Inside Britain’s only transgender clinic for children

There has been a huge increase in UK children seeking treatment for transgender issues. But critics say it has become a lifestyle choice. Louise France talks to trans kids at the Tavistock and Portman gender identity clinic and discovers the painful decisions they face

Nine-year-old Ash skips across the main road, a blonde ponytail swishing from side to side. She – Ash was born a boy but has wanted to be known as a girl since she was four – has just emerged from an appointment at the Tavistock and Portman Hospital’s Gender Identity Development Service in north London and what she really fancies is chicken and fries from the local KFC.

She’s jittery. A cocktail of relief and adrenaline. Ash is bright and she’s researched the facts (Google is useful like that). She knows about hormone blockers – monthly injections that will, if she is prescribed them, put her puberty on hold. She enjoys talking to the child psychotherapists and family therapists. They understand where she’s coming from. But sometimes they want to know how she feels – and that is tough to articulate when you’re not ten yet. You’re being asked to talk about big, embarrassing stuff like puberty when you don’t want to look at your body in the bath; when you’ve convinced yourself you are developing breasts although this is biologically impossible.

At least for now.

She tells the consultant that when she’s older she’ll have a womb transplant and have a baby. (She’s read about it online. “They do it in Sweden,” Ash says.) The consultant explains that it isn’t always straightforward, but that’s not what she wants to hear. When the questions feel too difficult, Ash, who wants to be a trans model when she grows up, gets teary and asks to leave the room.

It’s at home in southern England where she lets rip and it’s her mother, Terri, on whom she takes out the fear and confusion. Shouting, slamming doors. In the past she’s been taunted at school, beaten up, called a “she-male”. When she was seven she sent her mother suicidal texts. Sometimes family life revolves around how Ash feels from moment to moment.

The Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust (or Tavi, as it’s known by locals in the leafy, affluent streets nearby) is Britain’s only multidisciplinary clinic specialising in children and adolescents who are concerned that they were born the wrong sex. Eighteen years ago, when GIDS began, a team of five received around thirty referrals from children a year. By 2009, referrals totalled 96. In 2014 it was 697. This year around 1,419 children came for help, referred by GPs faced with a condition that they’ll most likely have very little experience of.

While, to put the figures into perspective, these numbers account for only 1 in 10,000 young people, the service is under huge pressure. Sixty new members of staff are about to start. Builders have been employed over the summer to carve up the office space in the Tavistock building, an incongruous, anonymous block with a statue of Sigmund Freud in the car park.

‘This isn’t left-wing parenting. It isn’t a fashion thing’

The average age of the young people who arrive in reception, with its gender-neutral toilet, is 14, but they are increasingly receiving inquiries from parents of children at primary school. Occasionally there are referrals for children as young as 3. One concern is that if these children socially transition – dress as the opposite sex, change their names – at this age, what happens if they change their minds?

I meet Ash and Terri again at home two weeks later. Ash is just back from school, quiet and hungry. She desultorily kicks a football about in her uniform (T-shirt, short grey skirt) and disappears to her bedroom (cluttered, shocking pink). Make no mistake, she looks like a girl. I catch myself staring at her, searching for clues to her biology. Ash is one of the main characters in the first episode of an ambitious and revealing new Channel 4 documentary series – three years in the making – about the Tavistock. It’s directed by Peter Beard, who won awards for his last documentary, My Son, the Jihadi. The first episode focuses on GIDS. It’s the first time they have allowed cameras inside.

We sit in the back garden and her mother explains why she’s decided to let Ash appear on television. “I wanted people to see that my kid is not a freak,” she says. Terri has wholly taken on board Ash’s feminine identity: she lets her wear nail varnish and crimp her hair, although she draws the line at lipstick on school days. “She is not a boy in the wrong clothes; she is actually a girl in the wrong skin. I wanted people to see how hard this is – this is a massive thing for a little kid.”

Ask Ash about being born a boy and she makes sense of it by splitting off her masculinity. She says the male part of herself was an older brother “that died or fell off a cliff”.

