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One of UK's youngest transgender children starts her transitioning journey aged 13...after realising she was in 'wrong body' aged just THREE

A 12-year-old who is one of Britain’s youngest transgender children has started transitioning – after realising she was born in the ‘wrong body’ aged just THREE.

Ash Lammin is, biologically-speaking, a boy.

But her mum says she insisted that she was a girl as soon as she could speak.

Terri Lammin, 43, said that watching her daughter – who was born Ashton – grow up confused and upset by her body was “heartbreaking”.

She said: “Although she was born male, from the moment she could speak Ash insisted she was a girl.

“By age five, she was asking ‘when is someone going to chop my winky off?’ – and questioning why she had it at all.”

Family photos from Ash’s upbringing therefore mask a very difficult period for the family, who live near Ramsgate in Kent.

In one, Ash is splashing around in a bath, wearing a sparkly mermaid’s swimming costume and looking like an average three-year-old girl – obsessed with pink and wearing a princess dress, the sort of thing that’s usually seen at birthday parties.

But, Terri revealed, the only reason she was wearing her swimming costume in the bath was to hide her body – which had dismayed her from an early age.

Ash says that it has been difficult growing up as a trans girl, but says she feels that she is firmly on the right path.

She said: “The journey is long and it’s still going, but I feel like the sense of victory is there through it all.

“I do feel accepted sometimes, but other times not.

“Not everyone is going to understand and people have to have their own opinions and I understand that. Some people might not like the idea of trans.

“I hope I inspire others but I just hope that love and acceptance comes through everything.”

According to her mum, Ash is the perfect example of a child who has been born in the wrong body.

Now, aged almost 13, she is embarking on a lengthy journey to transition her gender from male to female at an NHS-run clinic – and is one of the youngest in the country to do so.

Ash – who changed her name by deed poll to Ashley when she was eight – will start by taking hormone blockers to halt the onset of puberty.

She has researched the process incessantly – and eventually wants a womb transplant so that she can be a mother when she’s older.

While some critics have accused Terri of taking drastic decisions on behalf of a child who is too young to know better, she points out that Ash will take the blockers until she is 18.

At that point, she herself will decide whether to go ahead with gender reassignment surgery.

If she decides not to go ahead with it, Ash will come off the blocker – and her puberty will kick in just a few years later than her peers.

Terri said: “I never thought it was a phase, Ash was just Ash.

“When she was three she said to me, ‘I’m a boy because you gave me a boy’s name – it’s your fault.’

“I remember feeling horrible, because she blamed me. I personally thought maybe this was what an extremely camp gay man is like as a child.

“I’d never come across it before and I just went along with it. I just thought ‘if he’s happy, well that’s the main thing.'”

But Terri, who has seven other children, said that life became much harder when Ash started at primary school.

She said: “I sent her to school in a boy’s uniform. I felt awful, she didn’t want to wear it and I was making her.

“The school were great. The headmaster at the time said ‘if you think it’s going to make life easier then bring Ash in a girl’s uniform’, so I did.

“I was in a right state. I thought ‘everybody is going to think I’m weird’ – but Ash loved it, she found it easy.

“Before, when I was taking her into school, she was biting me and kicking me, she didn’t want to go in.

“As soon as she put the girl’s uniform on, she wanted to go every day.”

Despite the school’s willingness to help and the kindness of Ash’s classmates, Terri says that other parents were very difficult – leaving her out of social events and complaining that Ash was using the girls’ toilets.

She added: “When Ash was Ashton, she was invited to all the kids’ parties, even though she used to turn up in a princess dress.

“The parents didn’t mind then. But as soon as I let her be Ashley all the time, for a whole year she didn’t get invited to one party.

“The kids were fine; it’s not the children, kids play with anybody. It’s not until an adult comes in and says you shouldn’t do that then it changes.”

When Ash turned 11 and went to secondary school, she became a target for bullies who would throw things at her on the bus and shout ‘tranny’ at her – forcing Terri to take her out of the school after just one term.

Ash is now being home-schooled, and Terri is calling for better education within schools to teach children about transgender people.

She said: “I’d like to see the subject of transgender people included in some lessons, like there are about same-sex families.

“There needs to be more about liking people for who they are, not what they are.”

Ash suffers from anxiety and, her mum said, has openly claimed that she wants to die.

Terri said: “Some days she says ‘I’m so glad I’m me’, but other days she feels terrible. She asks why it has to happen to her and she hates herself.

“I tell her that some people are born with one leg, and they have to deal with it. I question whether it was a chromosome disorder that led to this – I would like to know why it happened.”

“She is so inspirational. She could easily have said ‘I’ll just be a boy’ but she feels so strongly about who she is she accepts the difficulties.

“But it’s a lot for a child to deal with.”

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Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

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FactCheck Q&A: How many children are going to gender identity clinics in the UK?

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• By Georgina Lee
• 24 Oct 2017

Figures seen by the Mirror suggest that as many as 50 children a week are being referred to the UK’s leading gender identity clinic.

FactCheck looks at what we know about children and gender identity services in the UK.

How many children are being referred to gender identity clinics?

Official figures from the Gender Identity Development Service (GIDS) at the Tavistock Centre in London show that 2,016 children were referred to them in 2016-17.

That’s about 39 kids a week over the course of the year.

But the Mirror says it has seen data that shows 1,302 children have visited GIDS in the last six months – which works out at about 50 children a week.

We don’t know yet whether that high referral rate will continue for the rest of the year. If it does, it will mean that the number of children referred to GIDS each week has risen by 2,500 per cent since 2009-10.

The number of children attending GIDS has grown every year since 2009-10, but saw a marked increase in 2015-16 – when patient numbers doubled compared to the previous year.

It’s not clear what caused this.

The British Social Attitudes survey began to collect data on the public’s views towards transgender people for the first time in 2016. They cited the fact that “transgender people and their stories are becoming increasingly visible in society” as part of the reason to address attitudes to gender in the survey.

It’s possible that high-profile transgender people, including Caitlyn Jenner, Chelsea Manning and Laverne Cox have brought the issue of gender identity to a wider range of children and parents.

How many children go on to become transgender adults?

Children who are referred to gender identity clinics like the GIDS at the Tavistock Centre are often diagnosed with “gender dysphoria”.

