Thinking about the body
On this page, we describe our approach to intervention and provide information about puberty and how to cope with it. We provide a staged approach to physical intervention that takes into account both physical and psychological development.
Many - although not all - adolescents we see consider at some point having physical interventions (such as hormone blockers and cross-sex hormones) to change their bodies.
As well as many people who do start physical interventions, there are many people who choose not to do so - or who decide to wait a while.
We are commissioned by NHS England, who set the service specifications for how we work. The specification was updated in 2016 following extensive input from a wide range of stakeholders and the public, plus an independent review of available evidence.
Staged model of care
Some young people we see go on to access a physical intervention to help them manage gender dysphoria. Others never want this, or their hopes change over time. For this reason, our approach to physical intervention has always been based on a staged model of care, which includes:
Stage 1: Assessment and exploration
The first stage of our work with any child or young person is an assessment and exploration of the nature of their gender identity (and, if applicable, their wishes for physical intervention).
Our assessments aim to gather a holistic view of the child or young person’s life, including:
- history of gender identity development and any concerns about the body
- family history
- the young person’s developmental and medical history
- attitudes of others (e.g family, school)
- sources of stress and support
We also include risk assessments around any self-harm and possible suicidal ideation and, with the family’s permission, liaise with any local services and with schools.
At the end of the assessment, we may make a referral to our endocrinologists (hormone doctors) for physical intervention. However, we might also recommend further therapeutic exploration before considering starting physical intervention.
Stage 2: Physically reversible interventions (hormone blockers)
A child or young person who has already started puberty can be referred to our endocrinologists for possible hormone blocking treatment. Sometimes we might also ask our endocrinologists to help determine whether or not a child has started puberty already.
The blocker is a physically reversible intervention: if the young person stops taking the blocker their body will continue to develop as it was previously. However, we don’t know the full psychological effects of the blocker or whether it alters the course of adolescent brain development.
The blocker allows the young person time to consider their options and to continue to explore their developing gender identity before making decisions about irreversible forms of treatment. We are therefore only able to offer the blocker if the young person continues to meet with us for ongoing psychological exploration and support, as well as attending appointments with our doctors and clinical nurse specialists.
The decision to have any kind of healthcare treatment always involves weighing up the different potential benefits and potential risks involved. For hormone blocking treatment, this includes reflecting on the limited scientific evidence base for their use in this context. As part of ensuring good quality decision making and to support patients and their families, we carry out an in-depth clinical review before any onward referral, including to our endocrine clinics at University College London Hospital NHS Trust and Leeds Teaching Hospital NHS Foundation Trust. These Multi-Disciplinary Clinical Reviews involve patients and those involved in their care and are designed to help assess their suitability for the treatment.
For under-16s, where a patient, their parent(s) or carer, and clinicians are of the view that a referral to the endocrinology clinic for hormone blockers is appropriate, the GIDS decision-making process will be reviewed by an independent Multi-Professional Review Group. Patients do not need to meet the review group. The group is there provide all parties assurance that due process has been followed. The role of the group is not to endorse or refuse treatment but to ensure the necessary steps have been taken and information has been provided to the patient and their parents/carers.
Stage 3: Partially reversible interventions (cross-sex hormones)
Cross-sex hormones (i.e. oestrogen or testosterone) can be prescribed from age 16 after around 12 months on hormone blockers. Cross-sex hormones will cause some irreversible changes to the body (e.g. oestrogen will cause the growth of breast tissues; testosterone will cause the voice to break).
As well as thinking about a young person’s gender identity development, we also pay attention to their psychosocial functioning, their emotional wellbeing and their physical health when considering the introduction of cross-sex hormones. For example, we would generally expect a young person to be engaged in meaningful social activity (e.g. in education or employment) in their preferred gender role.
Stage 4: Irreversible interventions (e.g. surgical procedures)
As a child and adolescent service, we do not provide any form of surgery. Given this, whilst the topic of surgery may come up in our sessions, we are not best placed to advise on surgical options.
Adult gender identity clinics are able to provide surgical interventions as well as cross-sex hormones. We will discuss a referral to adult services with young people well in advance of them turning 18 and work to facilitate a smooth transition between our teams.
