This is a guest post by the mother of an autistic adolescent girl who went through a teenage gender identity crisis, brought on by wider mental health issues. Many parents of teenage girls will recognise this scenario. We are very grateful to this mother for allowing us to publish her account, as a hopeful story with positive results that may inspire parents to keep on advocating for their child: some professionals will listen and take action.
Teenage gender identity crisis and a positive shift in mental health care and schools
I’ll keep the backstory short. It’s important but it’s not as important as how our gender-questioning teenage daughter realised that she was female, without any persuasion, and how two CAMHS services, one secondary school and one Local Authority realised that their own protocols were not fit for purpose. This isn’t a story of militant fighting. It’s a story of collaboration between a parent, a GP, a leader at a secondary school and two leadership teams in CAMHS. But above all else, it’s the story of one teenage girl in a mental health crisis.
Thankfully many adolescent girls “sail” through puberty (over the standard treacherous waters that most parents will know) with little more than teenage angst and a general feeling of their bodies not being up to scratch. This is itself is not an easy journey. Many adolescent girls are wracked with self-doubt over pretty much anything. Many are caught between wanting and loathing the stares of men, to validate that their bodies (and, to an extent, their personalities) are good enough, several not being able to articulate this through anything other than shouting angrily at family members about not being understood. Feminists will scream from the rooftops that this isn’t what self-worth is all about but social media counters that argument at every turn.
But what about girls who get so distressed about their bodies changing that it impacts their mental health? What about girls who turn to anorexia as the answer to take control over their changing bodies, or, more recently, girls who wonder if they are supposed be girls at all. Perhaps they are boys, born in the wrong body?
Our story began a year ago. Way before Hannah Barnes’ book Time to Think broke this issue back in to the mainstream news, and during the quiet that followed the Keira Bell judicial review case. Our 13-year-old autistic daughter told us that she was transgender and asked us for puberty blockers to help give her time to explore this. She cited the fact that she had always worn “boys’ clothes” and preferred “boys’ sports”, like playing football, as evidence. We always knew that dressing and feeling androgenous were very common amongst autistic girls and saw it as nothing more than supporting her to smash gender stereotypes, helped by so many amazing female role models such as the Lionesses in football.
As parents we discussed how we felt about her realising that it was deeper than this, that she could be transgender, and our conclusion was that it was similar in many ways to if she had told us she was lesbian. Not at all an issue. If she concluded that she was male, it would take us time to work through seeing our daughter physically change into a male, but we would support her and love her unconditionally. We told her we would look into puberty blockers to give her time to think.
What followed was lots of research and discussion as parents on our part, us saying no to puberty blockers (due to scientific concern about the impact on bone density and brain development), our daughter then starting her periods and blaming us for letting this happen, violent aggression (we called the police on three occasions as we had no idea what to do when she turned on us and one of her siblings), three overnight stays in hospital due to self-harm, social worker involvement and CAMHS crisis support. All with a backdrop that by now she had adopted a new “gender-neutral” sounding name within her school.
She was also being bullied daily by children, from multiple year groups, who enjoyed her (autistic) reactions of growling, hiding under tables or running away when they made a particular noise in her presence. Despite being very intelligent and desperate to learn, she stopped going to school except on rare occasions after October half term, trapped in her own head by the impact of her puberty-related distress and the bullying.
She began the road to recovery in hospital, meeting an amazing CAMHS counsellor who listened to her distress. He was curious about her preferred name and asked what her pronouns were. Many people ask her this when they hear the name that she asks them to call her. “I don’t know” came the response, just as it had on every other occasion previously. And there were many, many occasions that she was asked this question. The unconscious bias that somehow the pronouns associated with her biological sex needed calling in to question didn’t seem right somehow.