“From the moment Ash could talk, she has been like this,” Terri says. “She wanted to have dolls and wear princess dresses.” At first she was not concerned. She had other children and they’d wanted to dress up. “It wasn’t an issue.”

Terri and Ash. At four, Ash told her mother she was a girlTom Jackson

At nursery Ash wore dresses. “I’ve never seen her play with a boy,” her mum tells me. She sat down to pee, despite having brothers. When her father, a scaffolder – Ash’s parents split up when she was two – gave her trains for Christmas she refused to play with them. (Recently he has begun to accept Ash’s trans status, to the point of accompanying her to a meeting at the Tavistock. “I wouldn’t have her any other way,” he says in the documentary.)

Did Terri ever think, maybe my son is simply a girlie boy? Yes, she tells me. Her hunch was that Ash would grow up to be gay. “She just seemed to be an extremely camp gay man. And that was fine. We’re an open family. We have a lot of gay friends. It wasn’t an issue.”

Then when Ash was four she said, “Why do you keep calling me a boy? Why do you keep saying he? I am a girl. I am a she.” Terri remembers the moment vividly. Her distressed son was sitting on her lap in the living room, dressed in a Rapunzel dress with a wig. “She asked me, ‘Who is going to take my willy off?’ She wanted to know if I would take her to the doctors or would it fall off? That’s when I thought, this is a bit more than dressing up.”

Might Ash’s behaviour just be a phase? It’s common for children to experiment with gender roles. Terri explains that she has never once wavered. When school started, every morning was a battlefield. (Start talking about gender and you realise how traditional schools still are about the sexes: boys told to go on one side, girls on the other, unisex school uniforms uncommon.) “For the first year I tried to get her into the boy’s uniform, but she hated it. She’d be punching me, biting me, scratching me.” In the end, Terri asked the head teacher if Ash could wear a skirt and he agreed.

Two decades ago, the service received 30 referrals a year. This year, it was 1,419

Any ambivalence has been around whether to tell strangers. Is it better to be taken for a girl and carry the burden of the secret, or to be open about what is happening, with all its complexities? But what Terri would like are answers. “I’d really like to know why,” she tells the consultant at the Tavistock. “Where did this come from? She can’t have made it up, because she was too small. We didn’t know anyone who was trans. She’d never even heard of it. I know it’s normal for little boys to play with dolls but to never be interested in one car? To never be interested in Spider-Man? I’d like a reason. But it looks like I’m never going to get one.”

There is just one photograph left of Ash as a boy. It’s on Terri’s phone. All the others have been deleted or shredded. “We did it together,” Terri tells me.

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What would Freud make of Ash, born Ashton Andrew, name changed by deed poll this year to Ashley Julianne? In a very short space of time the idea that someone can be born into the wrong body has become mainstream. The word “trans” – short for transgender – has become part of our language. So much so in the LGBT world (lesbian, gay, bisexual and transgender), it can seem as though it’s the T that’s taking up all the oxygen. And now it’s trans children who are making the headlines. The award-winning US drama series Modern Family has introduced an 8-year-old trans character. Last month CBBC aired an online drama about a boy who wants to be a girl. Tumblr and Reddit have become a virtual space where children share their treatment options.

Yet I’d suggest that Dr Polly Carmichael, the consultant clinic psychologist who leads the GIDS unit, has one of the most challenging jobs in the NHS. Until now, she has turned down media requests, concerned their work will be misrepresented. (The most common misconception, she says, is that the service’s main job is to prescribe hormone drugs.)

Carmichael is a softly spoken, cheerful woman, who laughs easily. Watch her in the consulting room and she has a stillness about her that is calming. She also chooses her words carefully. This is an area where even the language used is hotly debated. (For instance, a trans teenager who was born a boy is referred to as a “natally assigned male”. An outsider can start to tie themselves up in verbal knots).

On the day we meet Carmichael has to choose the new colour scheme for the department’s revamp. Much trickier is the task of negotiating the demands of a vocal trans community, together with meeting the needs of children with complex emotional lives. Not to mention parents coming to terms, or not, with a child who says they are trans.