The NHS describes the condition as one where “a person experiences discomfort or distress because there’s a mismatch between their biological sex and gender identity”.

A 2008 study in the Netherlands concluded that “The majority of children with gender dysphoria will not remain gender dysphoric after puberty”. Although it also found that kids who experience very strong feelings of dysphoria are more likely to still have them in adulthood.

A separate study from 2011 found that only 2 to 27 per cent of pre-pubescent children with gender dysphoria continued to have those feelings once puberty hit.

However, research cited by the Tavistock Centre also suggests that gender dysphoria is more likely to persist into adulthood when it’s reported by kids over the age of 12.

In other words, older children and those with more intense feelings of gender dysphoria in childhood are more likely to become transgender adults.

Younger children who report milder feelings of gender dysphoria are less likely to feel the same after puberty.

The majority of children referred to the gender identity clinic at the Tavistock Centre in 2016-17 were over 13 years old, with the most common ages being 15 and 16 years old. We don’t know how many of these were diagnosed with gender dysphoria.

What treatments can children receive at gender identity clinics?

Not all of the children who are referred to gender identity clinics will be diagnosed with gender dysphoria.

But children who do receive a diagnosis can be treated with synthetic hormones that “block” puberty. According to the NHS, the effects of this treatment “are considered to be fully reversible” and can stop at any time.

Figures revealed to the Mail on Sunday earlier this year suggested that as many as 800 children in England – including some as young as 10 – are being treated with puberty blockers.

Once a child reaches 17 they can be seen in an adult gender clinic, and can receive standard adult treatments for gender dysphoria if it has been clinically diagnosed. This can include stronger cross-sex hormones, which are not necessarily reversible and will eventually make those who take them completely infertile.

The minimum age for gender reassignment surgery is 18 years old.

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The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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NHS Gender Dysphoria National Referral Support Services

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NHS Arden and Greater East Midlands Commissioning Support Unit (AGCSU) is one of the largest commissioning support units in the country and works with local and national NHS bodies to help deliver health services.

AGCSU has been commissioned by NHS England (NHSE) to provide a seamless service between the NHS Gender Identity Clinics and the NHS Surgical Providers (hospitals), to process referrals for specialised gender surgery for people over the age of 17 in England, Scotland, Wales and Northern Ireland. This service is known as the GDNRSS. NHS Gender Dysphoria National Referral Support Service (GDNRSS).

If you and your clinician decide that a referral for surgery would be appropriate for you, your referral will be handled by the GNDRSS.

The GDNRSS also runs a support line to talk about aspects of your surgery if you need further advice or support:

Tel: 01522 857799 Monday to Friday, 9am-5pm

If you do opt for surgery, and it is considered appropriate by your gender specialist clinicians, then it will be undertaken by surgeons commissioned by NHS England in line with the national service specification.

If you want to find out more about GDNRSS, download this leaflet -  NHS Gender Dysphoria National Referral Support Service.pdf

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Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

Media Information

• Release Date: September 16, 2022

Media Contacts

Kristin Samuelson

• (847) 491-4888
• Email Kristin
• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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The NHS Ends the "Gender-Affirmative Care Model" for Youth in England

Following extensive stakeholder engagement and a systematic review of evidence , England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth <18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. The abandonment of the "gender-affirming" model by England had been foreshadowed by The Cass Review's interim report , which defined "affirmative model" as a "model of gender healthcare that originated in the USA."

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning , and following an explicit informed consent process . The NHS states that puberty blockers can only be administered in formal research settings, due to the unknown effects of these interventions and the potential for harm. The NHS has not made an explicit statement about cross-sex hormones , but signaled that they too will likely only be available in research settings. The guidelines do not mention surgery , as surgery has never been a covered benefit under England’s NHS for minors.  

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

The key highlights of the NHS new guidance are provided below.* 

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

• The NHS has eliminated the “gender clinic” model of care where children are seen solely by a specialist gender dysphoria practitioner, replacing it with standard care in children’s hospital settings.
• Rather than “affirming” a transgender identity of young person, staff are encouraged to maintain a broad clinical perspective and to “embed the care of children and young people with gender uncertainty within a broader child and adolescent health context.”
• “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”
• Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.
• Treatment pathway will be shaped, among other things, by the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
• The care plan articulated by the Service will be tailored to the specific needs of the individual following careful therapeutic exploration and “may require a focus on supporting other clinical needs and risks with networked local services.”

2. Classifies social gender transition as an active intervention eligible for informed consent

• The NHS is strongly discouraging social gender transition in prepubertal children.
• diagnosis of persistent and consistent gender dysphoria
• consideration and mitigation of risks associated with social transition
• clear and full understanding of the implications of social transition
• a determination of medical necessity of social transition to alleviate or prevent clinically significant distress or impairment in social functioning
• All adolescents will need to provide informed consent to social gender transition.

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

• All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.
• Extensive focus has been placed on careful therapeutic exploration, and addressing the broader range of medical conditions in addition to gender dysphoria.
• For those wishing to pursue medical transition, eligibility for hormones will be determined by a centralized Service, upon referral from a GP (general practitioner) or another NHS provider.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

• The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.
• The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.
• Surgery is not addressed in the guidance as the NHS has never considered surgery appropriate for minors.

5. Establishes new research protocols

• All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.
• The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.
• The research will track the children into adulthood.

6. Reinstates the importance of “biological sex”

• The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.
• The NHS guidance refers to the need to track biological sex for research purposes and outcome measures.
• Of note, biological sex has not been tracked by GIDS for a significant proportion of referrals in 2020-2021.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

• The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence."
•  The NHS guidance states that treatments should be based on the DSM-5 diagnosis of “gender dysphoria.” 
• Of note, WPATH SOC8 has made the opposite recommendation, instructing to treat based on the provision of the ICD-11 diagnosis of “gender incongruence.” “Gender incongruence” lacks clinical targets for treatment, beyond an individual’s own desire to bring their body into alignment with their internally-held view of their gender identity.

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

• The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.
• neurodevelopmental disorders such as autistic spectrum conditions
• mental health disorders including depressive conditions, anxiety and trauma
• endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria
• risky behaviors such as deliberate self-harm and substance use
• complex family contexts including adoptions and guardianships
• a number of additional requirements for the multidisciplinary team composition and scope of activity have been articulated by the NHS.

