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Assessment and support of children and adolescents with gender dysphoria
  1. Gary Butler1,2,3,
  2. Nastasja De Graaf3,
  3. Bernadette Wren3,
  4. Polly Carmichael3
    1. 1Department of Paediatric and Adolescent Endocrinology, University College London Hospital NHS Trust, London, UK
    2. 2UCL Great Ormond Street Institute of Child Health, London, UK
    3. 3National Gender Identity Development Service, Tavistock and Portman NHS Trust, London, UK
    1. Correspondence to Professor Gary Butler, Department of Paediatric and Adolescent Endocrinology, University College London Hospital NHS Trust, London NW1 2PQ, UK; gary.butler{at}

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    There has been a large increase in the number of children and adolescents who question conventional gender expectations and seek recognition and acceptance of their gender diversity, wishing to develop a body that is congruent with their gender feelings.1 Professionals may be unsure how best to provide supportive care, how to access the national Gender Identity Development Service (GIDS) for children and adolescents, or how to deal with a transgender young person presenting with another clinical problem unrelated to their gender transition. Faced with very distressed young people, they may feel under pressure to initiate physical intervention without consultation with psychosocial colleagues. It is important that all professionals are aware of the care pathway for transgender children that may be of relevance in a range of paediatric settings. The purpose of this practice review is to present an up-to-date perspective on the care of transgender children and adolescents to guide management and to enable the provision of a practical, evidence-based approach to their support.

    Frequency of gender questioning in children

    Gender atypical behaviour is common among young children and can be part of general development. It is difficult to determine the exact incidence and prevalence of more intense and long-standing gender dysphoria (GD) in the UK and elsewhere as the total number of children and young people referred to the GIDS has risen exponentially since 20112 (figure 1). A striking feature of this increase is the large proportion of birth-registered females from 2011 onwards. This increase and the change in sex ratio is also seen in other countries.1 The reasons are not fully explicable and a number of questions arise. Is this increase due mostly to the greater tolerance of gender-diverse expression in westernised society? Is male status still regarded as preferable? Are all referrals to a specialist service appropriate and do all these young …

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    • Contributors GB conceived the idea, analysed the biological data and wrote the paediatric medical sections. NDG analysed the demographic and psychological data and cowrote those sections with BW. PC has had significant input to the final document.

    • Competing interests None declared.

    • Provenance and peer review Commissioned; internally peer reviewed.

    • Collaborators Kirpal Adu-Gyamfi, Caroline Brain, Claire Goedhart, Sara Kleczewski, Elaine Perkins, Tiffani Rees, Alice Roberts and Russell Viner from University College London NHS Trust; Sabah Alvi, Bindu Avatpalle, Paul Carruthers, Talat Mushtaq and Jenny Walker from Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust; and Noina Abid from Belfast’s Royal Hospital for Sick Children and Guftar Shaikh from Royal Hospital for Sick Children, Glasgow for also contributing karyotype results.