At the same time there is another group gaining ground: people who argue that we are at “peak trans”, that we’re living in a sexualised culture within which there is enormous pressure on children to fit gender stereotypes and where being trans has become a glamorous “lifestyle choice”. There is a view that this is a generation for whom, unconsciously perhaps, becoming the opposite sex is actually more acceptable than being gay, or not fitting clichéd ideas of what it means to be male or female.

No one can agree on what causes gender dysphoria. And why so many children now say they are experiencing it, or even what it is exactly. Is it a biological condition? A psychological one? Is it genetic or learnt behaviour? Is it nature or nurture? Nor is there one reason why there has been such a dramatic rise in cases – a 100 per cent increase in the past 12 months in Britain. Research is patchy.

What is indisputable is that this is an area that is moving faster than anyone might have imagined, even two years ago. “We are all learning,” says Carmichael. “There is no certainty in this area. Certainty is about being closed, which is unhelpful. It’s all about being thoughtful, and careful, and treating everyone individually. We don’t take a view on the outcome of a young person’s gender identification. Our job is not to pre-suppose anything about what they are going through.”

She goes on: “Some adolescents come here who are very troubled. They have only just told their parents.” There are a few who contact the unit directly, without having told their parents or their GP. “There is a feeling that you have to act as quickly as possible, often because of fears of self-harm.” According to a survey by Mermaids, the trans charity, 48 per cent of trans people under 26 say they have attempted suicide. “But on the other hand,” she says, “there are many young people we see who are doing really well. It’s all about promoting resilience in these young people.”

The difficulty is that building emotional confidence takes time and for some young people whose bodies are developing – and their parents who may just want this “sorted” – time feels like the enemy. “For families it can be very difficult because they are seeking certainty, but the reality is that we don’t have certainty.”

The explosion in the figures has led to the impression in the media that there are swathes of children gaily changing gender. The reality is more complicated. About 80 per cent of the children who come to the service before adolescence eventually change their minds. Most decide that they are gay, or bisexual. Conversely, for those who come during adolescence, the figures are reversed and about 80 per cent do pursue sex reassignment.

I’m allowed to sit in on a staff meeting where therapists bring along cases they want to discuss. Young children like Ash may be unusual, but they are not rare. Some have been coming to the unit for 12 years. Many of them, like Ash, will have been living as the opposite gender since they were at nursery and have built up longstanding relationships with their case workers. But one of the therapists mentions the case of a “natally assigned girl” who has been taken by his parents to America for a mastectomy. Children in a hurry to change gender – and parents who fear for their psychological wellbeing – are making potentially traumatic life-changing decisions that cannot easily be reversed.

This is what Carmichael and her team must grapple with. The increase in demand means children who used to be seen within 18 weeks currently have to wait nine months (although it is hoped that the recruitment drive will change that). Transgender groups complain about the delay, and argue that experts at units like the Tavistock are too cautious. Much of the debate swirls around hormone injections: both hormone blockers – prescribed at puberty to inhibit the development of secondary sexual characteristics such as breasts or facial hair – and cross-sex hormones, which the Tavistock prescribes at 16 to masculinise or feminise the body. Thus, a girl who wants to be a boy (a natally assigned girl) will be given testosterone (or “T”, as it’s known in the chat rooms). It’s after this that, when the person is 18 and goes into the adult service, they can opt for surgery.

80 per cent of patients who visit the clinic before adolescence change their minds

Hormone blockers are seen as a chance to put the brakes on development, to pause and think about the future. However, 90 per cent of patients go from hormone blockers to cross- sex hormones, hormones that leave teenagers infertile. And it’s these cross-sex hormones that cause the most controversy. In America they are prescribed at private clinics to patients as young as 12. There are some in the trans community who argue that the age limit is too high in the UK. Helen Webberley, a GP in Wales, has set up a private gender clinic and recently started treating children, a “handful” of whom, according to news reports, she has started on cross-sex hormones, including a 12-year-old. Meanwhile, the internet means that there is little to stop under 16-year-olds from buying cross-sex hormones online.

“Currently the zeitgeist is that you go with the child, following the child’s lead and wish at every step,” says Carmichael. “There has been a large decrease in the age at which cross-sex hormones are available, particularly in the US.

