“Being male is preferable to being female and vulnerable.”
(contributed by a parent in our group)
We wanted to express our gratitude to J.K. Rowling for shining a light, in her essay, on the gender distress that is causing increasing numbers of young women to propose radical changes to their bodies, even in their teens. The words in our title were spoken by a young trans man called Noah, whom we describe below. But responding to Rowling, Mermaids could “see no evidence that any of the young trans men we support are transitioning because they wish to escape womanhood for an easier male existence… we see it as a breath of fresh air.”  For us, things don’t look that simple, as we try to explain below.
Part One: Adolescent-Onset
Noah was born Arabella, “a strikingly good looking 16-year-old, birth assigned female. He is tall, of athletic build and androgynous looking.” Noah was a patient at GIDS, and what follow are the words of his therapists (who spent hours listening to him).  “As with many other adolescent assigned females referred to our service, Noah expressed in concrete ways the absolute rejection of his own female self and a disavowal of sexuality and sexual desire. Noah’s cross gender identification manifested itself post puberty and without a previous history of gender incongruence. This rapid onset of gender dysphoria in assigned females post puberty is indeed a worrying phenomenon we are observing more and more at the clinic.”
“Noah’s own account of what had brought him to our service was matter-of-factly summed up by him saying that he had been ‘assigned the wrong gender at birth’ and that he now was seeking to ‘re-align’ to his male gender and ‘get rid of gender dysphoria.’ Both parents had been told about this as a fait accompli with no previous indication.” Noah “presented as resolute and unwavering, as well as openly righteous and militant in relation to terminology and language. For instance he launched into a tearfully angry tirade about the director of GIDS being interviewed by BBC4 using the term ‘natal female’ whilst talking about a young trans male, instead of choosing the ‘correct’ ‘assigned female at birth’ descriptor.”
Noah – or at that time Arabella – had grown up “in an environment that favoured creative free expression and inquisitiveness and where intellectual debate and prowess were held in high regard, meaning that displays of emotionality, although an all too frequent occurrence, were an indication of vulnerability and could elicit mockery and humiliation.” “Both parents have experienced periods of depression requiring medication… Both parents’ resilience and internal resources have been stretched and at times depleted by the necessity of attending to their children’s needs… From the very first session the level of familial conflict and distress was palpable in the room.” There were four children, with “an older brother who has difficulties relating to his short-term memory, a younger teen brother who is autistic and attends a specialist school, and a latency age [younger] sister.”
“Noah’s experience of prep school had been one of ‘never fitting in’, being seen as ‘weird’ and struggling to make friends. In the year before his Eleven Plus exam he had become the target of bullying by a group of girls who used to taunt him by saying he was ‘anorexic’ because of his gangly appearance, and he also recalled being actively excluded from playground games for being ‘odd’. The ‘oddness’ and social difficulties had then been given a diagnosis of Atypical Autism, something Noah had, at the time, resented and struggled with.”
Noah “had not been preoccupied with gender thoughts until he had begun to develop at puberty towards the end of Year 8. He had chosen to attend an all-girls’ school primarily because it was a very good school and he is highly motivated academically. He retrospectively integrated his choice of a girls’ school, by stating that it is “okay for men to cross dress and wear girls’ uniform as well as experiment with make-up”. He experienced his pubertal changes as ‘gross’ and highly distasteful, his relationship to his body now disturbed by the appearance of periods, the pain and the bleeding and, we may add, the crushing reality of his biological sex. It was around this time that Noah began to superficially cut his upper thighs as well as having recurrent suicidal thoughts.”