Waiting times for our endocrinology clinics
The waiting times for our endocrinology clinic appointments can vary. We try to schedule these as soon as practicably possible but a wait of several months for your first appointment is likely. Please contact UCLH or the LGI for further information about the timings of your appointments
After the first visit it can take up to 3 months to get approval from the GP and their managing Clinical Commissioning Group to allow the blocker to be given at the surgery. The exact interval will also depend on the number of people waiting to be seen too. After that appointments are made at 6 monthly intervals. Failing to attend booked new or follow up appointments is unfortunately very common and this delays and slows down the service for those who genuinely want to attend.
Coping with puberty
How does puberty affect the body?
The age at which puberty starts is usually between the ages of between 8 and 14 years old, but it takes a number of years to complete and is a slow and gradual process. Young people who are born with a female body usually start puberty earlier than those who were born male-bodied. See the NHS Website for more information about the signs of puberty and when you might expect to see them.
During puberty, the release of sex hormones by either the testes (in people assigned male at birth) or the ovaries (in people assigned female at birth) leads to a range of bodily changes, including: growth of pubic hair and hair on the legs, armpits, etc; development of breasts (in people assigned female at birth) and increase in size of the testes and penis (in people assigned male at birth); the beginning of periods (in people assigned female at birth) or erections and ‘wet dreams’ (in people assigned male at birth). Both males and females will experience a growth spurt, which tends to occur earlier in females than in males. The start of periods and the production of means that fertility develops during this time. This is also a period of change in relation to emotional, identity, and sexuality development.
For young people who are experiencing gender dysphoria, puberty can often be a time of increased distress as their body develops differently to that which is in line with their gender identity. For some young people, this is the point at which they seek a referral to GIDS, and can also be a worry for pre-pubescent children who are concerned about the changes ahead. Although physical intervention (i.e. hormone blockers) is one way in which some young people decide to manage puberty [see website section about physical interventions], this is not the preferred or most suitable choice for everyone. There are other, non-medical, ways in which some young people manage their bodies which they find reduces some of their distress.
Why does puberty happen? Here’s the science!
The part of the brain called the hypothalamus activates a hormone called Gonadotropin-Releasing Hormone (GnRH) which then prompts the pituitary gland (another part of the brain) to communicate (by the release of Follicle Stimulating Hormone and Luteinizing Hormone) with parts of the body that make the sex hormones. In people assigned male at birth, these are the testes, which produce testosterone. In people assigned female at birth, these are the ovaries, which produce oestrogen.
Both males and females have both testosterone and oestrogen in their bodies, so it is technically incorrect to call them ‘male’ or ‘female’ sex hormones; in fact it is more to do with the balance of these substances within the body (i.e. males have a higher ratio of testosterone to oestrogen and vice versa). The hormone-blocking treatment prescribed to some young people who attend GIDS is a GnRH agonist, which means that that pituitary gland does not receive the message to release FSH and LH, and thus the progression of puberty is delayed.
For more information about puberty, visit the following sites:
What can I do to look after my general health and my body?
It is important for all of us to look after our physical health and our body, as well as our mental health, and of course, both have an impact on each other. We are more likely to feel overwhelmed by emotions when we have not been sleeping well, been eating an unhealthy diet, and been using drugs or alcohol. At the same time, it is more difficult to have the motivation to do exercise, to choose the right foods, sleep well, and avoid drugs and alcohol when our mood is low or we are feeling very anxious. It is therefore important to pay attention to looking after ourselves both physically and emotionally.
The NHS website includes information about healthy eating for adolescents. And the Kids Health website provides some advice on how to get a good night’s sleep
We all know that smoking is bad for our health for a number of reasons, including increased risk of a range of cancers, heart disease, reduced fertility and premature ageing, among others. Additionally, people who wish to undertake medical treatments to change their gender (i.e. cross-sex hormones or future surgery as an adult) will be advised to stop smoking altogether. This is because the risk of blood clots is significantly increased when an individual smokes at the same time as receiving hormone treatment, and surgical outcomes may not be as good. It is, therefore, best not to start smoking at all, but if you do smoke and want help to stop, your GP will be able to provide support and advice.
Another important area of looking after ourselves is sexual health. You might want to check out the sexual health guide for trans* people from Gendered Intelligence