Health & Wellbeing

Health and wellbeing for trans children and young people - Introduction

Learning Outcomes

By the end of this module, you should be able to:

  1. Discuss key physical and mental health issues for transgender young people
  2. Identify pathways for navigating sections of the health care system in Ireland relevant to transgender young people
  3. Identify sources of further support and information on health issues

Part 1. Mental health and wellbeing for transgender young people

Sources: 1Higgins et al. (2015); 2Strang et al. (2014)

Taking care of your mental health and wellbeing

It is important for all people to look after their mental health and wellbeing. Here is a list of things that may help support trans people’s wellbeing and ways a person can practice self-care:

  • Acknowledge positive qualities in yourself and positive aspects of your life.
  • Take the time to enjoy and practice your hobbies.
  • Engage in exercise and physical activity.
  • Stay connected with supportive family and friends.
  • Develop a strong support system and take a step back from people who are unsupportive.
  • Connect in with a transgender young person’s support group.
  • Maintain communications within the family.
  • Talk about your feelings.
  • Get enough sleep.
  • Eat well.
  • Drink less alcohol or avoid alcohol altogether.
  • Don’t be afraid to ask for help if you need it.

Developed from the Transgender Equality Network Ireland (TENI)’s ‘Heads up: Trans guide to mental health & wellbeing’ and with input from mental health care experts.

Part 1. Tips for taking care of your mental health and wellbeing

In this part, take some time to read some tips from trans young people about how they look after their mental health and wellbeing.

Surround yourself with people that accept you and your decisions to transition. It helps more than you could imagine.
Trans young person
What I did for my mental health was: 1. I stayed around positive, accepted and open-minded people, 2. I worked to keep my mind busy if I got stressed, 3. I workout a lot to get rid of my stress, e.g. running, weights and cycling, 4. [Listening] to music helps, 5. Also went to speak to a counsellor when things got a little tough but it wasn't always about trans.
Trans young person
When it feels like the entire world is against you, it probably is, but there are always people who care about you. No matter how bad things are or how dysphoric you feel, tomorrow will come and tomorrow will be different.
Trans young person
Find other trans people. Having friends who understand what being trans in Ireland is like is a godsend. If you can find people who understand and support you you'll feel so much better.
Trans young person
You've got to know things take time. In the end, someday, I will be the person I've always wanted to be…someday this constant anxiety I've had for as long as I can remember will fade away. That's what I tell myself to get through tough days.
Trans young person
Being trans is a gift. You get to understand and experience both binary genders…trans people are being themselves when they come out which is what most people cannot do. Remember you’re unique and there's no one else like you or ever will be like you on earth. You’re the driver of your own life. Don't let anyone take your seat.
Trans young person

Part 2. Physical health and wellbeing for transgender young people

Sources: 1. McNeil et al. (2013)

Healthcare pathways are currently under development, with further development of service pathways being discussed, with the hope of developing a national specialist centre. You should consult Transgender Equality Network Ireland (TENI) for the most-up-to-date information at www.teni.ie or 01 873 3575.

Health pathway for pre-pubescent children

It is important to understand that before a child reaches a certain development stage, there are no medical or surgical interventions available. Only a social transition is available, which should take into account the child, family, school, GP and Child and Adolescent Mental Health Services (CAMHS). For more information on social transitioning, please consider reviewing the ‘Social transitioning’ module.

In terms of supporting the health of a gender variant/non-conforming children, you may:

  1. Consider bringing your child to an art therapist. Art therapy can help your child with: “developing self-awareness and personal insight; improving sense of self and self-identity; encouraging self-expression; improving confidence and self-esteem; resolving inner conflicts; assisting with gaining a sense of control over difficult emotions and life situations; aiding emotional regulation improving and maintain healthy psychosocial functioning; promoting resiliency and improve coping skills; and supporting neuropsychological growth” (Irish Association of Creative Art Therapists (IACAT), www.iacat.ie, 2016). To find an art therapist in your area, contact the Irish Association of Creative Art Therapists (IACAT): www.iacat.ie

If your child/family member is experiencing significant distress, consider linking in with your GP, who may provide you with a referral to the Child and Adolescent Mental Health Services (CAMHS).