9. Establishes primary outcome measures of “distress” and “social functioning”

• The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning .
• This is an important development, as it establishes primary outcome measures that can be used by researchers to assess comparative effectiveness of various clinical interventions. 

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

• Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.
• Those choosing to take hormones outside the newly established NHS protocol will not be supported in their treatment pathway by NHS providers.
• Child safeguarding investigations may also be initiated if children and young people have obtained hormones outside the established protocols.

With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH guidelines and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.

The full text of the NHS guidance can be accessed here .

 * This is a transitional protocol as the NHS works to establish a more mature network of children’s hospitals capable of caring for special needs of gender dysphoric youth. A fuller service specification will be published in 2023-4 following the publication of the Cass Review’s final report .

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Britain’s youngest sex-swap patient to undergo gender reassignment surgery

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A woman who became Britain’s youngest sex-swap patient at 15 is preparing to have gender reassignment surgery.

Ria Cooper, who was born male, has had a turbulent last eight years after switching back to her male identity, Brad, when she was 18 because she felt she wouldn’t be accepted and find love.

She had often been dumped by boyfriends when their friends found out she was born male.

But now the 23-year-old is ready to get a final operation that will complete her switch to a woman.

She told the Sunday Mirror : ‘I’ve always known I was female – it was everyone else who was confused, not me. I was wearing make-up and heels at the age of 12, there was no question.

‘Only now I realise that made me even more unhappy. Now I’m going to be me – and I hope I will finally be happy.’

Ms Cooper, who took blockers to stop her puberty when she was transitioning, had been used by critics to cast doubt on sex-swap treatment for teens.

Her treatment also involved her being injected with female hormones that helped her form breasts.

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She became so upset when she became Brad again she attempted suicide twice, became a prostitute and also started using drugs.

She is now ready to put that all behind her and is looking forward to the rest of her life.

Ms Cooper has even decided to pay for some of the gender reassignment surgery herself in order to silence critics who don’t believe it should be offered on the NHS.

She has already forked out  £5,000 to have 34EE breast implants put in.

She plans to open a specialist beauty clinic that will primarily serve transgender people after she has the surgery next year.

Ms Cooper also wants to start a family and have children in the future.

She added: ‘I’d love to have a baby to cuddle and love and look after as they grow up. It’s not going to happen overnight, I know that. But I can dream can’t I?’

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Cass report: What gender treatments are currently available to children?

Recent changes have seen the closure of the Tavistock clinic and an end to the prescription of puberty blockers for youngsters.

Wednesday 10 April 2024 17:10, UK

A long-awaited report has found "remarkably weak evidence" to support gender treatments for children and made 32 recommendations – but what is the current system?

The major review - led by Dr Hilary Cass - was launched in 2020 after a sharp rise in referrals to the Gender Identity Development Service (Gids), which was the only specialised service in England for young people experiencing difficulties in the development of their gender identity.

The clinic, run by the Tavistock and Portman NHS Foundation Trust, had more than 5,000 referrals in 2021/22 - up from just under 250 a decade earlier.

But it closed almost two weeks ago with new regional hubs launched led by London's Great Ormond Street Hospital and Alder Hey Children's Hospital in Liverpool, in a bid to move away from a single-service model.

NHS England hopes they will be the first of up to eight specialist centres over the next two years and said children attending these clinics will be supported by experts in neurodiversity, paediatrics and mental health, "resulting in a holistic approach to care".

Around 5,000 children and young people are currently on the waiting list for referral into the new clinics, while the care of 250 patients was transferred to them.

Puberty blockers and hormones

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Last month, NHS England confirmed children will no longer be prescribed puberty blocker s at gender identity clinics, saying there is not enough evidence to support their "safety or clinical effectiveness".

The drugs will now only be available to children as part of clinical research trials.

Puberty blockers can be used to delay the development of physical characteristics which can make someone look male or female, allowing transgender young people to explore their gender identity and weigh up medically transitioning.

Taking them early in puberty may mean less treatment or surgery in the future, but critics have raised concerns over issues including consent, mental health risks and bone density development.

At the time of the move, there were fewer than 100 children on puberty blockers, who will continue their treatment at Leeds and University College London Hospital.

The NHS says children referred to one of the new clinics will be seen by a team, who will carry out a detailed assessment over three to six appointments over several months.

"Most treatments offered at this stage are psychological rather than medical," the NHS website says.

"This is because in many cases gender variant behaviour or feelings disappear as children reach puberty."

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Those diagnosed with gender incongruence or gender dysphoria who meet the clinical criteria may be given gender-affirming hormones "from around the age of 16".

But Dr Cass said in her report the current policy on giving children testosterone or oestrogen from age 16 should be urgently reviewed.

Young people aged 17 or older may be seen in an adult gender identity clinic but following the review NHS England said it would now pause first appointments at adult clinics for teens under 18, as well as bringing forward its review of adult gender services.

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• > Journals
• > BJPsych Bulletin
• > Volume 47 Issue 2
• > Transgender children and young people: how the evidence...

Article contents

Gender dysphoria and the onset of sexual feelings, adolescence and gender identity, teenage presentation of transgender, effectiveness of treatment, adverse effects of medical interventions, informed consent, conclusions, about the author, data availability, declaration of interest, transgender children and young people: how the evidence can point the way forward.

Published online by Cambridge University Press:  18 February 2022

The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.

Children first begin to develop a sense of biological gender at around the age of 2 to 3 years. Reference Boston and Levy 1 At this age, they are able to label pictures of boys and girls according to typical presentations of heteronormativity. At 4 years, boys understand that it is the possession of a penis that marks them out as biologically male and girls understand it is the lack of a penis that means they are biologically female. By this age, children have a sense of the stability of biological gender, an understanding that it remains constant with time. From this point up to the age of 6 or 7 years, their judgement of gender in pictures of clothed children is heavily influenced by appearance so that they label boys pictured in dresses as girls and boys with long hair as girls. By 7 years they recognise biological sex as constant and independent of external appearance. Reference Boston and Levy 1

By the age of 7 years, therefore, children understand three different concepts related to sex/gender identity: biological sex, self-perceived gender identity and social gender identity. They understand that they and others are biologically male or female, that they and others have a sense of their own gender identity as male or female and that they and others, depending on their appearance and clothing, are usually perceived by others as male or female. As they develop into adolescence and adulthood, people recognise that, with the use of hormones and surgical interventions, some features of biological sex can be changed. Both self-perceived gender identity and social gender identity may also undergo change.

