The ‘Natal female’ question by A Hutchinson and M Midgen

Dr. A. Hutchinson and Dr. M. Midgen are experienced clinicians who have both worked in the NHS Gender Identity Development Service for children and young people (GIDS).

The exponential rise in adolescent natal females (teenage girls) presenting at gender identity services over the last few years has been well documented. This phenomenon was noted first amongst professionals working in the field and latterly has been picked up by the press and the public. Back in November 2019, for example, Newsnight and radio 4 covered this issue. During the programme “Going back: The people reversing their gender transition” (File on Four, Radio 4, Tuesday 26/11/19) Dr. Elizabeth Van Horn (Consultant Psychiatrist in The Gender Identity Clinic, The Tavistock and Portman NHS Foundation Trust), in response to the question about this explosion in referrals of natal females presenting at the Gender Identity Development Service calmly remarked we ‘do not know’ what might be driving this rise.

This gave a surprising impression of a lack of curiosity, insight and experience on the part of current clinicians. We suggest, in contrast, that many others working in this field have been asking themselves this very question for several years. They have generated hypotheses to account for this noteworthy and concerning phenomenon and refute the claim that it arises solely out of reduced stigma and increased access to services.

We posit that there are multiple, interweaving factors bearing down on girls and young women that have collided at this particular time causing a distress seemingly related to gender and their sex. These factors comprise both the external world (i.e. the social, political and cultural sphere) and the internal (i.e. the emotional, psychological and subjective). The external and internal interact and feed each other [1].

It is notable that even speaking about these observable, and clinically relevant, factors are seen by some as evidence of a form of anti-trans rhetoric. This deeply disturbs the clinicians whose professional lives are dedicated to understanding the source and meaning of human distress. It is from this place that we speak.

In spite of apparent social gains for minority groups, our present-day culture obsesses in highly gendered ways over the signifiers of what it means to be a boy and a girl, a man and a woman. Girls are under ever more pressure to capitulate to the ‘pinkification’ and ‘pornification’ of girlhood. Girls who eschew these signifiers, who are uncomfortable or dissent from this demand, can often be lonely and isolated in their apparent idiosyncrasy. Sexual feelings awaken amidst sexual harassment and press reports of misogynist hate crimes. Dawning same-sex attraction can occur against a backdrop of homophobia; as well as a dearth of everyday, run-of-the-mill lesbian visibility. This is particularly relevant for girls drawn to an aesthetic which is viewed as ‘masculine’ (and therefore wrongly ascribed as ‘male’), but could be understood and owned as a butch lesbian identity if only these girls had access to it. Linked to this is the absence of critical feminist thought of the most elementary nature in the school curriculum. Failing that, even basic sex parity in the classroom would impact early on the sorts of messages both girls and boys internalise about their capacities and the expectations others have on them.

Changes to the body during puberty can bring about much more turmoil than is readily acknowledged. It is particularly disconcerting and shame-inducing for girls who begin menarche early, and have to navigate the whole mess and embarrassment of sanitary protection in primary school toilet provision often ill-equipped for this. There is embarrassment inherent in growing breasts, of these being noticed and pejoratively commented on and, worse, groped.

Crucially, it is important to acknowledge, that girls and young women have long recruited their bodies as ways of expressing misery and self-hatred. Bodies become the site onto which they can project their perceived failure to live up to society’s expectations of them and also their internal, psychic pain. Psychic pain that arises out of the manifold implications of being a suffering human being: trauma, abuse, neglect, bullying, social ostracism, bereavement to name but a few. Also, for some, the fear of leaving childhood behind, the terror of female adulthood, is overwhelming.

It is not unreasonable to hypothesise that developing gender dysphoria, and alighting on a trans identity as the way of understanding, can, in some instances, be the solution (cure) to the ‘problem’ of being born female. It could be 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.

We cannot ignore the role of the internet in this; whether cyber bullying, competitive instagram, exposure to pornography, sexualisation or the associated phenomenon of a sort of social and collective influencing. We know that there is a parallel world of on-line engagement where children and young people are engaging globally out of sight of any mediating influence or alternative explanation for their distress.

Whatever influencing factors, both exogenous / social and endogenous / psychological, there might be these are all happening within the wider context of the decimation of local child and adolescent mental health services (CAMHS) over the last decade. We are seeing a generation of young people emerge who have been poorly served by local specialist provision: a phenomenon recognised and documented here.

In the clinical setting we have become familiar with narratives, especially in younger children, resting almost entirely on the most superficial of signifiers: toys, activities, hair, clothes, a certain aesthetic upon which effectively the (self) diagnosis of trans is made, and a social role transition affected. Unfortunately these tropes are compounded and perpetuated by some “diversity” trainings delivered in schools.

We have also witnessed a coincidence of autistic spectrum conditions and gendered/ sexed distress. The lens of gender can seem very apt for these girls retrospectively to understand their difficulties: always feeling weird, not fitting in, struggling to understand social interactions and cues, bullied often, feeling themselves to be outside the norm. Additionally girls struggle physically with puberty; as a change from the familiar, often unpredictable, body sprouting and changing, unwanted thoughts and feelings.

The distress of their body seems to accrue over time for these young females; it was not primary. Socially transitioning might even have an iatrogenic effect on gender dysphoria as the body becomes a shameful secret that needs to be disavowed – we see embodied disconnection and alienation snowball. We are now hearing first hand from detransitioners that, had they not found this relatively novel way of understanding their difficulties (inevitably with the assistance of the internet) through the explanation of ‘trans’, the natural history would suggest they would find themselves living as lesbians. Furthermore, how they looked, lived and loved needed no apology.