“The big debate at the moment is the pressure to introduce cross-sex hormones earlier and earlier. We have done so at around 16 and we might introduce some flexibility around that. But 12? That is a big departure. The reality is that for some young people, things change all the time. For example, starting a relationship with someone can be associated with them thinking very differently about their gender. This isn’t straightforward.

“If young people are being given the strong message that it is the end of the world if they don’t get hormones immediately – perhaps the suggestion you should fast-track people who are self-harming – that is potentially damaging.”

As she says, with some understatement, “It is tricky, really tricky.”

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Matt, born Matilda, is one of the increasing numbers of natally assigned girls who wish to change gender. The trend at the Tavistock used to be more boy to girl by 3:1, but in the past five years the ratio has reversed. Matt is also on the autistic spectrum, which complicates the issues (according to the documentary, as many as 30 per cent of male-to-female cases are on the spectrum, a link no one can explain). Matt’s diagnosis means he finds it especially hard to talk about his emotions and the therapists must try to work out if the gender dysphoria is real or an obsessional fantasy. As Carmichael says, “We know he has an incredible imagination. Might it be a story he has created for himself?”

Matt, 12. As puberty nears, Matt and his parents have to decide on the use of hormone blockersTom Jackson

Rachel, Matt’s mother, was clear when she agreed to take part in the Tavistock series that she didn’t want to sugar-coat what Matt and the family has been – and continues to go –through. They live in Wales. It’s fair to say that in their part of the world transgender rights are not on many people’s radar. Sometimes it’s the small things that resonate. Matt, who loves swimming, was recently disqualified from a competition for being in the boys’ team. “I said to my partner, Pete, ‘Don’t flower it up.’ I want it as gritty as it gets so people see what it’s like.”

At the Tavistock, Matt’s caseworker, Dr Charlie Beaumont, encourages him to unpick his feelings, but Matt finds it painfully difficult to talk. His caseworker is concerned there “is a lack of consistency of gender presentation”. On the other hand, if not prescribed blockers, might Matt self-harm? Matt is 12. There are signs that breasts are beginning to develop. It’s not long now before periods will start.

There is a sense that time is running out, but Rachel tells the doctors tearfully, “I’m not quite ready to lose Tills.” She struggles with the impression that has come from Hollywood that being transgender is easy. “I hear all the stuff about people being gender fluid and think, this isn’t a fashion thing. There are people in the media who make this all look easy – a man one day, a woman the next. But the reality is it’s hard work. I wouldn’t wish it on anybody. This isn’t left-wing parenting. I’m not somebody going, ‘Look how fluid I am with everything.’”

Matt, who loves writing stories and is a massive fan of David Walliams (who wrote the children’s book The Boy in the Dress), is round-faced, with short hair and expressive big brown eyes. At passport control the authorities often cast around for a girl – “Where’s Mathilda?” and don’t believe his mum when she points to Matt. So much so, the family has a letter from GIDS for whenever they go abroad.

As early as aged two and a half, a health visitor commented that Matt – then known as Matilda, or Tills, which is what Rachel still frequently calls him, perhaps betraying her own bewilderment at the turn of events – had an unusually deep voice. “As she got older I always thought she was just a very strong tomboy,” Rachel says, looking back. “Detested wearing dresses, didn’t want to have her hair combed. I remember buying her knickers and thinking, why on earth does everything have to be covered in princesses? Aged five, she told me she wanted hair that didn’t move. In other words, she wanted me to shave her hair off.

“I wasn’t too bothered. Not until she started telling everyone she was a boy. At that point, I thought I’d better go to the doctor.” Hormone tests were carried out and the assumption was that this was a child who was intersex. When the tests came out negative, Rachel was referred to the GIDS unit.

What was that like? “Oh, they make you question everything,” she says. “I think they are trying to find out if this has been nurtured at all. Is this the child or is this the parent pushing their child to be something they don’t want to be? But I think they identified quickly that I wasn’t happy about it. Why would anybody want their child to face the kind of prejudice that was likely to come her way?” Matt struggled with his education and being bullied until he got a place at a specialist school where he is accepted as male. “At the old school I’d beg them not to be so gender specific. Now I worry that I sent him to the wolves every day.”