Why would a child who is suffering from gender-related distress and confusion be asked to make a binary decision about whether female pronouns should apply to her or not? She’s autistic and she thinks in absolutes. “I don’t know” was a perfectly valid answer to the question but every time it got asked, she felt more and more compelled to have an answer. After she finally said that she was “leaning towards male”, when asked by her GP in the days after the hospital visit, I suggested to her that perhaps it would be better to say “It’s something that I’m thinking about”. I advised her that it was OK not to have an answer until she had concluded her gender identity exploration.
As with the discussion with the CAMHS counsellor in hospital, the conversation a few days later with the GP centred around the distress that she was experiencing with her periods. In the weeks prior to these conversations, she had changed from saying that “a deep voice is all I want for Christmas” (a reference to wanting to be male) to “stopping my periods is all I want for Christmas”. A subtle yet important shift. Through discussion with the GP, she started the progesterone only pill, with the anticipated outcome that this would hopefully stop her periods. It wasn’t instant and she struggled with this.
More violent outbursts followed, alongside near-constant breakthrough bleeding and back-to-back periods for the next two months, coupled with demands that she needed stronger medicine. She never referred to puberty blockers, just stronger medicine. She’s now been taking this pill for over three months and things are settling down. She was given the option of taking the combined pill and leaving gaps for periods to happen every three months. She likes this idea and is still considering it as an alternative to the potential for random lighter periods on the progesterone only pill. This speaks volumes about her autistic distress and at her changing body and this trauma being alleviated by being given a modicum of control over what is happening to her.
Additionally, she was distressed about her breasts developing. Following a similar approach, by not changing the status quo of her biological sex but managing the immediate distress (and after seeking advice from another parent of an autistic girl who had similar distress) we bought sports bras. The sensory aspect of breast development, alongside the uncontrollable changing body, can be very distressing for autistic girls. She had previously been asking about chest-binders, having seen them talked about online. However, even she accepted that their safety needed calling in to question from what she had read.
When I looked myself, I found a huge subculture surrounding the use of chest-binders. One particularly concerning theme that came out was that the pain that they cause is a rite of passage and it will be relieved by the eventual gender-affirming “top surgery” (double mastectomy) which will free biological females from both the physical and emotional pain when they “get the body that matches their gender identity”.
Our daughter was very happy with her sports bras. She was also feeling very proud of herself that she was managing her periods effectively. She even started joking about how men wouldn’t cope with periods. We laughed along but reminded her that men had their strengths too (although her dad agreed that she was right, he wouldn’t cope).
Then came the referral letter from the hospital CAMHS team to the local support team. The letter changed her pronouns partway through (from she/her to they/them) but, more importantly, it stated in the observation section that she “identified as male”. There was nothing in the section which referred to her own views that indicated why this had been stated, nor any other explanation offered for this observation.
I wrote to the CAMHS hospital crisis counsellor and asked if he would reconsider this statement. I also asked where it had originated from, as I could not recall her identifying as male at any time during the appointment. The appointment had been lengthy and incredibly positive. It was clear that the counsellor was experienced and fantastic at his job. I even passed on a compliment via the hospital team about how great he was on the day. So why did his referral letter say something that was so clearly incorrect?
My letter went unanswered. I followed it up with a second letter, this time also writing to the senior leader who presided over this hospital crisis team and a number of others in the same NHS Trust. I still had no response. By now, our daughter’s initial assessment appointment with the local CAMHS team in our own county, to which they had referred her for ongoing care, was approaching. I started setting out a safeguarding approach to manage how the subject of gender identity could be safely explored without any unconscious bias and how the local CAMHS team could support us in securing the removal of the “identifies as male” statement.
By now, owing to lack of response from either team, I was stating in my correspondence that “identifies as male” was factually incorrect. Her CAMHS initial assessment appointment was approaching, she needed urgent access to mental health care (due to the continued impact of the bullying and being out of school) and I no longer had time to ask them to reconsider. I needed to be more direct. I also escalated everything to the CAMHS Head of Service in the county.