Health pathway for adolescents

  • Go to your family’s GP for a consultation.
  • Have yourself and your child explain the situation.
  • Request a referral to Child and Adolescent Mental Health Services (CAMHS) from the GP.
  • Within CAMHS, a psychiatrist or clinical psychologist may give a diagnosis of Gender Dysphoria or Gender Identity Disorder. It is important to know that the diagnostic status for Gender Dysphoria and Gender Identity Disorder may change or be removed completely in the upcoming International Classification of Diseases 11th Revision (ICD-11) due out in 2018. Early signs indicate that the diagnosis will be renamed and moved into the sexual health section of the ICD-11, so as not to be seen as a mental health condition.
  • CAMHS may refer you to the Treatment Abroad Scheme (TAS) or Tavistock and Portman NHS Foundation Trust Gender Identity Development Services (GIDS). This may be for advice on supporting young person, advice on whether to socially transition, for assessment for hormone therapy, or for support in a number of other areas. You can learn more about hormone therapy and how to access it on the following page of this website.
  • Not all gender variant / non-conforming children and young people go on to consider surgical interventions. Surgical interventions are not available for young people aged 16 and under (at a minimum) and these would not be a consideration until hormones had been accessed (point 5).

To learn more about hormones, please click here. To skip the section on hormones and to move to the next part of this module, please click here

Hormones 101

On this page, we have listed a number of key things you may want to know about hormones as relates to transgender young people, including how to access hormone therapy.

What are hormones and what do they do?

Hormones are substances naturally produced by the body. They include sex hormones. The male sex hormone, known as ‘testosterone’, is produced by the testes and the female sex hormone, known as ‘oestrogen’, is produced by the ovaries. Both females assigned at birth and males assigned at birth naturally produce some amounts of both testosterone and oestrogen.

“Along with genetic factors, sex hormones affect the development of the reproductive system, the brain and physical characteristics such as height and build, the way fat is distributed in your body and your muscle bulk.”1

In general, before birth, these sex hormones are associated with the development of sex organs (penis and testicles in males; clitoris, labia, ovaries, uterus, and vagina in females).

At puberty, these hormones affect the development of ‘secondary’ sex characteristics. In males assigned at birth, this includes: both facial, body, and pubic hair; the development of an Adam’s apple; voice deepening; a growth in the penis and testicles; erections; and increased height and muscle. In females assigned at birth this includes: the development of breasts; the onset of periods; the growth of underarm hair and pubic hair; and a more rounded body shape.

Why would transgender young people seek hormone therapy?

Transgender young people may seek hormone therapy to address discomfort they feel in relation to their physical body. An Endocrinologist is a health care professional who works with hormonal issues.

“The aim of hormone therapy is to make you feel more at ease with yourself, both physically and psychologically.1

‘Hormone blockers’, or GnRH Analogues (GnRHA), may be used in the early stages of development to ‘block’ the onset of a young person’s puberty. Hormone blockers may be helpful to trans young people: “1. their use gives adolescents more time to explore their gender variance/nonconformity and other developmental issues and 2. to facilitate transition by preventing the development of sex characteristics that are difficult or impossible to reverse if adolescents continue on to pursue sex reassignment2”. They are not prescribed until after first stages of puberty (known as ‘Tanner stage 2’).

‘Cross-sex hormones’ are hormones which are prescribed to masculinise or feminise the body and affect the sex characteristics described in the section above.

Are there any risks to hormone therapy?

