As charities call for NHS to lower age limit of 16 for hormones, parents are taking their children to private clinics for treatment
A doctor in Wales is prescribing cross-sex hormones to children as young as 12 who say they want to change sex, arguing that if they are confident of their gender identity they should not have to wait until 16 to get the treatment.
Helen Webberley, a GP in Wales, has set up a private gender clinic and recently started treating children, a “handful” of whom she has started on cross-sex hormones, including a 12-year-old.
“He had been on puberty blockers since the age of nine,” said Webberley. “He would have to now wait until 16 to get testosterone. This child has always been a boy, never worn a dress, always played with boys. He was so ready, his mates are starting puberty and he’s desperate to start puberty. I felt and the mother felt and the child felt it was the right time, so that child’s now on cross-sex hormones,” said Webberley, whose practice does not breach any current guidelines or laws.
Dr James Barrett, a consultant psychiatrist at the Charing Cross clinic, the oldest gender identity service in the UK, said he had concerns about treating children with cross-sex hormones.
“If you wait until puberty has got a little way along, a fair proportion of the children change the clinical presentation and feel more like straightforward lesbian and gay kids,” said Barrett. “They don’t seek social role change any more and will end up with no need for lifelong medical intervention, surgery and with no loss of natural fertility should they want children.”
He also expressed concern about the potential lack of clinical support for patients attending Webberley’s clinic, many of whom she interacts with electronically – via email, telephone and Skype – though she insists on face-to-face sessions for children.
According to NHS England guidance, cross-sex hormones can be prescribed from the age of 16, providing the patient has been on hormone-blocking medication for a year.
While NHS gender identity clinics are bound by the health service’s guidance, no guidance on this subject has been issued by the bodies that regulate private practitioners such as Webberley, including the National Institute for Health and Care Excellence (Nice), the Royal College of General Practitioners and the Royal College of Physicians.
NHS England is reviewing its guidance about the age at which hormones can be prescribed. Transgender support charities are calling for the age limit to be lowered, saying the current minimum age of 16 is arbitrary and suggesting clinicians should be able to make the decision of when to prescribe hormones on a case-by-case basis.
“Basing it on an age is completely inappropriate,” said Susie Green, head of Mermaids, a charity that works with trans children and their families. “We believe it should be in line with the young person’s maturity and their ability to understand what’s involved and the implications of what treating and not treating are.”
The calls for changes to the NHS protocol follow a dramatic increase in referrals to gender identity clinics across the country, particularly among children and adolescents.
In the past year, referrals of children and adolescents to the Tavistock and Portman clinic, which serves under-18s in England and Wales, and the Sandyford gender identity service (GIS) in Glasgow, which serves under-18s in Scotland, have doubled. Activists estimate there could be 130,000 trans people in the UK who want medical intervention such as hormones and surgery.
Some teenagers denied hormones buy them off the internet, which experts say is deeply concerning. “It’s really common, certainly with the older teens,” said Green. “A lot of them self-medicate because they just can’t wait and we know it’s pretty much endemic. It’s not illegal, but it’s not recommended.”
There are long waiting times for young trans people to get treatment at gender identity clinics. At the Sandyford GIS the waiting time for a first appointment is about 12 months.
While the Tavistock clinic has generally managed to keep waiting times below the 18 weeks recommended by the NHS from referral to treatment, increased demand has meant longer waits in recent months.
Green said Mermaids had recently had calls from parents who had been told their child would have to wait nine months for an appointment at Tavistock.
“I spoke to one family who will have to wait until November [for their daughter’s first appointment at the clinic],” said Green. “The mother was absolutely desperate because her daughter is 14, her daughter’s voice has started to break, facial changes and hair are around the corner, her Adam’s apple will become more pronounced. These are changes that will affect her for the rest of her life.”
NHS England’s evidence review examines concerns about the impact of hormones and hormone blockers on growth, bone density and cognitive development.
“The reality is we still don’t have the long-term outcome data,” said Polly Carmichael, the lead clinician at the Tavistock clinic. “What’s happening is our society is moving faster than the evidence base.”
Carmichael added that one hypothetical risk was starting hormone therapy in the early stages of puberty.
“It seems that there may be something about puberty that’s important in terms of identity formation and so there are questions about if you intervene in the early stages is the outcome going to be the same for that person as if you didn’t. But it’s incredibly hard for young people if there’s a feeling that there is a treatment on offer but they’re being denied it.”
Carmichael said she understood the “really strong polarised views” on the subject of lowering the age of hormone prescription.
“Do I think very strongly it should stay at 16? No. Do I think very strongly it should go down to 14? No. What I feel very strongly is what we want to be doing is what feels right for young people.”
Jay Stewart, the director and co-founder of the trans youth group Gendered Intelligence, said his organisation “wouldn’t be opposed” to lowering the age at which hormones were prescribed.
“The thing about hormones is they offer a powerful signifier to the world. For instance, you can identify as a man like I do, but if you don’t have those outward signifiers you’re going to find that the world’s not set up for you,” said Stewart.
However, he added that another step might be to lower the age at which surgery can be offered to trans teenagers. Current NHS guidance means gender reassignment surgery is not possible until someone is 18 and has been on cross-sex hormones for at least a year, or six months for chest reduction surgery among trans men.
“Some people will be looking to get access to surgery at 16, especially chest surgery. You’ve got people who have been binding [their breasts] since they were 11, so I think there might be health reasons to offer that,” he said.
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