“Aspects of femaleness/femininity seemed to be actively shunned by mother with statements attributed to both herself and her own mother, when she was Noah’s age, suggesting an intergenerational struggle in identifying with constricting, stereotypically binary gender roles. Mother reported that she herself had wanted to dress as and be male since, as she said: “Who does not want to be male?” and “Society is a much better place for males”, and she recalled how she had not wanted to be a ‘female woman’ when young. More importantly we also heard how mother had expressed to Noah the ‘threat of puberty and menstruation’ by deliberately talking about these in graphic details as something to be abhorred both physically and also in terms of their symbolic meaning.” “Noah recalled being told, when he was about five years old, that ‘girls have a small penis inside’ and that he had been waiting all this time for it to grow… in his memory, his male siblings used to ‘show their penis off’ making him feel lacking and endlessly waiting for a penis to ‘pop out’ “.
“Noah spoke of his conflict in relation to identifying as male as he saw men as sexually predatory beings by definition, but, he clarified: “Being male is preferable to being female and vulnerable.” He spoke with poignancy about feeling sexually assaulted on a number of occasions whilst on the train on the way to school by men rubbing themselves against him, other instances of being ‘cat called’, and an incident of “laying on a sofa with a male friend who then rolled over and licked my face”. When we explored Noah’s sexuality and erotic fantasies in his individual sessions, he spoke of a complete lack of sexual drive and desire.” “Noah has been in a long-term non-sexual relationship for a while, initially online, with an assigned male who identifies as female.” “One can hypothesise that Noah’s experience of objectification and premature sexualisation of his adolescent female body by males he encountered, somehow contributed to further disassociate him from his developing body and led him to seek a concrete, instant solution and a way to escape from such place of vulnerability by demanding a medical intervention.” A GIDS psychologist has remarked, “some of the young people at the service have had pretty traumatic childhoods; I can’t help but wonder what impact that might have had on their gender identities, and if transitioning to the other sex might seem as a way to reinvent themselves, to get rid of difficult pasts.” 
So GIDS referred Noah for puberty suppression, which was followed (as it nearly always is) by irreversible cross-sex hormones. In the words of the associate director of GIDS: “a lot of the young people—and anybody who wants it—have physical intervention. We have no record of turning people down for physical intervention” [6, at Q55]
Mermaids “see no evidence that any of the young trans men we support are transitioning because they wish to escape womanhood for an easier male existence.” Mermaids supports only a small fraction of the patients referred to GIDS, so may be unfamiliar with the broader contexts of adolescent-onset gender distress. GIDS clinician Dr Melissa Midgen provides a useful overview:
“I would like to convey that those of us who work in the service literally have seen hundreds of young people and their families, and such total immersion in this field simply cannot be replicated elsewhere. Everything I have learnt has been through observations within the ‘laboratory of the consulting room’ (A la Michael Rustin). My take home message is not any dispute about the existence of gender dysphoria as a set of symptoms and attendant experience, but rather the conflation of GD with transgender. The young people and children we see are a heterogeneous group, with their own histories, personal circumstances, family dynamics and social contexts. Many of them experience hatred of their sexed bodies; many of them feel profoundly uncomfortable with the gendered behaviour and presentation they understand society expects of them; some are aware that their same sex attraction would be unacceptable to those around them; some are experiencing the misery of abuse and neglect: complex trauma, attachment difficulties, depression and anxiety; some are diagnosed with ASD, ADHD and / or another psychiatric co-morbidity; some are simply lost, isolated and miserable teenagers or confused young children. Parents can genuinely feel that early social role transition has been the most compassionate response to their so called gender non-conforming children; and that physical treatment to correct the misery of ‘being trans’ is entirely appropriate if the misfortune is understood to be something along the lines of having been ‘born in the wrong body’. However, just as their multiple routes into gender dysphoria there will be many routes out of it. Transitioning socially and medically will be one treatment pathway, but it simply cannot be possible that a unitary solution is appropriate for everybody. For the abused boy whose penis has been violated and who has witnessed male enacted domestic violence, hatred and fear of his penis is an appropriate response – he might well want to cut it off, and understand that desire through the lens of ’trans’. For the girl with undiagnosed ASD who has always felt different, isolated, confused by ‘femininity’ and the social landscape of ‘girls’, whose tendency has been to dress, look and behave in ways which the adults around have designated as the way boys carry out these things, why would she not conclude she would be a better boy than a girl, and rigidly adhere to that belief. For the 4 year old boy who wants to dress in material fashioned in such a way that it is called a dress, and sing, and dance, and leans towards the more yielding and comfortable group of children called girls, and whose parents worry and convey fear of his effeminacy, and what it might mean, how much easier for everybody if it turns out he’s really a girl. This is what we have seen. And this is just the external world of these children and their families. When we bring into the mix identification, projection, unconscious symbol formation then we have multi-layered aetiology resulting in complex presentations. Let’s keep complexity at the heart of this.” 
