In 1989, when the Gender Identity Development Service (Gids) at London’s Tavistock Clinic opened, it received two referrals in its first year of operation. As Dr Polly Carmichael, current director of the service, observes, it was considered a career-limiting option for a clinical psychologist to specialise in the field of gender identity in young people – there weren’t enough patients. That is not how it has turned out. Last year, 1,400 children under 18 were referred to Gids, double the number the year before. Of these 1,400, nearly 300 were under the age of 12, with some as young as three years old.

The reasons for this exponential increase are obviously complex. One factor seems to be a huge shift in awareness of transgender individuals in wider culture. The attention paid to Caitlyn Jenner in America, and Kellie Maloney here; a transgender actor, Riley Carter Millington, playing a transgender role in EastEnders; the historic tragedy of the story told in The Danish Girl and the many public controversies about respect for trans rights have all informed this awareness.

It is never just a phase. if these kids do go through puberty, 29% self harm

It has helped to open up a space for greater acceptance and understanding, particularly in schools, but also for highly emotive and polarised debate about how best to help young people who believe they need to transition. At the sharpest end of this debate are the parents whose children are identifying themselves as transgender well before puberty, and sometimes living outwardly as the other sex. These children – and their parents – are more aware than ever that there are choices available to them to correct what they believe to be the error in their bodies. It can seem these choices are binary, the ultimate either/or, but the decisions parents have to make about intervening in their children’s biology are anything but clear-cut.

A couple of weeks ago I sat in on a day’s conference organised by Mermaids, a charitable support group for parents of children who identify as trans. The charity has been much in the news in recent weeks, in part because it has featured in the widely reported custody battle heard at the High Court that involved a boy of seven allowed to live “in stealth” as a girl, because his mother had become convinced those were his wishes. The judge in the case, Mr Justice Hayden, ruled that the boy should live with his father, and that the mother “had caused significant emotional harm to her son in her active determination that he should be a girl”. Mermaids had supported the mother in her belief that her son identified as transgender for two years and described the ruling as a “huge injustice and transphobic practice” which had been “devastating for the child”.

In another case it was reported that a family was taking legal action against a local authority for backing their 14-year-old daughter’s adoption of a boy’s name as a step towards changing her gender. The mother of the girl said she believed her daughter was too young to make her own decision. “The rights of parents in the UK are being eroded,” she claimed, “especially those who have traditional Christian values. It is leaving parents to feel fearful, vulnerable and intimidated.”

Josh, aged nine, started asking his mum questions about gender at the age of six. Stylist: Jo Sawkins at S Management. Digital Operator: Andy Swannell. Art Direction: Cathy Bell Photograph: Ross Bolger @ S Management

I went along to the Mermaids conference in part to try to make sense of some of these issues for myself. It seems to me unquestionably a wonderful thing that young people faced with some of the trauma of these feelings about who they are can find tolerant space in which to experiment with different expressions of their gender and be protected in law from discrimination. But as a parent, too, I find it hard to get rid of the feeling that the more choices you give to younger children, the more they are likely to adopt them for a variety of psychological reasons. Is a six-year-old, or an eight-year-old, or a 10-year-old, or a 12-year-old, really able to make informed enough decisions about the consequences of a complete shift in their gender involving deed poll name change and living “in stealth”? Are we formed in our gender identities before puberty or by puberty? And can the longer-term psychological consequences of these decisions possibly be known?

The Mermaids conference was addressed by Dr Norman Spack, a paediatric endocrinologist at the Children’s Hospital in Boston, Massachusetts and the guiding light of the British charity. Spack, 73, is an evangelist for what some parents of transgender children see as a revolution in the medical treatment of their kids. He sees gender through the lens of his own specialism – hormones – and has devoted his working life to having other people view this question in the same way. He dislikes the term “reassignment”. “We don’t reassign a person’s gender,” he says, “we just acknowledge what it really is and fix it.” At one point in his talk, Spack led his audience in an impromptu rendition of “The Times They are a-Changin” in honour of Bob Dylan’s Nobel Prize – but also to highlight the generational shift in attitudes toward gender identity that we are witnessing: “Come senators, congressmen please heed the call… There’s a battle outside raging…”

