Features

Is anyone listening?

The mental and physical health of trans young people is suffering, to the point they’re even accessing healthcare less often, and they continue to face considerable stigma. What can you do to help ensure they’re as healthy and happy as they should be? Journalist Phil Harris reports.

She was about nine when I caught her in the bath with a broken razor, about to attempt some self-surgery on her genitals.’

For Sarah, a mother of four, this discovery was a chilling new development in the already-traumatic life of her second-eldest child. Born a boy and christened Oliver, her child had from an early age questioned why she was a boy, and from the age of six had wanted to dress as a girl and be called Olivia.

Sarah says: ‘As a young child she would say “God has made a mistake with me and put me in the wrong body.”’

After the bath incident, Sarah sought an emergency appointment with a GP. ‘He was brilliant and very supportive, even though he admitted he had no experience in this area,’ she says.

Seeking the help of the GP turned out to be a wise move. Olivia’s experience at her school had been bleak. According to Sarah, staff turned a blind eye to the constant bullying and violent attacks Olivia received daily from other pupils. When Sarah complained, she was accused of child abuse for making Olivia feel confused about her gender identity.

‘The GP offered to sign Olivia off school, but she said she didn’t want the bullies to win. The school provided no support in tackling the bullies – I was told things like: “Children need to learn that their decisions have consequences.” One staff member would call Olivia “it”. 

This was how they treated an innocent and frightened child.’ Next, Olivia developed anorexia and began to lose weight alarmingly.

 

Trauma for trans people

A recent US study (Rider et al, 2018) revealed that just 38% of school-age trans young people describe their health as ‘very good or excellent’, compared with 67% of the non-trans (cisgender) students.

About 60% of the trans respondents had long-term mental health problems, and around 25% had physical disabilities or long-term health problems (such as asthma or epilepsy). In comparison, 17% of cisgender teens had psychological problems and 15% had physical health issues.

The situation is similar in the UK, where an alarming 84% of trans young people in the UK have self-harmed and almost half (45%) have attempted to take their own life. Nearly two in three trans pupils are bullied at school, while one in 10 have received death threats. One in three trans pupils say they are not able to be known by their preferred name at school, while three in five (58%) are not allowed to use the toilets they feel comfortable in (Stonewall, 2017).

While a growing number of schools are supporting their trans pupils, too many are not equipped to do so. The survey found that more than two in five trans pupils (44%) said that staff at their school are not familiar with the term ‘trans’ and what it means. Some even cited examples of school staff making fun of trans people (Stonewall, 2017).

Meanwhile, research shows that trans people generally experience significant inequalities in health, wellbeing and broader social and economic circumstances (PHE and RCN, 2015), despite legislation such as the Equality Act 2010, which makes it an offence to discriminate against trans people.

Matthew Waites, a UK trans youth worker and author of the book Supporting young transgender men: a guide for professionals, thinks that trans young people will try to balance the impact of mental health over the impact on their physical health, and will sometimes compromise one over the other.

He says: ‘Gender dysphoria [distress caused by a mismatch between a person’s biological sex and their gender identity] is a complex issue, and any health appointments relating to a health professional having to examine parts of their bodies that they don't want anyone to see, because of gender dysphoria, is a huge barrier to accessing healthcare.’

In fact, Rider et al (2018) also found that while more than half of young people had preventative health and dental check-ups in the past year, this was less likely to happen for trans teens.

It’s hardly surprising that trans young people like Olivia are more likely than their cisgender counterparts to have poor mental and physical health.

 

Stopping the stigma

Sarah, Oliver and Olivia are not the real names of the people in the opening story, partly because there is still a great deal of stigma around trans issues.

Sadly, nor is their experience of school hostility unusual, says Susie Green, chief executive of the charity Mermaids (which supports gender-diverse children, young people and their families).

‘Overall we find that usually school staff and other professionals just don’t know enough about the subject, or what to do about it.’

Stigma is an important factor in the way trans children are treated by parents, professionals and wider society, Susie explains, as many will try to discourage or deny what is happening.

‘A lot of the negative reactions are based around fear of the unknown, such as what it will mean about work, relationships and what others think. But denying something that is inherently part of someone is not going to make it go away. It will just make the young person feel invalidated, isolated and alone.’