The great majority of young children develop a self-perceived gender identity consonant with their gender assigned at birth, but some, from the age of 3 or 4 years, develop a self-perceived gender identity which is other than that assigned at birth. This sense of another gender identity can be accompanied by a feeling of discomfort or gender dysphoria. There are many autobiographical examples of the first awareness of gender dysphoria. The best known is that written by Jan Morris, who lived as a highly successful male journalist under the name of James Morris until her mid-30s when, following treatment with hormones, she underwent a surgical reconstruction and thereafter lived as a woman. Reference Morris 2 Jan Morris describes very clearly the onset of her gender dysphoria: Reference Morris 2 ‘I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1). Her sense of discomfort with her assigned gender at birth persisted throughout her childhood, adolescence and early adult life. She describes how, when in role as a young man, she used to pray ‘please God make me a girl’ (p. 39). Gender dysphoria persisted throughout her marriage and parenthood. It was only in her late 30s, after she had had gender reassignment surgery, that she felt at ease.

The majority of prepubertal girls and boys have a clear sense of their own gender identity as female or male. This is nearly always consistent with their gender assigned at birth; in some, like Jan Morris, it is not. In a study of adolescents who had been referred to a gender identity clinic in earlier childhood, Steensma et al were able to show that a high proportion of prepubertal children with gender dysphoria did not continue to show such dysphoria after puberty, Reference Steensma T, McGuire, Kreukels, Beekman and Cohen-Kettenis 3 a finding that had previously been reported by the same group. Reference Wallien and Cohen-Kettenis 4 Further, children who had shown gender-atypical behaviour (see below) without intense gender dysphoria did not generally show gender dysphoria in adolescence. Those with gender dysphoria who had been assigned a female gender at birth were less likely to desist than those assigned a male gender. Those who persisted were much more likely to have a homosexual or bisexual orientation.

A sense of gender identity must be distinguished from the presence of gender-atypical behaviour, which may occur with or without gender dysphoria. Gender-atypical behaviour (boys behaving like girls and having interests generally regarded as feminine and vice versa ) is not uncommon in the general population. In a total population study, using a standardised instrument, Golombok et al were able to identify 112 boys and 113 girls aged 3.5 years who showed gender-atypical behaviour to an extreme degree. Reference Golombok, Rust, Zervoulis, Golding and Hines 5 This represented about 2.2% of the population studied (S. Golombok, personal communication, 5 Jan 2021). Especially for girls, there was considerable continuity between gender-atypical behaviours at 3.5 years and such behaviour at the age of 13 years. These investigators do not report whether any of the children in their study were referred for gender dysphoria. The prevalence of 2.2% for gender-atypical behaviour needs to be contrasted with the much less frequent prevalence of 1 per 6800 Dutch adolescents aged 12 to 18 years who requested medical help for gender dysphoria. Reference Wiepjes, Nota, de Blok, Klaver, de Vries and Wensing-Kruger 6

Between 9 and 13 years of age, children start to experience sexual feelings arising from their genitalia. This onset of sexual feelings coincides with biological changes known as gonadarche. At this point, as a result of changes in the hypothalamus and pituitary, the gonads begin to secrete the sex hormones, testosterone and oestradiol, in relatively small quantities. This results in a modest growth of hair around the pubes and in the armpits and growth of the penis and breasts respectively. Spontaneous penile erections and clitoral excitement occur. Around 2 years later, positive feedback occurs in the hypothalamo–pituitary–gonadal axis which stimulates the testes to produce much larger amounts of testosterone and the ovaries to secrete more oestradiol, leading to menstruation. These hormonal changes also result in much more intense experience of sexual desire.

In the majority of children, sexual attraction is heterosexual but around 10% of 16- to 44-year-old adults report some previous sexual contact with a member of the same sex. Reference Mercer, Tantam, Prah, Erens, Sonnenberg and Soazig 7 Most of those who experience homosexual attraction are not transgender. Usually, they have not even shown gender-atypical behaviour; they have been typically masculine, if boys, and feminine, if girls. Transgender boys usually, but not always, feel attraction to others of the same natal sex, i.e. they have homosexual feelings, and transgender girls similarly feel attracted by others of the same natal sex. Inevitably, these sexual feelings are often associated with some degree of confusion and uncertainty. For most transgender boys and girls, however, homosexual feelings have the effect of confirming the child in their transgender role: ‘If I'm really a girl, it isn't surprising I'm attracted to boys’, a transgender natal boy might say to himself and vice versa for girls. But some transgender children develop sexual attraction for others of the opposite natal sex, again with the creation of confusion and uncertainty over the transgender role.

Adolescence is a social construction, i.e. it is a phase of life defined by society. Reference James and Prout 8 In Western society, it is regarded as beginning at the onset of biological puberty. Its end is not, however, defined biologically, but usually by a social criterion such as the age at which the individual develops significant autonomy. In practice, most psychologists, clinicians and members of the general public equate adolescence with the teen years, from 13 to 19, although many young people are well into biological puberty by 13 years and will have completed the biological changes of puberty well before 19 years. Recently, Sawyer and colleagues in an influential article have argued for an expanded and more inclusive definition of adolescence corresponding with the longer period of transition from childhood to adulthood now experienced by young people in Western society. They suggest that the period of 10 to 24 years is more consistent with this experience. Reference Sawyer, Azzopardi, Wickremarathne and Patton 9 It is of relevance that there is considerable variation in ages at onset and termination of biological puberty, some young people normally starting at 10 or 11 years old and others not completing puberty until their later teen years. Relatively recent neuroscientific studies have pointed to the fact that rapid biological changes occur in the brain during the teen years, Reference Mills, Goddings, Herting, Meuwese, Blakemore and Crone 10 but these are by no means specific to this phase of life. Reference Graham 11