These kids are desperate. they won’t have a bath or shower naked

In Spack’s view, and that of most of his audience, the times are not changing nearly fast enough for some children. Spack is a vocal, TED-talking advocate for early medical intervention in gender identity cases. He proposes following the model inspired by clinics in the Netherlands, in which children identifying as transgender are routinely given hormone-blocking drugs after the onset of puberty, and then move on to high doses of hormones to change their sex, and then later perhaps consider surgery. The most controversial part of this protocol is the age at which children are given the cross-sex hormones, the effects of which can be irreversible and may lead to a loss of fertility. The NHS guidelines currently state that no children be given this hormone treatment until they are around 16. Spack sees the age as arbitrary, and often cruel. “Why wait?” he asks.

In an arena of enormous doubt, this kind of certainty is seductive. Looking around the room at the conference, attended by many parents faced with these questions, you can sense heartfelt relief among some that there is an “answer” to their anxieties. As someone not faced with these anxieties, that relief seems open to the supplementary question of how a parent or child can honestly be certain this is what they want before the child has reached maturity.

Spack has no doubts. Genuine gender dysphoria is easily recognised, he believes. It is never just a phase, or a dressing-up box. “These kids don’t miss an opportunity to say, ‘This is who I am,’” he argues. “They have a fantasy that they are going to get the puberty they want, not the one they are programmed for. Tomboys don’t have that, boys who seem a bit feminine don’t have that. If these kids do go through puberty, 29% self harm.” Subsequently, he argues, up to 50% die prematurely of “psychosocial” causes, including addiction and suicide. Spack has, he says, put “about 200 children” on to hormone blockers at the onset of puberty. Of these, 100% have gone on to take cross-sex hormones because “no one changes their mind”. At which point, I think: no one?

‘We don’t reassign a person’s gender, we just acknowledge what it is and fix it’: Dr Norman Spack. Photograph: Getty Images

Among Spack’s highest-profile patients is a young British woman, Jackie Green, whose mother, Susie Green, is the CEO of Mermaids. Jackie had a desperate time in her teens – attempting to kill herself seven times – as her male hormones threatened to give her an identity she loathed, and her parents looked anywhere for help. Frustrated by what they saw as the slow process of the Tavistock, which has a perceived “monopoly” on gender-identity referrals in England and Wales, Susie Green contacted Dr Spack and took her daughter to his clinic in Boston. So outwardly successful was his treatment that Jackie was subsequently a finalist in the Miss England beauty competition.

Other Mermaids parents addressed the room with unhappier stories. Several criticised NHS provision, particularly for its rigid rule against giving children the cross-sex hormone before 16, and for the waiting times for a consultation at the Tavistock. Some parents had gone down the route of self-medication for their children, buying blockers and hormones from India or wherever, over the internet, for fear they would miss the “window” when transition was possible. Some turned to a GP in Wales, Dr Helen Webberley, who has a controversial private practice to address this sudden need.

Once you medicalise identity, then you only look for medical solutions

Webberley made headlines in the summer for “prescribing sex hormones to a 12-year-old”. She came to the stage at the Mermaids conference tearful – along with most of the room – about some of the stories she had just heard (in particular that of a trans girl who had been self-harming through school, only to be made the “prom queen” when she left). I spoke to Webberley after her speech, which had ended with her embracing Spack. Her clinic has been running for nearly two years. It started with a website, just to see what the response would be. She was immediately overwhelmed with emails and letters. “These people are so desperate,” she says, “and they spend a lot of time on the internet. I think that is how it snowballed. At long last there was a doctor willing to help.”

Webberley has had 500 young patients, 50 of whom have “gone on to treatment”. She has 3,500 adult patients. Most of her consultation is through Skype and email, though she has a face-to-face meeting with children and their parents before prescribing drugs. She shares Spack’s sense of urgent mission: “It is radical, but that doesn’t mean it is wrong.”

