief report: Autistic features in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders, 45, 2628–2632. Spack, N. P., Edwards-Leeper, L., Feldman, H. A., Leibowitz, S., Mandel, F., Diamond, D. A., & Vance, S. R., (2012). Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. Retrieved from http://pediatrics.aappublications.org/content/129/3/418 Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Gender transitioning before puberty? Archives of Sexual Behavior, 40, 649–650. Steensma, T. D., Cohen-Kettenis, P. T., & Zucker, K. J. (2018). Evidence for a change in the sex ratio of children referred for gender dysphoria: Data from the center of expertise on gender dysphoria in Amsterdam (1988–2016). Journal of Sex & Marital Therapy, 1–3. Steensma, T. D., Zucker, K. J., Kreukels, B. P. C., VanderLaan, D. P., Wood, H., Fuentes, A., & Cohen- Kettenis, P. T. (2014). Behavioral and emotional problems on the teacher’s report form: A cross-national, cross-clinic comparative analysis of gender dysphoric children and adolescents. Journal of Abnormal Child Psychology, 42, 635–647. Stoller, R. J. (1964). The hermaphroditic identity of hermaphrodites. The Journal of Nervous and Mental Disease, 139 , 453–457. Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M., . . . Luong-Tran, C. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525–1533. Telegraph. (2014, June 27) Re: Facebooks’ 71 gender options come to UK users. Retrieved from http://www .telegraph.co.uk/technology/facebook/10930654/Facebooks-71-gender-options-come-to-UK-users.html Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2, 65–77. Twist, J., & de Graaf, N. M. (IN PRESS). Gender diversity and non-binary presentations in young people attending the UK national gender identity development service. Clinical Child Psychology and Psychiatry. VanderLaan, D. P., Postema, L., Wood, H., Singh, D., Fantus, S., Hyun, J., & Zucker, K. J. (2015). Do children with gender dysphoria have intense/obsessional interests? The Journal of Sex Research, 52, 213–219. 12 Clinical Child Psychology and Psychiatry 00(0)

Van der Miesen, A. I., de Vries, A. L., Steensma, T. D., & Hartman, C. A. (2018). Autistic symptoms in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders, 48 , 1537–1548. Vrouenraets, L. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., & de Vries, M. C. (2015). Early medical treatment of children and adolescents with gender dysphoria: An empirical ethical study. Journal of Adolescent Health, 57, 367–373. Wiepjes, C. M., Nota, N. M., de Blok, C. J., Klaver, M., de Vries, A. L., Wensing-Kruger, S. A., & Gooren, L. J. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in prevalence, treatment, and regrets. Journal of Sexual Medicine, 15, 582–590. Williams, C. (2016). Radical inclusion: Recounting the trans inclusive history of radical feminism. Transgender Studies Quarterly, 3, 254–258. Winter, S., De Cuypere, G., Green, J., Kane, R., & Knudson, G. (2016). The proposed ICD-11 gender incongruence of childhood diagnosis: A World Professional Association for Transgender Health Membership Survey. Archives of Sexual Behavior, 45, 1605–1614. Wood, H., Sasaki, S., Bradley, S. J., Singh, D., Fantus, S., Owen-Anderson, A., & Zucker, K. J. (2013). Patterns of referral to a gender identity service for children and adolescents (1976–2011): Age, sex ratio, and sexual orientation. Journal of Sex & Marital Therapy, 39 , 1–6. doi:10.1080/0092623X.2012.675022 Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health, 14, 404–411. Zucker, K. J., Bradley, S. J., Owen-Anderson, A., Kibblewhite, S. J., Wood, H., Singh, D., & Choi, K. (2012). Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism. Journal of Sex & Marital Therapy, 38 , 151–189.

Author biographies Nastasja M de Graaf currently works as a PhD candidate at the Centre of Expertise on Gender Dysphoria at the VU Medical Centre in Amsterdam and was previously based at the Gender Identity Development Service in the UK as a Research Psychologist. She has experience of conducting research in conjunction with both clinics and has numerous publications in her name. Polly Carmichael is GIDS Director and a Clinical Psychologist who works with gender diverse young people and their families at GIDS.