Susie, whose own child questioned her gender at the age of four, has received constant abuse and even death threats over the work of the charity, and calls transphobia the ‘last bastion’ of discrimination.

‘Most of society now rightly considers it unacceptable to discriminate against people based on the colour of their skin or their sexual preference. But many seem to think it’s still okay to be openly anti-trans, even though it’s outlawed in the Equality Act.’

However, there are signs that things may be changing, with trans issues now having a higher prominence than ever before, and there is an international ‘trans day of visibility’ on 31 March each year.

Technology is also playing a large part in changing attitudes, according to Bernard Reed, a trustee at the Gender Identity Research and Education Society (GIRES). He says: ‘Young people are very media savvy and find it much easier to access information and speak to similar people. Trans young people are not as isolated as they used to be.’

Infographic

Your role

Susie says there is much that public health nurses can do to help children who have gender identity issues – and their families – and that school nurses can play a particularly important role.

‘Young trans people may disclose to staff at school. If this happens, it’s important to listen to the young person and not try to persuade them to do or be something else. They shouldn’t be embarrassed or ashamed of how they are feeling.

‘School nurses can give support and guidance, and obviously won’t break any confidences. They may end up taking an advocacy role and help the young person to discuss the subject with others, such as family members.

‘It needs to be acknowledged that what the young person is thinking and feeling isn’t a choice, and they may have been struggling with it for years. If a school nurse hears that disclosure then it is a big responsibility.’

School nurses can also refer young people to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust, which is specifically for children and young people experiencing difficulties with gender identity.

This national specialised service is the only one of its kind in the UK, and will carry out a full assessment – they also have a clinic in Leeds, and satellite clinics. Often working alongside child and adolescent mental health services (CAMHS), GIDS staff will help the young person to choose a path that best suits them. Unfortunately the waiting time for a GIDS appointment is now 14 months, as demand has been increasing dramatically. Professionals should judge the Gillick competence of the young person before referring, and they will take responsibility for referring, even without parental consent if necessary. School nurses can also refer to GPs and CAMHS. The pathway may lead to hormone treatment and ultimately surgery, although this is not the case for the majority for GIDS referrals. Susie acknowledges that some adults are likely to consider trans in young people as a phase, and be tempted to simply monitor it and wait for them to grow out of it – generally termed ‘watchful waiting’.

‘Of course children should be allowed to experiment and explore,’ Susie says. ‘But if they are consistently saying that’s who they are, then this should be respected. They have to go through so much to become who they are, and it takes a lot of bravery and commitment.’

School nurses are also well placed to influence school thinking generally about discrimination and creating a culture of knowledge and acceptance, Susie adds. The issue may become more acute for young people when they hit puberty and their bodies begin to change.

Claire Elwell, who has over a decade’s experience as a school nurse in the north east of England, agrees that school nurses are very well situated to support young people with gender identity issues, but says education and funding shortcomings often act to prevent better care.

‘School nurses are very open-minded and any training would be warmly received and added to the already wide knowledge-base they have. Trans and gender issues are often areas that sow confusion among professionals and the public, and better education could help to breach the gaps.

‘But there are fewer school nurses on the ground now, and that has an impact. Some drop-in services exist; however, these are time and venue-limited sessions, so young people don’t have much opportunity to talk to us about their issues.’

Claire points out that many professionals seem to lack knowledge on trans issues, and so it is likely that many teachers will struggle with the subject.

 

Practical steps

While there may not yet be quite the body of guidelines deserved on trans issues for those looking after young people, professional guidance is out there – many advice and guidance documents have been created by charities or support groups, and some have been produced by health organisations such as individual NHS trusts (see Professional guidance, overleaf).

Matthew says there are many practical steps school nurses in particular can take, both to support young people and promote inclusive environments. For example, they can call ahead to other professional services that young people may need access to, such as gynaecology or sexual health services.

‘That way, they can decide how a young person wants to be addressed when they get there and the young person won’t have to explain themselves and their identity before they start to discuss the issue.’