The general public regard various behaviours as characteristic of adolescence. These may be summarised as impulsiveness, a tendency to take risks, moodiness and fractious relationships with parents. The public image of adolescents accords with this view of ‘the typical adolescent’. It is certainly the case that some teenagers show these characteristics, but population studies suggest that they make up no more than about 10–15% of this age group, Reference Offer and Schonert-Reichel 12 although they are certainly the most conspicuous. Another important and, in the context of this article, the most relevant feature of adolescence is thought to be self-questioning about identity. Young people of this age are seen as preoccupied with the question ‘Who am I?’, a question relating to all aspects of their identities, including their gender and sexuality. Such self-questioning is not experienced in intense form by most teenagers. The prevalence of ‘identity problems’ was found to be 14.3% in a group of 15- to 18-year-old American high school students Reference Berman, Weems and Petkus 13 and a similar prevalence of ‘identity distress’ was found in a study of Flemish adolescents and young people aged 14–30 years. Reference Palmeroni, Claes, Verschueren, Bogaerts, Buelens and Luyckx 14 The considerable increase in exposure of teenagers in the past 10 to 15 years to social media replete with references to gender identity would make it surprising if there had not been at least some increase of such self-questioning and confusion in this area.

Clinics serving the adolescent transgender population observed a change in the referral pattern after about 2005. Most notably, the gender identity clinic in Toronto, Canada, reported a dramatic increase in referrals at that time. Reference Aitken, Steensma, Blanchard, VanderLaan and Wood 15 At the Portman Clinic in London (part of the Tavistock and Portman NHS Trust) referrals increased very significantly from 2009 to 2016. Reference De Graaf, Giovanardi, Zitz and Carmichael 16 At the Tampere University Hospital, Finland, referrals between 2011 and 2013 far exceeded the number expected from the findings of epidemiological studies. Reference Kaltiala-Heino, Sumia, Työläjärvi and Lindberg 17 This had not been the case previously. There were two other changes in the referral pattern over this period. First, previously, roughly equal numbers of boys and girls had been referred, whereas the increase was associated with much higher numbers of those who had been assigned female gender at birth. Second, previously, the rates of mental ill health among referred children had been about the same as in the general population, Reference Olson, Durwood, DeMeules and McLaughlin 18 whereas now much higher rates of psychiatric disorder, including autism, were reported. Reference Palmeroni, Claes, Verschueren, Bogaerts, Buelens and Luyckx 14 , Reference De Graaf, Giovanardi, Zitz and Carmichael 16

It is therefore clear that from 2005 in Toronto and a few years later in other centres, the characteristics of patients referred to transgender clinics in their early and mid-teen years changed very significantly. In considering the reasons for this new pattern, Aitken et al Reference Aitken, Steensma, Blanchard, VanderLaan and Wood 15 suggest that one possibility is that, during this period, societal factors made it easier for gay and lesbian youth and their families to seek clinical care. It could be argued, those authors say, that it became easier for girls to ‘come out’ than boys. It might therefore be easier for girls to opt for a transgender identity. Although there is no evidence to this effect, transgender natal girls who found themselves attracted to girls at puberty might have also found it easier to come out as transgender than hitherto. This implies that the increased presentation at adolescence was of girls who had experienced gender dysphoria since their early years. There is another possibility. It is that girls in their teens who are showing mental health problems for other reasons might, searching for an answer to their identity problems or distress, be influenced by social media to question for the first time their gender identity and to see gender change as an answer to their mental dilemmas. This might be more likely if they had previously shown ‘tomboyish’ behaviour. This possibility has been suggested in considering reasons for an increase in referrals of natal girls to a gender identity service between 2009 and 2016. Reference Aitken, Steensma, Blanchard, VanderLaan and Wood 15 However, both these possibilities remain hypothetical at present and the reasons for the increase in referrals to transgender clinics is unknown.

Although one should not draw conclusions from a single case, it is of interest that one of the claimants in a judicial review brought about because they felt they had been inappropriately treated with puberty blocking drugs gives an account of her transgender development very much in accord with this second possibility. The claimant described a highly traumatic childhood in which she showed many gender-atypical behaviours: ‘ From the age of 14 she began actively to question her gender identity and started to look at YouTube videos and do research on the internet about gender identity disorder and the transition process’ (para. 78). 19

Although some cases of first presentation of transgender in the early teen years may arise from so-called adolescent identity problems or identity distress, it is likely that others do occur because the young person has been reluctant to come out as transgender beforehand, even though gender dysphoria has been present from the early years. Further, it is well established that such reluctance may persist well into adulthood, so that there are a number of recorded cases of people who have waited until their 30s or 40s to make this decision. Reference Golombok 20

There is a need for both quantitative and qualitative research to investigate the early histories of girls referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years.

Life for children who are transgender from their early years can be challenging. At home, they have to try to communicate how they feel to potentially sceptical parents. At school, they are likely to experience disbelief, mockery and bullying. To cope they need resilient personalities as well as sensitive and understanding parents who are able to explore and talk openly about their children's feelings with acceptance and without trying to influence decisions one way or another. For, as we have seen, although some prepubertal children persist in their transgender identity, in the course of time many will, for reasons we do not understand, desist. Reference Steensma T, McGuire, Kreukels, Beekman and Cohen-Kettenis 3 It is remarkable that most children who have been transgender from a young age reach adolescence without developing a higher-than-expected rate of significant mental health problems. Reference Kaltiala-Heino, Sumia, Työläjärvi and Lindberg 17

Many prepubertal children and their parents will benefit from having available a sympathetic counsellor, psychotherapist or other mental health professional. This will allow exploration of the reasons for the presence of gender dysphoria. Material from voluntary organisations such as Mermaids may be helpful, but parents of young children need to monitor this to ensure that their children are not being encouraged to persist, but are just accepted for what they are at the present time. Difficult decisions about changes of name and the use of toilets need to be negotiated with hopefully sympathetic, open-minded teachers.

As puberty approaches, difficult decisions have to be made. The Amsterdam group has been offering transgender adolescents puberty blockers for 30 years, their first case having been treated in 1991. Reference Cohen-Kettenis, Schagen, Steensma, de Vries and de Waal H 21 The group has pioneered an approach to assessment and management of gender dysphoria. It has produced a protocol for medical treatment of transgender children and adolescents that has been widely followed, Reference De Vries and Cohen-Kettenis 22 for example in Italy, Canada, the USA and the UK. The protocol is summarised below and in Box 1 :

(a) Psychological counselling for children and parents starts well before any medical treatment is considered and continues while such intervention is being administered.

