Who is best placed to make decisions for a child? Is it right to force a child to conform to the expectations associated with having a penis or a vagina? Or, as some people see it, is gender defined by genitals? What if that child is severely distressed? Should you allow your child to transition to their preferred gender and risk physical violence and death threats? Or should the child keep their true identity secret, and risk suicide?

These are the choices facing the parents of transgender children in Ireland today. They have two options: Do you try to align the mind of a transgender person with their body? Or do you adjust their mind to make them more comfortable with their body?

Increasingly, the overwhelming weight of international research and best practice is pushing parents towards a reluctant conclusion: the minds of transgender people cannot be aligned with their body. They can live full and well lives only when they are accepted and recognised in their true gender, whether or not they transition medically through hormones and/or surgery.

“Seeing a therapist has helped me to gain insights, but this is not a mental health issue as it is sometimes perceived. It is, for me at least, a physical issue. There’s nothing wrong with my brain, but my body has developed in the wrong way,” says Richie, a 15-year-old transgender boy.

The families of transgender kids often find themselves at the centre of a wider discussion of gender politics, but there’s a world of difference between, on the one hand, a boy who likes dresses and dolls or a girl who loves football and “male” clothes and, on the other, a child who persistently identifies as the opposite sex over more than six months, is distressed when identified as their natal sex and is showing signs of depression, anxiety or destructive behaviour. Now, with the Oireachtas debating the Gender Recognition Bill – which will make Ireland the last country in Europe to legally recognise transgender people and includes provisions around children – the fate of these families rests in political hands.

Dr Lisa Brinkmann is a clinical psychologist who specialises in sex and gender issues. For more than a year, she has been working with the family of a four-year-old child who was born female but identifies as male. “There is no need for an early diagnosis [of gender dysphoria],” she says. “What families need is support around any needs or difficulties that the child is having.”

There’s less stigma about a girl who displays stereotypically masculine behaviours, says Brinkmann. “Girls can be Pat, Charlie or Steve and are cheered on as ‘tomboys’. It’s much harder for a boy to reverse gender roles.”

Transgender children are often forbidden from using the toilet of their preferred gender. They hold it in, especially at school, and consequently are vulnerable to kidney and urinary tract infections. Transgender children have as much interest in sport as anyone else, but they often can’t take part in PE because their school won’t treat them as either male or female when it comes to team games, and because they’re not facilitated with a place they can safely and comfortably change their clothes; these factors can lead to weight gain.

Dr Colm Costigan, a paediatric endocrinologist at Our Lady’s Children’s Hospital in Crumlin, Dublin, has been involved in the care of six transgender adolescents over the past three years. After a diagnosis, which can usually be given only with the support of parents, Crumlin can provide hormonal blockers (called gonadotropin- releasing hormone analogues or GnRHa), which delay the onset of puberty.

Best practice seeks to get the young person safely, and in good mental health, over the age of 16; then, they can consider taking hormones to bring them in line with their preferred gender. After 18, surgery is an option, but not everyone takes it.

Prof Donal O’Shea, one of the country’s foremost endocrinologists, treats transgender people at St Columcille’s Hospital in Loughlinstown, Dublin. He says puberty blockers have potential side effects, including the emotional and psychological fallouts from hormones. But, he adds, these are minor compared with the mental damage that can be done by forcing a young person to live in and be recognised as the wrong gender. “Hormone blockers are safe and they are reversible. In other parts of Europe, the debate has moved on to what is the optimum time to start the blockers . . . Ideally, these kids would not go through full puberty.”

O’Shea is a love-hate figure in the transgender community. He has long advocated for increased resources for transgender people, but has a scientist’s caution. He says that regret, if it happens, can be physically and emotionally catastrophic, and this is why there must be a stringent diagnosis of gender dysphoria before anyone can medically transition, as required by the terms of the proposed Gender Recognition Bill. “You have to look after the minority within the minority: it doesn’t always make me popular but that is a medical view.”

Ongoing debate

There’s an ongoing debate about when is best to intervene with blockers. Until recently, the UK’s Tavistock Centre, a pioneering centre of excellence for the support of transgender people, wouldn’t provide them below the age of 12; evidence-based studies have changed that policy. “The usual recommendation is to give blockers once established puberty has begun, from about the age of 14-16, depending on stage,” says Costigan. “There is a concern that, before this, a diagnosis of gender dysphoria is not secure.”

Sarah, the mother of a seven-year-old male-assigned child who identifies and lives as female, says that these children have been let down. “The [Tavistock] decision that puberty blockers were being introduced according to the stage of a child’s puberty, rather than age, was hard fought and won in order to keep children alive – it is as stark as that.

“Can you think of any other condition where this would go on? Pre-pubescent children are offered cancer treatments when this same treatment can render them infertile. But we can see the advancement of cancer cells under a microscope. We can’t see gender dysphoria until we see [suicide] attempts, chronic self-harm, anorexia, depression, anxiety and dropping out of school.”

The majority of transgender adolescents in Ireland are not going to Crumlin. Instead, they are hiding and suppressing how they feel; they are socially transitioning or have already done so; or they have gone abroad for hormonal treatments that they can’t get here or in the UK.

About 1-2 per cent of transgender people will regret their transition; this may be because of social and psychological pressures or undiagnosed mental illnesses that can manifest as gender dysphoria. Pre-adolescent transgender children have only just begun to identify themselves, after centuries – if not millennia – of deep suppression and oppression. As yet, there is virtually no data about the number of these pre-adolescent children who ultimately transition.

Almost all adolescents who express a transgender identity, however, will follow through, and most of these are aware of their identity from their earliest memory.

By Peter McGuire