Professionals can also accompany young people to appointments where appropriate, and this can encourage positive mental health and emotional wellbeing, Matthew says.

‘If professionals see things that need addressing with regards to services and the way they treat young people because of their identity, it’s always important to challenge this.

‘This will demonstrate to young people that they can take control in a positive way. Being a role model who challenges bad practice can give young people the confidence to address health needs in the future, because they'll have the tools to cope if something does go wrong.’

Matthew also thinks simple and inexpensive steps at healthcare provider organisations, including schools, can make a difference. ‘We all know that money is tight within services, but things like putting up posters that explicitly state you’re a trans-friendly organisation will go a long way to encouraging young people to open up.

‘Having gender-neutral spaces such as toilets and changing facilities, as well as using gender-neutral language in policies and procedures that young people may access, will go a long way to ensuring that young people feel safe in accessing services.

‘Using gendered language that doesn’t quite fit a young person’s identity makes a very clear statement that organisations may not be trans friendly. Things like that may seem very minor, but it’s always noticed. It sends a clear message that organisations aren’t educated and don’t understand trans issues. ‘If young people start to feel that impact, they are less likely to want to engage with services, less likely to address health issues, and their mental health will suffer as a consequence.’

On the other hand, if schools take a positive approach this can have a significant impact. In the case of Olivia, she eventually switched schools, and the experience could not have been more different.

‘They have been brilliant,’ her mother Sarah says. ‘With the school’s help, I offered to speak to the staff and parents, and give them a chance to ask questions. I wanted to be completely transparent and honest.

‘I explained Olivia’s experience and journey, and the fact that she wanted to live as a girl. The only questions I got asked were about how I am coping and what to do about play dates. Everyone has been incredible and embracing, and some even brought me in spare dresses.

‘Olivia now has a nice group of friends. Her eating problems have disappeared, and she goes to and from school with a smile on her face.

‘Before our experience, I used to think trans people were damaged emotionally and possibly trying to change themselves to run away from problems. But I’ve seen that it’s not like that.

‘We just want acceptance, tolerance and understanding, and for everyone to be comfortable in their own skin. That doesn’t seem too much to ask.’


 

Professional guidance

  • Free e-learning on caring for gender-variant young people bit.ly/Elearn_GIRES_trans
  • PHE’s Preventing suicide among trans young people gives information on the law and effective communication bit.ly/PHE_young_trans
  • The Trans Inclusion Schools Toolkit has practical advice bit.ly/trans_schoolkit
  • Health factsheets produced by the National LGB&T Partnership bit.ly/trans_health
  • NHS guidance on gender dysphoria bit.ly/GD_NHS
  • GIRES Training for health professionals and schools gires.org.uk
  • Mermaids UK A charity for trans young people, from parents of trans children mermaidsuk.org.uk
  • GIDS One-of-a-kind NHS centre offers guidance for young people, parents and professionals gids.nhs.uk
  • Sandyford Integrated sexual, reproductive and emotional health service across Greater Glasgow and Clyde bit.ly/sandyford_Scot UK
  • Trans Info Links to guidelines and protocols for healthcare professionals from UK organisations uktrans.info 

Via Twitter: @Genderintell, @AllAboutTrans, @TmsaUk


 

References

Glen F and Hurrell K. (2012) Technical note: measuring gender identity. Equality and Human Rights Commission. See: https://www.equalityhumanrights.com/sites/default/files/technical_note_final.pdf (accessed 18 April 2018).

Kuyper L and Wijsen C. (2014) Gender identities and gender dysphoria in the Netherlands. Archives of Sexual Behavior 43(2): 377-85.

PHE and RCN. (2015) Preventing suicide among trans young people: A toolkit for nurses. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/417707/Trans_suicide_Prevention_Toolkit_Final_26032015.pdf (accessed 17 April 2018).

Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. (2018). Health and care utilization of transgender and gender nonconforming youth: a population-based study. Pediatrics 141(3): e20171683.

Stonewall. (2017) School report: the experiences of lesbian, gay, bi and trans young people in Britain’s schools in 2017. See: www.stonewall.org.uk/sites/default/files/the_school_report_2017.pdf (accessed 18 April 2018).

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