Transgender issues: ‘Referrals have gone through the roof’

Despite an eight-month waiting list, a four-stage care pathway assessment and an assortment of clinical tests, the number of young people over the age of 14 who want to change gender has increased significantly since 1989 

Despite an eight-month waiting list, a four-stage care pathway assessment and an assortment of clinical tests, the number of young people over the age of 14 who want to change gender has increased significantly since 1989 

Leeds Gender Identity Clinic General Infirmary team members (L to R) Sabah Alvi, Talat Mushtach, ​​​​​​Jenny Walker, Paul Carruthers, Stacey Dover and Hima Bindu
Picture: John Houlihan

The NHS gender identity development service was established in London in 1989. Back then there were only one or two referrals a year. In 2009 it became a nationally funded service with bases in Leeds and the Tavistock centre in London. Referrals have risen by 50% every year with 1,800 referrals last year.


increase in referrals year on year since 1989

Leeds covers the north west of England and Scottish borders and there are satellite clinics in Brighton, Cardiff and Exeter. To cope with demand, the number of staff has doubled. A multidisciplinary team now consists of clinical nurse specialists and consultant paediatric endocrinologists, psychologists, psychiatrists, family therapists, social workers, psychotherapists, researchers and senior trainees.

‘It appears that gender dysphoria is cemented in puberty’

‘Referrals have gone through the roof,’ says children’s endocrine and gender identity nurse specialist Paul Carruthers of Leeds Children’s Hospital.

‘Three quarters of our referrals are aged 14 and over. It appears that gender dysphoria is cemented in puberty.’

Just why the number of referrals has increased so rapidly is not clear, but media coverage and online information have increased awareness.

Leeds Gender Identity Clinic team meeting with Jenny Walker (right) and Stacey Dover
Picture: John Houlihan

There is an eight-month waiting list, it is a rapidly-changing field, and there are four stages in the care pathway.

Stage one

Initially there is a detailed assessment by one or two mental health professionals. Three to six in depth assessments are undertaken covering developmental stages, social and medical history, and the DSM-5 diagnostic (diagnostic and statistical manual of mental disorders) criteria. If the young person is diagnosed as gender dysphoric they will be referred to the endocrine team.

Stage two

The family visits the endocrinology team for an educational session covering treatment, fertility preservation, smoking cessation, bone health, vitamin D supplements, and transition to adult services at 18.

‘What 14-15 year old thinks about having children and having to think about having to freeze their eggs or their sperm? Not many, but this patient group unfortunately do have to think about it.


Number of referrals in the past year

‘Some are so desperate for hormones and say they “just want my hormones’’ or want their hormones blocked. They might say they don’t want children or they will adopt. So we make it clear the difficulties they are likely to face because, depending on how far they go with treatment, they may possibly be rendered infertile.

‘Usually the parents are in tears because they know the reality more than the young people,’ says Mr Carruthers. The team will then encourage the family to see their GP to find out what fertility treatment policy exists in their area.  

Health promotion is important: cross-sex hormones cannot be prescribed to anyone who is a smoker, vitamin D supplementation is covered to encourage healthy bones and to raise awareness of osteoporosis. Bone scans and blood tests are undertaken.

‘Usually the parents are in tears because they know the reality more than the young people’

Examinations are embarrassing as many will not like looking at themselves. At this stage, however, if the young person changes their mind treatment with hormone blockers (GnRH analogues) is reversible.

Stage three

There is ongoing mental health assessment and if the young person is not engaging with the process they will be discharged. Equally, if they are found to be accessing treatments bought from the internet they will be discharged as the clinic will not take medical responsibility for them.


Three quarters of referrals are for children aged 14 and over

After taking blockers for about 12 months, at about the age of 16, they can access cross-sex hormones – testosterone and oestrogen. Treatment begins with small doses which are increased every six months. This is partially reversible depending on the amount of hormones they have received. Around 60% of young people will decide not to proceed to physical treatment. 

Stage four

Surgery is only undertaken in adult centres and the young person can choose which of the seven centres in the UK they wish to have treatment at. Waiting lists vary from six months to two years. Speech therapy to help with their voices can also be arranged.


Most young people have low mood and lack of concentration. Some will have anxiety, have self-harmed and have suicidal ideation. Many will have relationship problems and there might be safeguarding issues as the young people are vulnerable to online sexual exploitation.

Mr Carruthers says: ‘These young people are the bravest I have come across. They have feelings of confusion and shame, a lot of bullying goes on, from family members as well as peers, so some of them will start to be ostracised.

‘These young people are the bravest I have come across’

‘Quite a large proportion of them are on the autism spectrum. I don’t know why and there is ongoing research.’

Mr Carruthers and Jenny Walker, his fellow gender identity nurse specialist in Leeds, advise that the terminology used is important and do not assume if someone looks male or female that they are.

Terminology for the transgender community

  • He or she, they or their
  • Natal/assigned at birth. Natal often used by professionals in the acute sector, but the individual may prefer I was assigned male/female at birth
  • Trans male or female
  • Cisgendered – I was assigned at birth, I am not transgender.
  • Gender queer – for example, Conchita Wurst who won Eurovision in 2014.
  • Gender fluid – have not made their mind up or remaining gender fluid.
  • Agender – neither male nor female.

‘The questions they ask can make you feel childish’

At fourteen and a half, Alex revealed to his mother that he wanted to be a boy.

Already a patient with child and adolescent mental health services for a needle phobia, he was referred to the clinic.

Before Alex could begin treatment to become a male he had two years’ worth of consultations.

Alex Bolt with gender identity nurse specialist Paul Carruthers 
Picture: John Houlihan. Picture shown with consent

‘Did their best’

‘They talked to me about a lot of things, like how long I had felt like this and what exactly was it that I felt. They wanted to work out whether it was gender identity disorder or something else.

‘They did their best. They are experienced at what they are required to do, but it can make you feel childish and kind of stupid. Not the people, but the questions,’ says Alex.

The clinic and Alex’s school liaised on how best to support him. The school, did change Alex’s names and pronouns of certificates, but there we still some issues.   

‘In my year, the males didn’t want me to use male toilets. The school came up with the idea of using an authorised personnel only toilet, but I had to ask reception every time I used the toilet, which was embarrassing,’ he says.

Hormone therapy

In March 2016, Alex started blockers and then in March 2017 he started hormone therapy.

Now, at 17, Alex is looking at adult services. He is thinking about having voice coaching lessons and a double mastectomy. 

When Alex revealed to his mother, Adele Bolt, that he wanted to live as a boy she says she was not surprised because she works in a sixth form college and ‘deals with all sorts of issues’.

‘Alex definitely sowed the seeds by asking questions such as: “What do you think about gay people and what do you think about transvestites?”

‘Everyone I’ve told say that I must tell Alex that he is loved and supported,’ she says.



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