Webberley’s is dismayed by the fact that her work has been subject of criticism from senior psychiatrists at the flagship UK hospital for transgender provision at Charing Cross. She is due to meet NHS commissioners, though the service she offers is not through the NHS (patients who go on to treatment pay a £150 flat fee and then £20 per month for her consultative advice). “They want to try to stop me from what I am doing because it is embarrassing for them,” she says. “I do put my career on the line to do this. But these kids are desperate. They won’t have a bath or a shower naked. They will change their pants in the dark. They want a puberty blocker so they don’t grow breasts, or so their voices don’t break. And then you have to wait your 18 weeks to get to the Tavistock or whatever.”

‘We don’t and can’t know the longer-term outcomes of these decisions’: Dr Polly Carmichael. Photograph: Nicholas Bowman/Sunday Mirror

While I am talking to Webberley it is hard not to get caught up in her passion for her cause, her conviction that she is doing her best by the families who come to her. When I come away, though, doubts resurface. Can these kinds of psychological diagnoses really be so clear that you can base them on late-night emails?

When I subsequently speak to Dr Polly Carmichael and members of her multidisciplinary team at the Tavistock, it is clear they do not share the conviction that diagnosis for prepubertal children can be so straightforward. Carmichael says that because the treatment pathway identified by Spack is relatively new, “We don’t honestly know and, in fact, you can’t know the longer-term outcomes of these decisions.” The only proper longitudinal study has been from the Dutch clinics which pioneered this work, but even that is based on a mixed cohort of children at different stages of puberty who were given the blocker. The Tavistock is soon to begin publishing its own research into a more homogenous group of children who have been given hormone blockers starting in 2011. “We have to move forward on the evidence base while respecting that individuals will have very strong beliefs in what is right and wrong,” Carmichael says.

The Tavistock approach itself is too radical for some. After a long period of assessment and counselling, it moves a proportion of its young patients on to blockers and some on to cross-sex hormones at 16 but, Carmichael argues, to ever think of gender dysphoria only as something to be “fixed” by hormone treatment is really “a medicalisation of the complexities of identity and once you have done that, you look only for medical solutions”. The Tavistock offers a team that includes endocrinologists as well as psychologists, psychotherapists, family therapists, psychiatrists and others.

Onward march: Poppy went back to school this year, using her new name. Photograph: Ross Bolger @ S Management

Since the spike in referrals, the clinic is finding different patterns in the young people they see. While the younger children “are often presenting in a binary way”, thinking that their only solution is a change of hormones and a change of sex (some very young children, Carmichael says, come armed with ideas not only about what surgery they need but which surgeons they would like to perform it) older teenagers are often thinking “in a more diverse way” about their identity and the fluidity of their gender, and can be supported to explore expressions of who they are that for some may not involve medical intervention.“We are trying to treat whole young people,” she says. “For example we have had a couple of young people who have, after a lot of discussion, decided to reject a binary approach because they want to preserve their fertility. This is not to say that their cross-gender identification has changed, just that they have chosen to prioritise retaining fertility over achieving a more consistently male or female physical presentation.”

Carmichael is caught between entrenched voices who, on the one hand, believe hormone treatment of trans-identifying children misguided in any case and, on the other, see it as the only way forward. She tries, courageously it seems to me, to defend the complexities of the middle ground. “People start to think if you have these feelings at a certain age then this is the only path to follow,” she say. “And that isn’t the case. Every young person who comes to us has different needs.”

That fact is reinforced by the two mothers who, through the Mermaids charity, have spoken to the Observer for this feature and whose stories appear on these pages. Some readers will find the parents’ acceptance of their child’s determination to choose their gender identity as a cause for celebration, others will retain doubts that these questions can be resolved with the kind of clarity that Lucy and Claire express in relation to their nine-year-olds. Such complexities will be further explored, no doubt, in the reaction to a Channel 4 documentary that will air later this week, the first time a broadcaster has been allowed access to the work of Gids. The programme, one of three on the Tavistock, examines the lives of two children attending the clinic for assessment. Watching, it is impossible not to empathise with the unbelievably hard choices faced on all sides. But also, hopefully, to believe that with the right support, there are now ways forward for these children that even a generation ago would have been hard to imagine.