Hormone blockers:

  • There may be risks to a young person in not being able to access hormone blockers or from the development of irreversible secondary sex characteristics. There are concerns about its long-term physical impact; however, early research results are encouraging2-3.
  • Completely reversible.
  • Use guided by the World Professional Association for Transgender Health (WPATH)’s ‘Standards of Care.’2

Cross sex hormones

  • There are some health risks associated with cross-sex hormones.2 These should be explored fully with your family member’s health care provider.
  • Semi-reversible
  • Use guided by the World Professional Association for Transgender Health (WPATH)’s ‘Standards of Care.’2

How do we access hormone therapy in the Republic of Ireland? 4

If your child (under 16 years) is referred to Treatment Abroad Scheme (TAS) or Tavistock and Portman NHS Foundation Trust Gender Identity Development Services (GIDS) by CAMHS:

  • Tavistock does the assessments for hormone therapy (3-6 assessments) and then forward on its recommendations to the Paediatric Endocrinologist to prescribe hormone blockers. Paediatric Endocrinologist is a health care professional who deals with hormonal issues for young people and children.
  • Currently, this required assessment service is not available in the Republic of Ireland. Tavistock comes over to Dublin every few months to deliver the service and conduct these assessments.
  • Tavistock will keep seeing the child; however, they prefer the child remain under the care of CAMHS.

The process for accessing cross-sex hormones ages 16+ years of age:

  • TENI suggests that your child/family member collect as much information as possible about their diagnosis and situation from CAMHS, or the community mental health or primary care provider they are seeing before attempting to access hormones.
  • Cross-sex hormones can be accessed from Professor Donal O’Shea, Endocrinologist in Loughlinstown, Dublin or Dr. Marcia Bell, Endocrinology, in the Galway Clinic.
  • Cross-sex hormones should be accessed in conjunction with a mental health support worker, e.g. a private counsellor, psychotherapist or therapist.

Sources: 1Gender Identity Research and Education Society (GIRES)(2007); 2Coleman et al. (2011); 3Cohen-Kettenis et al. (2011); 4Subject Matters Experts (SMEs) in Transgender Equality Network Ireland (TENI). Full references included at the end of the module

Part 2. Personal stories

In this part, take some time to read stories from other families and trans young people about their experiences in accessing healthcare and support.

Well [names clinic] has been a help in getting me to sign to agree to him to start the transition, but you are sort of left to do a lot yourself. I got onto [TENI] who talked to me on the phone and was a great help.
Mother of a 16-year old trans young person
As my child was already attending [names hospital], I approached the psychologist we had attended in there. She then approached our consultant on our behalf, who has written a referral to the Tavistock. Because there is no centralised system to deal with transgender children, we did feel a bit at sea. Our endocrinologist had only dealt with a couple of children, but once we contacted TENI you feel connected to all these other families country wide.
Mother of an 11-year old trans child
We were fortunate to get into the healthcare system quickly maybe because my son got a private diagnosis and everything fell into place easily.
Mother of a 20-year old trans young person
Oh God, we having been waiting to see [names consultant] a long time. We have been on a waiting list to see [names doctor] since [names dates], and have never received a letter or phone call…The healthcare system in Ireland is a joke regarding trans people.
Mother of a 20-year old trans young person
I was waiting 4 years for a letter from the GIC (Gender Identity Clinic) and it turns out they sent it to the wrong address in the wrong country. Doctors are not educated. I personally think the health care system in Ireland is crap anyways rather you’re trans or cis.
Trans young person
I didn’t deal a lot with the healthcare system as my wife was much better at this than I was. Anyone I dealt with in [names location] were very good, but overall I think there is lack of knowledge by GP's.
Father of a 24-year old trans young person
The delay in obtaining appointments is scandalous...
Mother of an 18 year-old trans young person
I've never really came across any bad experience with the healthcare system. I think the only bad thing is when money low it’s hard to save up money to pay for [names procedure] and that is a lot of money, so it's a very slow and long waiting system in Ireland to get [names procedure] done.
Trans young person
Our GP openly said he had no knowledge and didn't quite know what to do. I referred us onto a paediatric endocrinologist in [names location] after we had obtained a private assessment from a psychologist. The clinician in [names hospital] first mislaid the referral so our GP had to do another, and on receiving the second referral wrote back and said that she would not be comfortable treating my son as she didn't have enough knowledge. We did get seen by the adult service in [names location] eventually.
Mother of a 20-year old trans young person
It was a leap of faith to travel to another country and trust the surgeon with my son. Thankfully, it was a success. It was cheaper to travel to [names country] and there was no long waiting list to deal with. That was not the case in Ireland.
Mother of a 20-year old trans young person
The psychiatrist I see at one of the main mental health services in Dublin told my mother that he thought that mental health issues were causing me to think that I'm genderfluid, but that I wasn't really. My mother wasn't the most supportive before that, but she made an effort. After my psychiatrist said that to her she stopped making any effort to understand or support me, and started referring to me as "gender confused" instead of genderfluid. My parents told me that because he's a medical professional he knew better than me. My mental health has suffered because of a "mental health professional" telling my parents that my identity as a trans person isn't valid.
Trans young person
[Names clinic] is a joke in my opinion. The waiting list is too long and even the head doctors don't understand everything I say to them. I've had to educate more professionals about being trans than I would have liked to.
Trans young person