In summary, in the clinic we witness this toxic collision of factors: a world telling these children they are ‘wrong’; they are not doing girlhood (or boyhood) correctly. They realise their nascent sexual desire is going to be problematic; they struggle in puberty because it is uncomfortable, weird and unpredictable (particularly heightened if they happen to be on the autistic spectrum).

In all of our good-willed attempts to be empathetic, to share the pain of these very young people, we adults must not lose sight of the risk of joining too closely with them. Their pain is real, their way of making sense of it may be helpful, but it may not. Adults and professionals have a duty to step back from the feelings, whether their own or the young people’s, in order to consider what is fundamentally in young people’s interests. Listening can occur at many levels. We can hear and respond to distress without agreeing with the other person’s explanation of why they are experiencing it.

The significant treatment decisions being made are adult decisions. It is simply not possible for a child or adolescent to conceptualise a loss of fertility or sexual pleasure before they have developed their adult body.

We are dealing with strongly held beliefs and associated feelings. On the one hand is a novel belief that we are all born with an innate ‘gender identity’ but sometimes, tragically, for some trans people they are born into a sexed body that is misaligned from that gender identity.  From this perspective, the problem is a tragedy of birth, as with other genetic or physical difficulties. From this position it would seem and feel as though the only sane and morally congruent thing to do is to speed up access to medical treatments. After all, if this is a medical/physical problem then, of course, a medical/physical solution will be most apt. Why would you want to hold a person back from that? However, even if this were true, there would still be many questions about the long-term trade offs of pre and post puberty ‘gender affirmation’, and different regimens and operations. Ethics would still demand high quality research into the size of harms and benefits of major medical interventions on a healthy body for a psychological indication.

On the other hand is the belief that no one has a gender identity that is discrete and separate from the rest of their identity/personality. The body we are born into is, therefore, just that. People with gender dysphoria usually exist within a healthy body, regardless of how they feel about it. From this position, the gender identity, however conceptualised, must have been formed through the developmental processes that the young person has undergone. If we believe this, then the only sane and morally congruent way to alleviate the distress is to explore their past and ongoing developmental processes in order to help them make sense of, and influence, their distressing feelings. We would consider the use of therapy to help alleviate this distress as virtually mandatory, as this is what we usually apply to distress. From this position. it would be unethical to intervene at the level of the physical body at all, as this is not the problematic feature.

When we frame the conflict in this area as being related to differences in, albeit deeply held, adult beliefs then we can also allow room from which we can compassionately relate to those we disagree with. We can see that (most) actors in this story are trying to do the best for themselves, their children or their patients, even if we think that their approach is not the right one.

Currently there is no way to distinguish amongst these children and young people, other than subjective accounts emerging within a meta culture in which even suggesting that social contexts, let alone trauma and co-morbidity, can lead to gender dysphoria is seen as transphobic.

As a final thought, the continual collapse of ’trans and gender non conforming children’ into one seamless category is highly problematic and moreover is, most likely, in part responsible for the self-perpetuating inflation of the identification of so-called’ trans kids’. Gender non conforming children are just that – not conforming with rigid social norms. In the past they might, indeed, have been labelled “tomboys” or “cissy boys” but they were not taken to professionals for “affirmation” of being wrongly “assigned” a sex at birth. Perhaps if they were left alone, and actively supported to be non conforming, this would inevitably dismantle some of the basis upon which ’trans’ is superimposed onto the presentation.

We have wondered whether the early attempts to intervene in respect of gender dysphoric children have been problematic in themselves. For example, an attempt to encourage children to play with ‘gender appropriate’ toys (or more accurately ‘sex-appropriate’: prescribed ways females and males are expected to behave) and peers, and engage in similar behaviours and activities. These might have left children feeling alienated from themselves and internalising shame / disapproval. Inadvertently, the message was exactly a ‘trans’ message – you’re not really a boy if you enjoy the things girls seemingly (and are expected to) enjoy, and vice versa.

Sadly, the present criteria in the DSM (The Diagnostic and Statistical Manual of Mental Disorders) can only exacerbate the problem:

A1: A strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one’s assigned gender).

A2: In boys…a strong preference for cross-dressing or simulating female attire; or in girls…a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical female clothing.

A3: A strong preference for cross-gender roles in make-believe play or fantasy play.

A4: A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.

A5: A strong preference for playmates of the other gender.

A6: In boys…a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls…a strong rejection of typically feminine toys, games, and activities.

A7: A strong dislike of one’s sexual anatomy.

A8: A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

A hypothesis is that if A2 to A6 (inclusive) is where these children start, they could look to A1 as a solution to these, and then A7 and A8 follow inevitably.

If these early presenters – and more importantly their parents, caregivers and educators – had been vigorously instructed in some basic gender / sex deconstruction, it’s worth wondering whether “trans” as a solution to childhood GD would have gained such traction over the years. Have we seen an historic iatrogenesis?

17th February 2020


[1]: It is worth noting that we are distinguishing between sex and gender, and the distress therein. ‘Gender’ means the socially imposed expectations demanded of a girl by dint of her ‘sex’, meaning being born female. These two discrete yet over-determinedly related categories of experience interact much as the factors stated above.


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