Josh: transitioned from female to male in December 2015

Lucy is mum to Josh, 9

I realised that Josh might not just be a tomboy when he was six and his teacher said he didn’t quite know his place in the world. I believe in being honest with my children so when Josh started asking me last year if there were operations where women could cut off their boobs I said yes, but told him it was very painful and difficult. Really, I was hoping to put him off the idea, but he carried on asking

the questions.

Our GP referred us to the Tavistock clinic. I’m glad we’re in the system now as when Josh starts puberty hopefully there will be hormone blockers available if he wants to use them.

You can’t discipline this out of a child. It’s not them being naughty

It was at the end of last year, during the Christmas holidays, that Josh asked me if he could start using another name instead of his birth-name – Lexie.

For the first few months after his transition I told Josh repeatedly he could go back to being Lexie any time he liked, but he’s never shown the desire to change his mind.

At first his behaviour became quite challenging. He could be awkward and difficult, but I think he was just testing the boundaries of his new identity. When he realised all the normal rules still applied, he settled down. I think now that he’s more confident since his transition - at first he was very worried he would never be a proper boy, but I tried to keep reassuring him that it’s much more about how you present yourself than what’s in your pants.

School has been very supportive - the other children simply accept that he’s a boy.

The practicalities have been harder. I still say, ‘Morning, girls’ and then have to correct myself to ‘Morning, kids’, and getting used to male pronouns has been difficult, too. I do worry about the future and that the road we’re going down is only going to get tougher, but wanting to change gender isn’t something you can discipline out of a child - it’s not them being naughty or misbehaving, it’s something deep inside. Jenna Sloan

Poppy: transitioned from male to female in December 2015

Claire is mum to Poppy, 9

When Poppy was five she saved up her pocket money to buy a dress, which she loved. We enrolled her into a drama club as it was a safe place for her to be able to dress up how she wanted and express herself, but as she grew older it became increasingly difficult to treat her as a boy, when she was clearly a girl.

She grew her hair longer and adopted a feminine voice. I didn’t know whether I should be correcting the checkout assistant who told me, ‘Your daughter is so helpful.’

Phoebe, my older daughter, came out as gay when she was 15, and I recognised the same signs in Poppy, the stress of not being able to live as who you really are. She would drop coins into the well at the bottom of our garden and wish to become a girl, and by the time she was seven she started telling me she was in the wrong body.

She would drop coins into the well in the garden and wish to be a girl

There was no question of me not letting her do this - it was simply what had to happen. As a parent I can put my foot down and say, ‘No, you can’t wear your sandals in the rain,’ but I can’t put my foot down and not allow my child to be herself. I did lots of research and the self-harming and suicide rates for young people who are trans and unsupported at home are frighteningly high, so all we could do was be led by her and support her in becoming a happy and confident girl.

Poppy went back to school this year as a girl, using her new name. The change was remarkable – her confidence blossomed and her school work has improved. The school asked speakers from organisations supporting young trans people to come in and talk to staff and pupils about what was happening. It has taken her dad time to get his head around it. He was brought up as a Muslim in Senegal. But he says: ‘God gave me a daughter and I love her.’

My main fear now is that if we don’t get medical support she’ll start puberty as a boy. I think that would be intolerable for her.

Poppy wrote a story recently where she compared her transition to a trapped

bird being set free and finally learning to sing. Jenna Sloan

The Mermaids charity offers family and individual support for teenagers and children with gender identity issues. For more information, go to mermaidsuk.org.uk

Channel 4’s series about the Tavistock, Kids on the Edge, starts on 16 November at 10pm

This article was amended on 15 November 2016 to clarify that the hormone blocking medication described is only administered after the onset of puberty, not before.





