Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020

Abstract

Trends in clinical referrals to specialist gender services historically comprised more assigned male at birth young people. In the last decade, this has shifted in adolescent samples to more assigned female young people. An updated review of the current patterns of referrals is important to better understand the potential changing needs of clinically referred gender-diverse children and adolescents. We assessed the demographics of referrals to the Gender Identity Development Service (GIDS) and their attendance patterns from 2017 to 2020. During this period, 9555 referrals were received in total, most were in adolescence (n = 7901, 82.7%), and more assigned female (age range = 1–18 years; M = 14.05; SD = 2.5) were referred than assigned male young people overall (n = 6823, 71.4%). A larger proportion of assigned female adolescents (assigned female: n = 5835, 62.3%, assigned male: n = 1897, 20.3%) and assigned female children (n = 988, 10.6%, assigned male: n = 640, 6.8%) were referred. For 2%, sex assigned at birth was unrecorded, 83.4% were White British and 36.6% had an unidentified ethnicity. Only 4% did not attend a first appointment, indicating the need for care from this specialist service. With more young people presenting to gender services, understanding the demographics of young people seeking gender care is vital for service provision. Future research should explore how to increase access to gender care for ethnic minorities, and how to support those accessing services.

Keywords

Gender diversity gender identity referral demographics gender dysphoria gender care

Introduction

Gender identity refers to an individual’s internal sense of their own gender. This may differ from their sex assigned at birth and is not always binary (Thompson et al., 2022). Gender Dysphoria (GD) is defined as a “marked incongruence between experienced/expressed gender and sex assigned at birth” which causes distress (Diagnostic and Statistical Manual of Mental Disorders, 2013). Not all gender-diverse people experience GD and for those who do, dysphoria may change over the lifespan (World Health Organization, 2019).

An accurate understanding of proportions of individuals identifying as gender-diverse is essential for ensuring adequate health care provision (Goodman et al., 2019). Goodman et al. (2019) reviewed the size and distribution of gender-diverse populations combining literature from 17 countries and spanning five decades. It was estimated that approximately .1%–2% of the population were gender-diverse and that this depended on geographic location (Goodman et al., 2019). Prevalence estimates in children and adolescents range from approximately 1.2% and 2.7% across New Zealand and the USA (Clark et al., 2014; Rider et al., 2018) and estimated at 1:2000 (.05%) in the Netherlands and Belgium (Olyslager & Conway, 2007). The differences in estimates may be owing to differences in referral criteria, terminology, definitions, and methodology between studies (Thompson et al., 2022).

It is important to note that not all gender-diverse people experience GD. Incidence rates of gender-diverse young people (i.e., children and adolescents up to age 18 years old) with a GD diagnosis have been noted as .41–12.23 per 100, 000 in the British Isles, and estimated as 1.6 per 100, 000 in the UK (Khadr et al., 2022). In a German school-based population, .9% of adolescents aged between 10 and 16 years reported experiencing GD (Becker et al., 2017). Even though GD is noted as a rare clinical presentation (Graham, 2022; Khadr et al., 2022), it is well documented that referrals to specialist gender services have increased in the last 5–10 years, for instance in Holland and the UK (de Graaf et al., 2018b; GIDS, 2019; Thompson et al., 2022; Wiepjes et al., 2018). This rapid increase has been particularly apparent in adolescents, although reasons for the increase remain unclear (Morandini et al., 2022) as there is no consensus on the explanations proposed. Morandini et al. (2022) suggest that increased social acceptance of identifying as gender-diverse has allowed young people to acknowledge their GD more openly (Morandini et al., 2022). It may also be that services are more accessible.