Emma Watson also responded to Rowling’s essay, reassuring her public that “Trans people are who they say they are, I and so many other people around the world see you, respect you and love you for who you are.”  But in facilitating Noah’s escape from his female body, do we collectively fail to give Arabella the love and respect she deserved, for who she was? If so, it is a gross failure, not only of medical ethics and the uses of science, but a failure in our respect for women, in our compassion for difference, and in our deployment of public resources for the common good. Recently GIDS clinicians called this escape “the ultimate act of self-harm. A form of self-harm hardly noticeable to many because it is so aligned with the disavowed but ever-present attack on gender non-conforming women that exists throughout society.”  When J.K. Rowling and other women are attacked for raising concerns about the welfare of vulnerable young people, that ever-present misogyny is all too noticeable.
So, how did we get here?
Part Two: Early Childhood-Onset
In the 2000s, two parent advocacy groups, GIRES and Mermaids UK, asked the NHS to provide children with a new medical intervention for gender dysphoria, then being trialled in the Amsterdam gender clinic. These were children with a lifelong conviction that they were in the wrong body, whose distress became unbearable with the changes of puberty. As the NHS commented at the time, “their sense of despair frequently leads to extreme pressure being placed on clinicians to act and provide immediate solutions through physical interventions which may not be clinically appropriate.”  But parents were so committed to early medical intervention that some even took their children to clinics abroad. So strong was the faith that GIRES even suggested that it could eliminate autism: “young people who have been successfully treated, are often described as having no residual ASD. The symptoms have disappeared once the dysphoria has been treated.” 
The new Dutch solution was a puberty-blocking hormone “developed to ameliorate treatment outcome in adolescent patients with an early onset of GID.”  It was given to children from age 12 upwards and prevented the body from growing in ways unhelpful to later sex-reassignment surgery (ultimately the goal was to ‘pass’ in adulthood as a member of the other sex, enabling the individual to more comfortably get on with their lives). Since most cases of early childhood gender dysphoria are transitory, the absence of medical intervention is integral to its effective management in a majority of cases; so understandably there was concern about unnecessary interference in children’s natural development. There were no guarantees, but the head of the Dutch clinic made clear that it was intended only for adolescents “who have from very early on (toddlerhood) shown a clear and extreme cross-gender identification in all social environments and want to adopt both the social role of the other sex and SR [sex reassignment]”. 
This extreme gender dysphoria was a very rare problem that impacted a few dozen families each year. And to its credit in 2008 the NHS convened an international conference to consider whether to adopt the “experimental” Dutch approach. [12, 13] It was (and remains) a controversial intervention unsupported by good evidence. Endocrinologist Russell Viner was “concerned about the effects of suppressing puberty very early, particularly on the brain, which is developing extremely quickly at this age”.  Even today the NHS says that “it is not known what the psychological effects may be. It’s also not known whether hormone blockers affect the development of the teenage brain.”  But these determined parents overcame the doubts and obstacles, and in 2011 the NHS adopted ‘the Dutch protocol’ for children aged 12 and up, as part of a small uncontrolled research study.[12, 16, 17] Consistent with the Dutch, patients were eligible only when “throughout childhood (defined as over 5 years) the adolescent has demonstrated an intense pattern of cross-gendered behaviours and cross-gender identity”. 