(b) Once Tanner stage 2–3 is reached, and not before, gonadotropin-releasing hormone analogues (GnRHa) are prescribed where there is a clear indication that this is the appropriate course. This medication is given to block pubertal changes, so that the bodily changes rejected by the young person do not occur. Such treatment is only offered to children and young people aged 12 years and older who have intense gender dysphoria and no significant mental health problems. Informed consent by the young person and by the parents is required. The purpose of the use of puberty blockers is to ensure that young people with gender dysphoria do not live through pubertal bodily changes they find abhorrent. Further, the blocking of pubertal changes means that when, as is nearly always the case, transgender adults choose to have at least some degree of gender reassignment surgery, some procedures, particularly bilateral mastectomy for those assigned female gender at birth, will not be necessary.

(c) With careful assessment and selection, a very small minority of young people prescribed puberty blockers (between 1.4 and 3.5%) change their minds and do not wish to proceed further. Reference de Vries 23 For the large majority who do wish to proceed, around the age of 16 years or older, cross-sex hormones are prescribed. For this treatment to be started, the young person must be living in the role of the preferred gender. Again, informed consent by the young person and, preferably, the parents is required.

(d) At the age of 18 years or older, those (again the great majority) who meet eligibility criteria can begin the process of gender reassignment surgery. Such surgery occurs variably according to the degree and at the pace desired by the individual concerned.

Box 1 Management of gender dysphoria Reference De Vries and Cohen-Kettenis 22

(1) Make a full assessment as early as possible

(2) Follow with supportive counselling throughout childhood and adolescence

(3) Subsequent interventions should only take place with informed consent, first by parents and then by the young person, with reflection before each phase

(4) If intense gender dysphoria persists, consider using puberty blockers at Tanner stages 2–3

(5) Consider use of cross-sex hormones at age 16

(6) At age 18–19 and subsequently, consider gender reassignment surgery

The aims of treatment are twofold:

(a) to explore with the child or young person with gender dysphoria the reasons for their discomfort with their gender assigned at birth and to consider alternative ways forward, including living in the role of their birth-assigned gender or pursuing medical intervention that will enable them to transition;

(b) in those who choose to live in their preferred transgender role, to start treatment, pausing for reflection before each step, first with puberty blockers, then with cross-sex hormones and finally with gender reassignment surgery to relieve gender dysphoria.

Among those who opt for medical treatment, the degree of success of intervention is measured by the absence of gender dysphoria and mental health problems and by the presence of psychological well-being. Ideally it would be possible to quote findings from a number of controlled trials of each of the interventions. Given the impracticability of obtaining agreement from children and young people with intense gender dysphoria to participate in controlled trials, the findings from uncontrolled but carefully conducted studies provide the main evidence for effectiveness.

There have now been a number of such uncontrolled studies, in which patients have been followed up to see whether their physical and psychological states have improved or deteriorated after the use of puberty blockers alone Reference de Vries, Steensma, Doreleijers and Cohen-Kettenis 24 – Reference Costa, Dunsford, Skagerberg, Holt, Carmichael and Colizzi 26 and puberty blockers followed by cross-sex hormones followed by surgery. Reference de Vries, McGuire, Steensma, Wagenaar, Doreleijers and Cohen-Kettenis 27 – Reference Smith, Van Goozen, Kuiper and Cohen-Kettenis 29 The most recently published study of the effects of puberty blockers was reported from the Portman Clinic, London. Reference Carmichael, Butler, Masic, Cole, De Stavola and Davidson 30 This study reported on the short-term outcome over 2 years of 44 children and young people aged 12 to 15 years when they started treatment with puberty blockers. Overall, the patient experience was positive. Although there were some children who showed some negative outcomes in mood and quality of relationships with family and friends, the majority showed positive change. There was no change in the rate of parent- or child-rated behaviour problems or risk of self-harm. All adverse effects, when they occurred, were mild. In line with other studies, only 1 of the 44 children and young people treated with puberty blockers did not go on to request cross-sex hormone treatment.

All the studies quoted above have provided valuable information. In all cases, there has been benefit from the interventions for the majority and an absence of significant harm. The most recent critical review of the use of puberty blockers has concluded: ‘Although large long-term studies with diverse and multicultural populations have not been done, the evidence to date supports the finding of few serious adverse outcomes and several potential positive outcomes. This literature suggests the need for transgender youth to be cared for in a manner that not only affirms their gender identities but that also minimises the negative physical and psychological outcomes that could be associated with pubertal development’. Reference Rew, Young, Monge and Bogucka 31 In all published cases, the majority has reported benefit from the interventions and an absence of significant harm. Where it has been measured, an improvement in psychological well-being has always been found. It is well established that adults who transition ‘experience fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction’ than before the transition and show no wish to revert to their gender assigned at birth. Reference Ruppin and Pfafflin 32

It should be added that the use of puberty blockers in early adolescence has been strongly criticised. Reference Evans 33 , Reference Evans 34 It has been claimed that there has been undue reliance on an affirmative approach (self-identification) in making a transgender diagnosis, that the complexity of the underlying problems of young people presenting as transgender has been inadequately assessed, that a high proportion of those who are treated with puberty blockers regret that they have received this treatment and that the young people who have been treated have not been capable of giving informed consent to treatment that has such profound implications for their future.

The effect of puberty blockers is generally, though not universally, regarded as reversible. Their use has been associated with apparently reversible stunting effects on height velocity and bone maturation. Reference Smith, Van Goozen, Kuiper and Cohen-Kettenis 29 , Reference Delemarre-van de Waal and Cohen-Kettenis 35 General cautions that have been expressed by clinicians about the possibility of irreversibility, such as those by Professor Butler and Dr de Vries quoted in a judicial review, 19 are no more than one might expect in relation to a large number of interventions in routine use. Caution about possible harm is always an appropriate clinical stance. It should not be taken to mean that the intervention in question should not be used where it is indicated.

There is one undeniable loss that occurs as a result of the use of puberty blockers. The individual does not go through the experience of the ‘normal’ adolescence he or she would have had without their use. However, most transgender young people do not consider this to be a loss or in any way regrettable.