The Gender Identity Development Service (GIDS) is a highly specialist service for young people up to the age of 18 seeking support regarding distress in relation to their gender identity in the UK. The NHS service specification (2016) (GIDS, 2022a) widened referral criteria to allow general practitioners (GPs) to refer to this specialist service in 2012, making access more available. An observed change in referral patterns worldwide was noted after 2005, and past research (de Graaf et al., 2018b) evidenced this observed change in the GIDS, with referrals increasing between 2009 (n = 50) and 2019/20 (n = 2700); of note, a 382% increase was documented in referrals from 2014/15 (n = 678) to 2018/19 (n = 2590) (GIDS, 2022b). A similar increase was observed in North America (Aitken et al., 2015) and internationally (Skordis et al., 2019).

Another shift documented in referral demographics relates to earlier research indicating initially that more assigned male at birth children presented to gender services (Cohen-Kettenis et al., 2003; Di Ceglie et al., 2002). This subsequently shifted to larger proportions of assigned male than assigned female children at younger ages (at ages 3–9 years), and more assigned female than assigned male adolescents at 12+ years old (de Graaf et al., 2018a) attending services. This rise in adolescent female referrals has been documented globally (Arnoldussen et al., 2020; de Graaf et al., 2018b; Khadr et al., 2022; Thompson et al., 2022). There are a number of competing hypotheses put forward to explain this shift which remain unevidenced, including that young people assigned female at birth potentially experience reduced stigmatization (Arnoldussen et al., 2020), experience distress more acutely during puberty (Aitken et al., 2015), or may feel more able and supported to ask for help when in distress. Research in community samples however seems to indicate a more equal spread, with marginally higher proportions of assigned male young people identifying as gender-diverse (Turban et al., 2022).

Ethnicity demographics of referrals to the GIDS indicate a largely white (91.1%–93.35%) service user cohort, with ethnic minority populations found to be lower (<10%) than those seen in other child and adolescent mental health services (de Graaf et al., 2019; Manjra et al., 2022). It is not clear if there are additional barriers in accessing services alongside the established health inequalities which continue to affect ethnic minority populations in all aspects of health service provision (Manjra et al., 2022). Thus, it is important to understand whether these demographic trends continue to be prevalent in services. This may help us to further understand how services consider service provision in the future.

The present research

The present research aimed to explore referral demographics to the largest child and adolescent gender service in Europe, extending previously reported demographics (de Graaf et al., 2018b; Kaltiala-Heino et al., 2020; Morandini et al., 2022). Updated understanding of the potential shift in the patterns of referral demographics is important to better understand how these patterns compare across the world, and the potential changing needs of gender-diverse children and adolescents attending services (de Graaf et al., 2018b). It is also vital to understand whether referral demographics match those attending services, to gain an accurate picture of whether demographics of those initially seeking help accessed this support. Thus, the present research aimed to assess the number of referrals to the GIDS from 2017 to 2020, to identify patterns of demographics (sex assigned at birth and age at referral) over this 3-year period. We further explored other patterns of demographics such as ethnicity, referral year, and whether the first appointment was attended.

Based on the stated literature, it was hypothesized that more adolescent assigned female at birth young people would be referred to the service, and that there would likely be more assigned female young people referred during adolescence (12+ years old), and more assigned male young people (<12 years old) referred in childhood. It was also hypothesized that, owing to the specialist nature of the service, most referrals would attend their first appointment, and that the demographics of those attending would closely match the demographics of those referred.

Method

In this retrospective review, referrals to the GIDS across a three-year time period (April 2017 – March 2020) were examined to explore the pattern of demographics across referrals.

Materials and participants

The GIDS only accepts referrals from a range of professionals as well as clinical support groups, which forms the inclusion criterion for this report. Referrals are read by clinicians and are accepted if a clear need for the service is indicated and on adequate completion of the information required. This includes gender history, current mental health needs, current support structures, and management of risk in the community, among others. Management of risk relates to how potential risks to self (e.g., suicidal ideation or self-harming behaviors), and from others (e.g., abusive home environment) are being managed by relevant healthcare professionals and local services at time of referral. Referral forms include the young person’s sex assigned at birth and identified gender. Rejected referrals were not included in demographic analyses. The most common reasons for rejecting a referral include instances where the form was poorly completed (with little information or no information about gender-based concerns or distress), and where a young person was 18+ years old. Ethnicity data was taken from the Trust patient data systems and included a mixture of referrer-defined (from the referral form) and self-defined (from Patient Details forms of those who went on to attend the service) ethnicity. Children were categorized as <12 years old, and adolescents as 12–18-year-olds to explore group differences across age.