Then two things happened. Firstly, the numbers of children referred to GIDS started to balloon, as they did at clinics in other countries: over the decade, patients went from dozens to thousands. This took GIDS by surprise. In their 2011 planning estimates of future patient numbers, they reckoned on a maximum 110-150 cases a year, and “if these estimates are significantly in error, it is extremely unlikely that there would be more than 200 cases per year”. Numbers broke 200 the very next year, and in the most recent year there were over 2700 referrals to GIDS, plus more than 1000 under-18s referring to adult clinics [18, 19, 20]. On its website, GIDS wrote: “Just like everyone else in society we are going through a process of trying to understand what is happening”. 
Secondly, under continuing pressure from parents, GIDS expanded use of the medical interventions. It removed the lower age limit, and as its associate director explained to a House of Commons committee in 2015: “It used to be that you could not get puberty suppression until you were 16. Now it is at any age, effectively.” [6, at Q57]. The puberty blocker was lifted out of the research study and introduced into general clinical service as GIDS’s “established practice”, meaning that the study’s requirement for a history of lifelong dysphoria from early childhood no longer applied. [22, at 220.127.116.11, 3.4.3] And now, alongside earlier access to puberty blockers, the earlier availability of cross-sex hormones was under consideration too. The GIDS associate director again: “organisations like Mermaids put it on the agenda for us all the time and are very unhappy about our sticking to the international guidelines at the moment.” “I know that Susie and Mermaids would like a fast track so that young people who are already well into puberty and feel that they know that they want to move forward into physical intervention would bypass our assessment process and move straight into physical intervention. We feel that is not an ethical way to practise.” [6, at Q57, Q64]
Again to GIDS’s surprise, the new patients and their experience of gender identity were quite unlike the children the puberty blocker had been devised to help. Their preoccupation with gender began in adolescence; and where previously boys had made up the majority of cases, now it was girls (though significantly more boys were also being referred than before); adolescent-onset patients were – like Noah – more psychologically ‘complex’; and whereas early-onset children wanted to change from one sex to the other, often adolescent-onset patients wanted to opt out of that binary altogether. It’s worth quoting the GIDS associate director at length here:
“a large proportion of our young people are not clear that they want help and support until they are in or coming out of puberty. This is the surprise to us: that many of the young people, and increasing numbers of them, have had a gender-uncontentious childhood, if you like, and it is only when they come into puberty and post-puberty that they begin to question. That now represents a substantial proportion of our group…. our numbers have doubled every year for the last five years and the range and the sort of presentation we are seeing is varying so much. We are not having what you might see as the ones who are in the highly regarded Dutch study, which is this group of now 55 young people being tracked over time, who have had lifelong GIDS, very supportive families and very few associated difficulties. That sort of profile is a very small proportion of our young people. The range, the terms of gender binary – we are having more and more young people coming forward with really quite disrupted attachment histories; more looked-after children. On a typical referral day, we are really concerned about the complexity of many of the young people coming forward. My point about that is that many of them are not identifying their gender issues as being deeply significant to them until their mid-teens” [6, at Q51]
So the clinic had set in motion this new treatment which was then overtaken by events. The Dutch study provided weak evidential support for life-changing medical intervention in a highly selective group of early-onset patients, but it did not speak to the adolescent-onset group at all. “Virtually nothing is known regarding adolescent-onset GD” writes the Finnish psychiatrist Riittakerttu Kaltiala-Heino.  The Royal College of General Practitioners finds “significant gaps in evidence for nearly all aspects of clinical management of gender dysphoria in youth”  which mean (says Oxford University’s Professor of Evidence-Based Medicine) that “treatments for under 18 gender dysphoric children and adolescents remain largely experimental. … The current evidence base does not support informed decision making and safe practice in children.”  A newspaper reported last year: “The whole service should have been halted when the number of ‘transgender’ cases first exploded, one of the clinicians said. “That’s the point we should have stopped because we didn’t know what we were doing.” ”  The emergence of young people who have felt it necessary to transition a second time, back to their original gender role, adds urgency to the need for review.