The use of cross-sex hormones exposes the individual to the risk of a metabolic abnormality in about 15% of cases, but the significance of this finding is not clear and it does not seem a contraindication to their use. Reference Colizzi, Costa, Scaramuzzi, Palumbo, Tyropani and Pace 36 Further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones.

The competence of young people to give informed consent to the use of puberty blockers and cross-sex hormones is currently a matter of great relevance to clinical management. In UK law, 16 years is regarded as the youngest age at which it can be assumed, on the basis of chronological age, that a young person can give informed consent to a medical procedure. Below that age, it is widely accepted that, in considering whether a young person is capable of giving informed consent, the so-called Gillick principle should be applied. This principle, expressed by Lord Scarman in a 1985 House of Lords judgment and repeated in the above-mentioned judicial review, 19 is that ‘as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to […] understand fully what is proposed’. There is a controversy as to whether, because of the unusually complicated issues involved, children under the age of 16 could ever have the cognitive competence to give consent to puberty blockers or cross-sex hormones. This matter was considered in great detail in the judicial review whose judgment was published in December 2020. 19 This court decided that young people under 16 years could not give informed consent to the use of puberty blockers. Further, the court ruled that, even in cases where parents give their informed consent and clinicians are in agreement, an application should be made to the courts for authorisation before a child under 16 years can be administered puberty blockers. However, on appeal, this decision was reversed. The Appeal Court decided that the initial judgment had placed an improper restriction on the Gillick test and that it would not be appropriate for an application to the courts to be required before a child could be administered puberty blockers. 37

There is a need for systematic psychological investigation into the capacity of children and young people to make decisions in this area. Although there is some evidence on the capacity of young people aged 14–16 years to understand medical procedures, there is no evidence relating to the specific question of their understanding of the use of puberty blockers and cross-sex hormones, for example, in comparison with that of older people. Such evidence should be obtained. In the meantime, it would seem reasonable to rely on the findings of Weithorn & Campbell, whose study provides the most relevant data. Reference Weithorn and Campbell 38 These investigators looked at 24 individuals in each of four age groups: 9, 14, 18 and 21 years. They tested their competence to make informed treatment decisions in a series of medical dilemmas, involving conditions such as epilepsy, diabetes and psychological problems. The children, adolescents and young adults were given the nature of the problem, treatments options, expected benefits, possible risks and consequences of failure, and then assessed on how much they understood. The 14-year-olds did as well as the 21-year-olds. The 9-year-olds did distinctly less well. Although it is many years since this study was carried out, until more relevant evidence is produced, there is no reason why its findings should not be regarded as highly pertinent.

One can conclude from the evidence that gender dysphoria is a relatively rare but well-defined condition, characterised by a strong desire to be of the gender opposite to that assigned at birth and by an insistence that one is, indeed, of the other gender. Affected transgender individuals are usually aware of its existence by the age of 5 years. Gender dysphoria needs to be distinguished from gender-atypical behaviour, where those assigned male gender at birth showed an interest in activities generally preferred by girls and vice versa . Marked gender-atypical behaviour occurs in around 2–3% of the population, most of whom are not transgender. Further, many children who show gender dysphoria before puberty do not continue to do so during and after pubertal changes occur. However, if gender dysphoria does persist into adolescence, its intensity tends to increase at this time.

From about 2005 until the present, there has been a considerable, perhaps tenfold, increase in the number of children and young people referred to gender identity clinics. This change has been observed not just in the UK, but in Canada, the USA and Finland. These more recent referrals have differed from previous cases in three ways. More recent referrals have been older, often not presenting until the early teen years. Whereas previously referrals were relatively evenly balanced between those assigned male and female gender at birth, there is now a considerable preponderance of those assigned female gender at birth. Further, whereas previously children and young people with transgender did not show high rates of behavioural and emotional disturbance, this is not the case for recent referrals.

The assessment and management of gender dysphoria has been pioneered by a Dutch group based in Amsterdam. This group has laid down a number of principles of management, which have been widely adopted by gender identity clinics in other countries. The effectiveness of this sequence of interventions is now reasonably well established, with good evidence that it relieves gender dysphoria and usually improves psychological well-being. Physical side-effects may occur but as far as can be ascertained at present, not to a degree where possible harm outweighs benefit. There are, however, unresolved issues concerning the capacity of young people with gender dysphoria to give informed consent to the use of puberty blockers.

There are a number of gaps in knowledge requiring urgent attention. First, it is unclear whether the considerable increase in referrals to gender identity clinics in the past 15 years is due to greater willingness of early affected individuals to come out at this age or whether clinics are dealing with a different population with different needs. There is clearly a need for both quantitative and qualitative research to investigate the early histories of those assigned female gender at birth referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years. Second, although it is reasonably well established that the use of puberty blockers is not accompanied by serious adverse effects, further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones. Finally, there is a need for research into the capacity of children and young people, compared with older people, to understand the implications of the use of puberty blockers and cross-sex hormones.

Philip Graham is Emeritus Professor of Child Psychiatry in the Institute of Child Health, University College, London, UK.

Data availability is not applicable to this article as no new data were created or analysed in this study.

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

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• DOI: https://doi.org/10.1192/bjb.2022.3

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England Overhauls Medical Care for Transgender Youth

The National Health Service is closing England’s sole youth gender clinic, which had been criticized for long wait times and inadequate services.

By Azeen Ghorayshi

The National Health Service in England announced on Thursday that it was shutting down the country’s only youth gender clinic in favor of a more distributed and comprehensive network of medical care for adolescents seeking hormones and other gender treatments.

The closure followed an external review of the Tavistock clinic in London, which has served thousands of transgender patients since the 1990s. The review , which is ongoing, has raised several concerns, including about long wait times, insufficient mental health support and the surging number of young people seeking gender treatments.

The overhaul of services for transgender young people in England is part of a notable shift in medical practice across some European countries with nationalized health care systems. Some doctors there are concerned about the increase in numbers as well as the dearth of data on long-term safety and outcomes of medical transitions.

In the United States, doctors specializing in gender care for adolescents have mixed feelings about the reforms in Europe. Although many agree that more comprehensive health care for transgender youth is badly needed, as are more studies of the treatments, they worry that the changes will fuel the growing political movement in some states to ban such care entirely.