Alongside this, I had been working with our daughter’s GP to create a set of safeguarding needs and provisions, relating to gender identify exploration, that could be included in her Education and Health Care Plan (EHCP). Like many autistic children, our daughter has an EHCP which supports her needs in the education system. I didn’t want to stop her exploring her gender, but instead wanted guardrails so that she could explore it safely without the unconscious conflation of “gender identity” and her autism-related distress at puberty.
The GP had a special interest in both supporting transgender health and autism. He agreed that safeguarding was important for her, owing to her vulnerability as an autistic child, especially as the Cass Review is yet to conclude and provide guidance that will help health care providers and other institutions, such as schools, in supporting gender-questioning children.
I used an early draft of what would later form part of the GP’s EHCP submission to create a safeguarding request document that I shared with both the hospital crisis and local CAMHS teams. I also cited passages from the Interim Report of the Cass Review and asked them why they had undertaken an intervention on my daughter’s behalf. The Interim Report makes it very clear that “social transition [e.g. a change in pronouns] is not a neutral act” but was an “active intervention”. Not only had they socially transitioned her in their paperwork by changing her pronouns, they had also stated affirmatively that she “identified as male” without any good reason.
It was clear to me that the only possible pathway available to her from this point was a referral by the local CAMHS team, following the initial assessment appointment, to the Gender Identity Development Service (GIDS) clinic so that she could explore her gender identity under specialist care. Despite being closed, I understand that it is still accepting referrals and remains the only pathway for any child who is experiencing gender incongruence or gender dysphoria. All roads lead to GIDS as it is too complex a field to be managed any other way. This is why the Cass Review is so important: these children are in distress and need urgent care.
The local CAMHS service told me that they could not accept our safeguarding request because it was against their policy to do so, nor could they guarantee not discussing pronouns if our daughter told them her preferred name. They also told me that they could not disregard the “identifies as male” statement in the original referral. Although it was a difficult conversation, it was delivered with compassion and understanding. However, it was made clear to me that if we did not attend the appointment, we would need to wait several months until we were offered another. We would be back in the queue, effectively as if we had cancelled the initial assessment.
After much weighing up of risks and benefits, we decided that, in line with the findings of the Interim Report from the Cass Review, it was not safe for her to attend the appointment owing to the almost inevitable referral to the GIDS and “because [social transition or other similar affirming care] may have significant effects on the child or young person in terms of their psychological functioning.” We knew already that the GIDS model was gender-affirming (rather than exploring without bias) right from the point of entry.
In other words, despite her broken mental health, this appointment was likely to lead to it being worsened rather than alleviated. Turning away from the service that was there to protect our daughter at this great time of need was one of the hardest decisions we have ever had to make as parents. But we knew it felt right.
What happened next was a whirlwind of positive surprises which will we hope will have an impact not only on our daughter but on many other girls like her: autistic girls (who form a significant cohort of GIDS referrals) and any other girls who question their gender identity during a traumatic experience in puberty.
Firstly, the senior leadership from the CAMHS team which governed crisis teams in multiple hospitals contacted me. They wanted to meet to discuss my concerns. The meeting was incredible. The original counsellor was present, and he explained why “identified as male” was in the paperwork. He said that our daughter had never identified as male but instead it was an observation provided by the hospital nursing staff. Observations and inputs from hospital staff form part of the report.
At one point the senior leader suggested that a mistake had been made by including this subjective observation, which would be rectified. In response to this I stated that they had not made a mistake but instead, I understood that they had simply been following their protocol to gather information from multiple sources to support a child in distress.
We also discussed that our daughter was no longer actively questioning her gender identity and our experience of how this had unfolded. As they only dealt with the point of crisis, they had never had direct access to a follow-up story before. It was an incredibly positive discussion and they advised me that they would now review their protocols with a change to follow, using my communications and safeguarding statement as a start point while they wait for guidance from the Cass Review. This would impact all CAMHS hospital crisis teams that operate under their umbrella.