But for Mermaids, we are living in a welcome new era of openness: “talking to young trans boys and men, it’s clear that something has changed in the way children and teenagers feel able to express who they are. While some see that as a cause for alarm, we see it as a breath of fresh air as we continue to emerge from the social ice age that was the bridled, hypocritical and corseted Victorian age. Just as there has been a rise in the number of young people feeling safe enough to come out as gay and bi at school, so there’s also greater freedom to speak openly about gender identity. It isn’t clear why transgender boys are now more represented than transgender girls in the population, but surely it’s a good thing to allow young people to explore their identities?” Undoing society’s restrictive expectations places on our male and female bodies would be progress but, as GIDS itself recognises, transition can re-enforce those expectations: “There is always a risk that the work of GIDS in offering physical intervention itself represents a potentially oppressive acceptance of a version of gender that many – not just gender non-conforming people – experience as limiting”.  Mermaids see the identity anxieties of the young as a rejection of Victorian values, while others wonder if the young are embracing a ‘new Victorian’ censoriousness. [29, 30, 31] Mermaids’ vision is of children freely exploring their identities, but Noah’s therapists at GIDS were clear that transitioning “is different to an adolescent creative exploration of alternative ways to be and ‘people to be like’, in that irreversible medical treatments on the body can foreclose future development and change.”
If there were a 4000% rise in the incidence of another childhood health condition that was deemed so serious that far-reaching life-long medical intervention was a standard treatment, then we would focus resources on prevention, on exploring its causes and on improving testing for the condition, and a multiplicity of treatments would be entered into trials. But none of that is happening here. As a society we must be more curious about the causes of gender dysphoria and its extraordinary rise, and about the populations it affects and how. Why do adolescents locate the source of their problems in their own bodies? How can we best help them overcome their difficulties without the need for hugely invasive and burdensome medical procedures? What has gone wrong to make increasing numbers of intelligent young people like Noah experience being female as inferior to being male? And medical intervention, when it is indicated, must be supported by high-quality evidence, so that we – parents and funders of the public health system – can be confident of its safety and efficacy.
J.K. Rowling wondered if she too might have tried to transition in youth: “I could have been persuaded to turn myself into the son my father had openly said he’d have preferred…. As I didn’t have a realistic possibility of becoming a man back in the 1980s, it had to be books and music that got me through both my mental health issues and the sexualised scrutiny and judgment that sets so many girls to war against their bodies in their teens.” Things are so different now, for as Noah’s therapists at GIDS observed: “Young people access our service with the clear expectation of being entitled to a physical, concrete medical ‘cure’ that will offer respite and a solution to the pains of growing up”. If so, that can’t be right: neither for their health, nor society’s.
 Marina Bonfatto & Eva Crasnow, ‘Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service”, Journal of Child Psychotherapy (2018)
 Niccie Le Roux, Gender Variance in Childhood/Adolescence: Gender Identity Journeys Not Involving Physical Intervention (DClinPsy thesis, UEL 2013)
 Personal communication
 Cohen-Kettenis & Pfäfflin, Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices (Sage, 2003)
 H Asscheman, ‘Gender identity disorder in adolescence’, Sexologies (2009)
 The Times, 21 July 2008
 HRA Application 10/H0713/79
 HRA Application 11/LO/1512
 FOIs to all English GICs;
 Delemmarre-Van de Waal & Cohen-Kettenis, ‘Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects’, European Journal of Endocrinology (2006)
 R Kaltiala-Heino, H Bergman, M Työläjärvi, L Frisén ‘Gender dysphoria in adolescence: current perspectives’, Adolescent Health Medicine & Therapeutics (2018)
 The Times, 8 April 2019
 Michael Barone, ‘Is American entering a new Victorian Era’?, Washington Examiner, 27 July 2015
 Maximilian Forte, ‘The New Victorianism’, Zero Anthropology (2016)
 Clint Margrave, ‘Is Anti-Woke becoming the New Woke?’, Aero Magazine, 21 January 2020