“How do we draw the line so that we keep care individualized while maintaining safety standards for everyone? That’s what we’re trying to sort out,” said Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the incoming president of the World Professional Association for Transgender Health, who is transgender. “It’s the people on the ground who need to make these decisions, not people in Washington or state legislatures.”

The N.H.S. said current patients at the Tavistock clinic could continue to receive care there before transferring to two new hubs at children’s hospitals in London and Manchester. The new clinics will expand the country’s gender services while making sure children are adequately treated for autism, trauma and mental health issues. The specialists will also carry out clinical research on gender medications.

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New Hampshire teen one of the youngest to have gender reassignment surgery

by Kenneth Craig

A high school student in New Hampshire is being called a 'pioneer' after becoming one of the youngest people to undergo gender reassignment surgery. But her long and challenging journey began when she was just a child.

At 17 years old, Emily Tressa finally feels fully herself. Last month, she became one of the youngest patients in the country to undergo gender reassignment surgery. Emily says, "For me, it feels almost like I'm finally fully complete now."

Emily was born a boy, but says she always knew she was a girl. "I used to look in the mirror and be like, is it only me? Am I the only one that feels like this? That I'm trapped in the wrong body?"

As a young child, she changed her name and started dressing as a girl. First at home and later at school. With her parents support, and under the care of doctors and psychologists, Emily eventually started taking hormone blockers to prevent male puberty and then estrogen to develop a female body.

Dr. Jess Ting is director of surgery at Mount Sinai Center for Transgender Medicine and Surgery. He says, "Emily is a pioneer because she is at the forefront of this new generation of young kids, adolescents who are realizing what they are much earlier in life and are able to transition even before puberty."

Dr. Ting performed Emily’s reassignment surgery at Mount Sinai Hospital in New York. He created female anatomy that is fully functional.

His team has completed 12-hundred various operations. Dr. Ting considers it a life saving surgery, given the alarming rates of attempted suicide among transgender youth.

Emily's mother, Linda, says her only fear is what would happen if she tried to hold Emily back. “We saw the unhappy boy and we saw the happy girl. And we knew the statistics and we knew we'd much rather have an alive daughter than a dead son.”

Emily has become an activist and uses social media to let others know they're not alone. She says, "I don't want people to feel like that. It's OK to be who you are and just present to the world as yourself."

Experts say there are still many barriers for transgender people when it comes to accessing appropriate care and that contributes to long-term health problems. Recently, the American College of Physicians published new guidelines for doctors to help them better understand medical issues specific to this population.

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Peri-operative care of transgender and gender-diverse individuals: New guidance for clinicians and departments

New guidance on peri-operative care of transgender and gender-diverse individuals is published in Anaesthesia to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. The guidance has been produced by a working group of experts including Dr. Stuart Edwardson, Royal Infirmary of Edinburgh, Edinburgh, UK; and Dr. Luke Flower, Victor Philip Dahdaleh Heart and Lung Research Institute, Cambridge, UK, and colleagues.

The number of people openly identifying as transgender and/or gender diverse has increased significantly over the past decade, most likely as a result of emerging clarity and comfort with open expression. Census estimates from 2021 identified 262,000 people living in the UK identifying with a gender that does not correspond with that assigned at birth. It is worth noting that this is a lower estimate than others, most likely due to hesitation of people to disclose.

Around 50% of transgender and gender-diverse people are currently undergoing some form of medical treatment for gender affirmation (whether this is hormonal therapy, surgical affirmation or both), and a further 25% are not currently accessing gender-affirming medical interventions but wish to. Many aspects of these interventions provide specific and important considerations for the anesthetist in the peri-operative period.

The authors say, "Transgender and gender-diverse people comprise a significant and varied minority with specific health care needs that are often both poorly misunderstood and met. It is our collective responsibility for this inequity to be addressed.

"Transgender and gender-diverse people, in addition to some specific needs, experience the same health problems as everyone else and will therefore present to all services, whether specialist or not. This guideline sets out a structured explanation of current evidence and practicalities to be considered for any anesthetist looking after a transgender and gender-diverse patient in any scenario or area of the hospital."

They add that the new guidance is necessary as there is currently no existing guidance covering the scope and focus of this document.

The working group's key recommendations

• The patient's preferred name and pronouns should be confirmed and used at all times. This is an important way of showing respect and decreasing the risk of gender dysphoria.
• There should be a process in place whereby a patient can privately and safely disclose both their sex at birth and gender as part of pre-operative assessment. Digital pre-assessment questionnaires can provide this in an elective setting.
• All forms of social, medical and surgical gender affirmation should be identified at pre-operative assessment, and sensitive explanations given to the patient for the purposes of inquiring. Anesthetists should be aware that many aspects of gender-affirming care may not be present on a patient's health record (including gender-affirming surgical procedures).
• A pre-operative pregnancy test should be offered to all patients who have a uterus and ovarian tissue between the ages of 12 and 55 years, regardless of the use of contraception.
• All specific peri-operative considerations for transgender and gender-diverse patients, including name and pronouns, should be communicated with the team at the surgical brief. Transgender status need only be shared with the patient's consent and if it is deemed important for the safety of their care. It should be given the same level of confidentiality as any other sensitive personal information.
• Chest binders should ideally be removed, with the patient's consent, before anesthetic intervention.
• Hormone therapy should be continued throughout the peri-operative period unless there are specific contraindications. Patients should be counseled on the risks and benefits of this with the aim of making a shared decision.
• Transgender and gender-diverse patients should be cared for in an environment that respects their gender identity. In some circumstances, this may involve providing a single room.
• Organizations should have clear guidance for the care of patients who are transgender and gender-diverse. This should include specific educational materials to increase awareness of issues impacting their access to high-quality care.
• All areas of peri-operative and perinatal practice should embrace gender-inclusive language to honor all identities.
• Pregnant patients who are transgender or gender diverse should be seen in an anesthetic clinic in the antenatal period to inform and support decision-making and plan care before presenting in labor.

The authors conclude, "The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While they may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anesthetists are educated on specific considerations when caring for these patients.

"This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period."

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New push for mRNA bird flu vaccine development: WHO

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