They have now retracted and replaced the original referral letter. In the replacement letter our daughter is described as female and it is stated that she answered “I don’t know” when asked her pronouns. Other important information, relating to the root cause of her distress, from the original CAMHS in-patient appointment was also included in the replacement referral that was sent to the local CAMHS team who would be supporting her next.
It didn’t stop there. The same senior clinician who had told me that we would be waiting months for a new appointment called me back. She wanted to see me. My communications had started a conversation in the CAMHS leadership and wider teams about their protocols and whether they were fit for purpose. She also wanted to work together to agree how they could support our daughter with her mental health needs. We booked two appointments on the same day (the clinician was driving in from several miles away), one for me to meet with her and another senior member of the CAMHS team, the second for them to both meet with our daughter and me for the initial assessment to start the mental health support process.
Although the door for discussion had been opened, I anticipated that this would not be an easy conversation because gender identity is such a polarising subject, particularly at present in politics and the media. On the contrary, the conversation tackled the difficult subject head on. There was absolute agreement that puberty distress in an autistic girl should not be conflated with gender identity confusion. Both need to be managed separately. And in the case of our daughter, there was currently little if any evidence that she wanted to continue her gender identity exploration.
Following the success of the first appointment, we continued on to the second: the initial assessment with our daughter present. I had not raised the subject of gender identity with our daughter for weeks, and she had not raised it either. So, when I gave her the CAMHS form to fill in with her personal details, I had no idea what she would select from the gender tick box options. My money would have been on “prefer not to say”, but she selected “female”.
I knew that the CAMHS clinician would ask her why she had chosen her (nick)name. In the first meeting we had agreed how this could be asked without any leading implication that it was related to gender identity. If our daughter said it was gender-related, her dad and I were comfortable with this because we will follow her lead and explore what is right for her. I had fully expected her to say that her real name sounded feminine and that she doesn’t feel particularly feminine. To be honest, if I had been given a name that sounded more feminine than I felt, I would probably come up with my own nickname too. Her answer: “I just like the name”.
Incredible progress is also being made at our daughter’s school regarding gender identity and how it is approached by school staff. Owing to the bullying, we are in the process of moving schools, with the support of both her current school and the Local Authority. But the ripple effect that I’ve seen in the mental health care system is just as strong at her current school. Inclusion-focused staff at her current school had already started looking at their own protocols and policies, which are common across many schools and are in line with training that had been delivered internally using guidance from external LGBT advocacy groups such as Stonewall.
They opened reflective conversations to take in all views about the best way to support children who wanted to change their pronouns and names in school without their parents being informed. They were observing that LGBT inclusion was particularly attractive to vulnerable “misfits”, that significant numbers of adolescent girls were talking about the fact that they may be trans. It was as if a social contagion had taken hold.
I have no doubt that my communications with the school have helped to springboard what they are now doing to change their approach. But the real credit goes to the school, under the guidance of one incredible staff member, for taking ownership to address this. Unbeknownst to me, this staff member had already raised the subject with the Local Authority so that by the time we were requesting gender identity safeguarding be added to our daughter’s EHCP documentation, through the GP’s submission, the answer was a resounding yes. It was such a relief to realise that I was no longer pushing treacle up hill and that our daughter was getting the support that she needed.
Equally, it was fantastic to hear that the Local Authority is using our case study to examine its protocols that support vulnerable children across the whole of the county in which we live. During the EHCP review meeting, they told me that number of EHCP referrals in our county has gone up by 50% since the pandemic. They also told me, that the pattern of autistic girls who were questioning their gender identity was there in plain sight. They have the power and the desire to change so many children’s lives for the better.
Our story shows that professionals in both health care and education are finding the courage to speak up and deliver the support that they know children like our daughter need. Our story shows what happens when the nuances that sit behind a child in distress can be explored without any unconditional bias. It’s certainly not been an easy journey, and I’ve needed to be assertive as well as collaborative, but I have the utmost respect for every health care and education professional that has been on this journey with us. Together, we are moving mountains.