‘There’s nobody asking, why do so many teenage girls not want to become women?’

Despite his being happier at school, Rachel still checks on Matt through the night because she is worried he might hurt himself. She has got rid of anything that could cause harm – the cords on a blind, dressing-gown ties.

In the documentary we watch Rachel weighing up the pros and cons of hormone blockers. “My concern is that it suppresses things. Maybe if she did go through puberty, she’d click into girl mode and be actually, ‘I want to be a girl now.’ I don’t think that will happen, but my worry is that I really am interfering. Now this isn’t nature, it is nurture. On the other hand being able to press the pause button could be a good thing.”

What does Tills/Matt think? “Tills thinks the rest of the world has gone mad. Just leave me alone. What’s wrong with me? I’m just me.”

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Stephanie Davies-Arai is a parent coach behind a website called Transgender Trend, concerned about the rise in the number of children referred to gender clinics. She argues that, “We are setting children off on a path towards sterilisation and medicalisation. It is an experiment that has no precedent … Are we really willing to so readily accept that a child is the ‘wrong’ sex at this age, rather than address the bullying and the culture that tells him so?” It’s a view, she says, that has lost her friends – “There’s a feeling that if you don’t go along with current trends you are transphobic.”

At first I presumed Transgender Trend was religiously or politically motivated, but that doesn’t seem to be the case when we meet. Her view, thoughtfully argued, is that when she was a teenager she, too, would have questioned her gender. “I would have been trans. Because I was not only a tomboy; in my head I was a boy. My sister and I went through our pre-pubescence calling each other Mike and Bill. Until my mid twenties, I didn’t want to be a woman. I was a rebel. I look at what is going on and think, I would have gone for this.” She doesn’t think children can make a decision about gender until their mid twenties when the brain has reached maturity, and that living as the opposite sex at a young age means “you are changing that child’s brain, you are building a new identity and by the time you are 12, puberty is the enemy”.

Ash and one of her brothersTom Jackson

Her concern is that, with the help of social media, there might be more awareness around trans, but we’re ignoring the issue of social contagion. Davies-Arai argues that it’s become cool to be “trans”, more accepted than being a lesbian, for example, which is one possible reason why referrals of teenage girls have increased so dramatically. She has heard of clusters of girls binding their breasts and saying they are boys; that parents complain their children are coming home saying, “I’m not sure if I am a boy or a girl,” after a class talk about transgender. “Any kid who is like I was – outside the crowd, a bit awkward, the ones who don’t fit in – all ‘gender non-conforming’ kids are included under the trans umbrella now and they are being given no alternative way of understanding their feelings of distress.”

But what would she do if her traumatised seven-year-old child announced he/she wanted to change sex? “I would say, be quite casual about it. Don’t make a big fuss. Take it away from gender. Parents are advised now to take it very seriously – and I think that is the last thing you do. Address the bullying instead.”

If Davies-Arai does have an agenda, it is a feminist one. Almost 1,000 natal females were referred to the Tavistock last year. Might this be more about girls struggling with puberty and their bodies? “There’s nobody asking, why do so many teenage girls not want to become women? I think that’s what we should be asking, rather than accepting the least likely answer, that they are really boys. It seems a way for us not to seriously look at the culture we are bringing our girls up in.”

To some degree, Carmichael might have sympathy with this last argument. What she and her team try to figure out, over months and years, is, “How far are the physical changes one seeks motivated more around feeling that you fit in and are accepted by others?

“You might think, gosh, what are we doing?” says Carmichael. “But there isn’t a right and a wrong. No one has the answers. It is an evolving picture with many voices contributing. All we can go on is that people who have taken this route feel this was the right thing to do.”

In the documentary, Beard, the director, says to Ash, “Some people change their minds …”

“Some people. Not me,” she responds. Do you think you’ll be a girl for ever, he asks.

“Yes,” she replies. And turns a cartwheel.