A priori power analyses (G*Power 3.1) (Faul et al., 2009) indicated a sample of 180 for adequate power (β = .80) based on a medium effect size (.25) for the hypothesized interaction of sex assigned at birth and age at referral.

Procedure

Data were extracted from an online electronic patient record system and included age at referral, sex assigned at birth, ethnicity, referral year, and whether the first appointment was attended. Duplicates were removed from the dataset before analysis (Figure 1). Referrals to the GIDS were categorized as accepted and rejected. Due to the retrospective nature of this review and use of full anonymization, exemption for ethics approval was granted.

Figure 1.

Breakdown of Included and Excluded Data. Note. *first appointment cancelled includes cancelled by trust, by young person and by discharge. **Awaiting first appointment includes upcoming appointments.

Statistical analysis

The data was checked for outliers and missing data. Statistical analyses were conducted using SPSS 27. A chi-square test of independence was used to examine the association between referral year, sex assigned at birth, and age at referral. The remaining analyses were descriptive and focused on reporting the main demographics of the young people by sex assigned at birth, and age at referral. Further information was gathered for accepted referrals including ethnicity, referral year, and whether the first appointment was attended (e.g., number of “did not attend” (DNA) appointments). The data are reported as means, percentages, standard deviations, and effect sizes indicated where relevant.

Results

Participant demographics

A total of 9829 referrals were made to the GIDS between 2017 and 2020. Referrals over age 18 (n = 211) were removed in line with sample criteria. A final sample of 9555 young people (age range = 1–18 years; M = 14.05; SD = 2.5); 2537 (26.6%) assigned male at birth, 6823 (71.4%) assigned female at birth, and 195 (2%) had an unrecorded sex assigned at birth (on the referral form), were referred to the GIDS. Of these, children, 1654 (17.3%) were aged 12 years and under and the remaining 7901 (82.7%) adolescents were aged between 12 and 18 years old. A yearly breakdown of self-defined and referrer defined ethnicity was analyzed for 6104 young people. Ethnicity data was analyzed after removing all young people with no information available for ethnicity. Missing ethnicity data was owing to referrers not providing this data in the referral, information being missing, or young people feeling unable to choose or refusing to choose an ethnicity group. Overall, across the 3 years (2017–2020), of those whose ethnicity was identified, 92.7% were of a White background, and for 36.6% ethnicity was unidentified. Ethnicity data contained a mixture of self-defined and referrer defined information (Supplementary Table S1).

Sex assigned at birth, age at referral, and referral year

On average, more assigned female at birth young people were referred to the service (n = 6823, 72.9%) than assigned male young people (n = 2537, 27.1%), and more adolescents (aged 12+ years; n = 7901, 82.7%) than children (under 12 years; n = 1654, 17.3%) were referred. In particular, more assigned female (n = 5835, 62.3%) and assigned male (n = 1897, 20.3%) adolescents were referred than assigned female (n = 988, 10.6%) or assigned male (n = 640, 6.8%) children (Table 1). Under 12-year-old referrals across assigned gender indicated a marginal shift to previously reported findings (de Graaf et al., 2018b), with 21.7% more assigned female children referred (n = 659) and 6.8% more assigned male children (n = 640), but overall ratios of assigned gender of child referrals remained similar over the years. Whilst the assigned gender split between adolescents was more apparent, with 126.43% more assigned female referrals (n = 3258) and 56.78% more assigned male referrals (n = 687) than previously reported by de Graaf et al. (2018a).

Table 1.

