Re-ordering gender: T e challenge of responding to trans and non-binary young people in CAMHS


Damian McCann It has been suggested many young


people and indeed children are identifying as transgender and/or non-binary and this appears to be posing particular challenges and dilemmas for practitioners within CAMHS settings encountering this relatively new clinical population. For instance, the dramatic increase of 100% in children and young people referred to the Tavistock gender identity clinic over recent years, is both a testament to the need, as well as highlighting the demands on practitioners within CAMHS as they struggle to defi ne their role in this increasingly complex and what is often seen as a specialist area of practice, requiring specifi c training to work with trans, non-binary and gender expansive youth. Increasingly, children and young


people are being referred to CAMHS with what is termed ‘gender identity confusion’, or, utilising CAMHS as a clearing-house since, in order to progress their gender reassignment, they require a referral to a specialist gender identity service. Embedded in these referrals is an unspoken concern from both referrer and parent(s) or carer(s) that a more considered assessment of the individual’s situation is undertaken. As a consequence, practitioners within CAMHS are charged with the responsibility for undertaking a comprehensive assessment, designed to inform the decision as to how best to proceed. In other instances, the question of gender identity arises during the course of treatment and this too can pose particular challenges when the adolescent, following disclosure of a trans-identity, worries about involving their parents and siblings for fear of rejection yet, at the same time, may also be requesting hormone treatment. This is perhaps understandable given that we live in a cisgenderist world, which has the potential to place these young people at risk from their families and from communities at large.


16 An instance of this concerned a sixteen-


year-old who was assigned female at birth, but was convinced of the need to proceed with gender reassignment. At the same time, she continued to identify as female, even to the point of using her female name. I came to understand that others within her immediate friendship-network, as well as her online acquaintances, were also exploring their gender identity. It therefore seemed she needed a space to think further about the specifi c issues concerning her own journey. Furthermore, she was keen to exclude her parents from this exploration, fearing she would be rejected. Working individually with her over a number of months allowed her to refl ect further on the nature of her gender dysphoria and, through this exploration, she felt more able to involve her parents in a general discussion of identity issues as well as advancing the desire to change her appearance, that is, clothes, hair style, etc., which she felt would align her outer presentation to her inner experience. Interestingly, having achieved her new appearance, this young woman decided that she had gone as far as she needed to go and did not proceed with a referral to a specialist gender identity service, whereas others within her friendship network did. Carroll (2010) suggests that minority


youth are often more aware of gender and sexual diversity, as well as the broad range of sexual and gender expressions, than was the case in previous generations. An increasing number of sexual and gender minority youth are happy to identify as gender non-binary and many are coming out as trans young people, with or without medical intervention. Although some may identify as transgender or transsexual, many now label themselves as gender- queer or non-binary, androgynous, third gender, a-gender, inter-gender, bi-gender, poly-gender, gender fl uid, etc. In many respects, although this can be


viewed as a positive development, for some practitioners it can feel as if they are entering an alien world where one’s level of knowledge and understanding is tested and where, like a number of these children and young people, they too are on a journey as they work to engage with the nature and meaning of non-binary identities. Furthermore, the potential confusion for young people themselves, therapists and indeed society at large, when coupling gender identity with sexuality, adds another layer of complexity. Simply put, trans and non-binary people have the same range of sexual orientations as other people but may choose to express these in individual and unique ways. For instance, terms such as straight, heterosexual, gay, and lesbian may not be as relevant to these young people in terms of sexual orientation and, indeed, a number will feel more comfortable embracing bisexual, pansexual, queer orientations or no orientation at all; something that may also be true for some cisgender people. In essence, non-binary signifi es the absence of connection with any sexual or gender label taken for granted within society (Carroll, 2010). Read more on this in Amanda Middleton and H Howitt’s article on trans sexualities in this issue. A further consideration, and one that


confounds the issue when attempting to draw conclusions about a child or young person’s gender identity, is that relating to autistic spectrum disorders. It has been suggested that between 8-10% of children and adolescents seen at gender clinics around the world meet the diagnostic criteria for autism, whilst a further 20% have what are regarded as autistic traits (see the meta-analysis by van der Miesen et al., 2016). This can pose particular challenges for these individuals as transitioning by its very nature involves change, fl exibility and self-advocacy,


Context 155, February 2018


Re-ordering gender: The challenge of responding to trans and non-binary young people in CAMHS


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