Activity

If appropriate for your family member’s age, ask your family member if you can speak to them for a few minutes about their healthcare needs. Ask whether they have any concerns about their health and wellbeing. If so, discuss what they may be.

Brainstorm a strategy with your family member. Review some of the guidelines presented in this module and discuss which might work for your family and specific healthcare situation. Write a plan of action for how you want to move forward.

Key messages summary

It is important for everyone to pay attention to their mental health and wellbeing, especially those who may be more at risk.

There is currently no set pathway for navigating the healthcare system in Ireland. Having a plan and learning information about what to expect can make your experience easier.

Further resources related to this module

Brill, S. and Pepper, R. (2008). Chapter 8: Medical issues for transgender children in ‘The transgender child: A handbook for families and professional’ by Brill, S. and Pepper, R. [Book available to buy from Amazon.co.uk or other booksellers]

PDF - health pathway for prepubescent children.

PDF - health pathway for adolescents.

PDF - Hormones 101.

Other resources:

https://tavistockandportman.nhs.uk.

http://www.hse.ie.

Sources used in developing this module:

Cohen-Kettenis, P., Schagen, S.E.E., Steensma, T.D., de Vries, A.L.C., and Delemarre-van de Wassl, H.A. (2011) Puberty suppression in Gender-Dysphoric adolescents: A 22-year follow-up. Archives of Sexual Behaviour, 40 (4), 843-847.

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R., Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., Lev, A. I., Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B., Schechter, L. S., Tangpricha, V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S., Wylie, K. R. & Zucker, K. (2011) Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism, 13(4), 165-232.

Gender Identity Research and Education Society (GIRES). (2007) A guide to hormone therapy for trans people: Trans wellbeing and health care. London, UK: DH Publications Orderline.

Higgins, A., Downes, C., Murphy, R., Sharek, D, de Vries, J., Begley, T., McCann, E., Sheerin, F., and Smyth, S. (2016) The LGBTIreland Report: The National Study of the Mental Health and Wellbeing of Lesbian, Gay, Bisexual, Transgender and Intersex People in Ireland (pp. 1-308). Dublin: Gay and Lesbian Equality Network and BeLonG To Youth Services.

McNeil, J., Bailey, L., Ellis, S., and Regan, M. (2013) ‘Speaking from the Margins’. Dublin, Ireland: Transgender Equality Network Ireland (TENI).

Strang, J.F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L.E., Berl, M., Walsh, K., Menvielle, E., Slesaranskey-Poe, G., Kim, K.E., Luong-Tran, C., Meagher, H., and Wallace, G.L. (2014) Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behaviour, 43(8), 1525-1533.

Subject Matters Experts (SMEs) in Transgender Equality Network Ireland (TENI).

Transgender Equality Network Ireland (TENI). (2016). Heads Up: Trans guide to mental health and wellbeing. Dublin, Ireland: Transgender Equality Network Ireland.