Frequencies and chi-square results for referral year by sex assigned at birth and age at referral.

Age groups	Referral year (total n)	AFAB		AMAB
Age groups	Referral year (total n)	n	%	n	%
Children	2017 (365)	201	55.1	164	44.9
	2018 (395)	250	63.3	145	36.7
	2019 (548	338	61.7	210	38.3
	2020 (320)	199	62.2	121	37.8
Adolescents	2017 (1744)	1291	74.0	453	26.0
	2018 (2072)	1581	76.3	491	23.7
	2019 (2324)	1807	77.8	517	22.2
	2020 (1592)	1156	72.6	436	27.4
Total	2017 (2109)	1492	70.7	617	29.3
	2018 (2467)	1831	74.2	636	25.8
	2019 (2872)	2145	74.7	727	25.3
	2020 (1912)	1355	70.9	557	29.1
Total		6823	72.9	2537	27.1

Note. N = 9360. The overall sample referred to GIDS between 2017 and 2020 was 9555. However, 195 (2%) of the sub sample did not identify themselves as assigned male or female at birth and therefore were not included in this crosstabulation. Children were categorized as 12 years and under, and adolescents as 12–18-year-olds to explore group differences of referrals made to GIDS between 2017 and 2020. AFAB: assigned female at birth; AMAB: assigned male at birth; n: subsample; %: percentage. The age range for the sample was 1–18-year-olds, M = 14.05; SD = 2.5.

There was no significant association between referral year, sex assigned at birth and age at referral for those aged under 12 years, χ2(3) = 6.48, p = .90, φ = .63. Mean age at referral for those under 12 years was 8.68 years. This was found to be significant for those aged 12+ years old, χ2(3) = 16.31, p = <.001, φ = .46 with most referrals made in 2019, largely for assigned female at birth young people (1807, 77.8%) as compared to assigned male at birth young people (517, 22.2%). The mean age at referral for those 12+ years old was 14.76 years. The lowest number of referrals were received in 2020 (assigned male: 436, 27.4%; assigned female: 1156, 72.6%; Table 1). Descriptive statistics exploring age at referral and referral year showed similarities in mean age across the years. Referrals made in 2019 were on average marginally younger (n = 2933, M = 13.93, SD = 2.40) and oldest in 2018 (n = 2477, M = 14.13, SD = 2.49) compared to referrals made in 2017 (n = 2109, M = 14.11, SD = 2.62) and 2020 (n = 2036, M = 14.08, SD = 2.28).

Table 1 also shows the total percentage of assigned female and male at birth young people referred for each year from 2017 to 2020. Most referrals were received in 2017 for assigned female at birth young people (n = 1492, 70.7%), and in 2019 for assigned male at birth young people (n = 727, 25.3%). The lowest number of referrals were received for both assigned male and female at birth young people in 2020 (n = 557, 29.1%; n = 1355, 70.9%).

First appointment attendance by sex assigned at birth and age at referral

Table 2 indicates first appointment attendance by sex assigned at birth and age at referral. Overall, the majority of the sample had either attended a first appointment or were awaiting a first appointment (69.92%; Table 3). 15% were discharged prior to first appointment as they no longer needed the service. Only 4.7% of appointments were cancelled (and re-scheduled), and 4% were not attended.

Table 2.

First appointment attendance by sex assigned at birth and age at referral.

Age groups	First appointment attendance	AFAB		AMAB
Age groups	First appointment attendance	n	%	n	%
Children	Attended	376	60.06	250	39.94
	DNA	0	0	0	0
	Awaiting first appointment	419	63.7	238	36.2
	Cancelled by young person	56	61.5	35	38.4
	Cancelled by Trust	3	33.3	6	66.6
	Referral rejected	32	50.79	31	49.2
	Discharged	63	61.16	40	38.83
Adolescents	Attended	2694	75.7	861	24.2
	DNA	0	0	0	0
	Awaiting first appointment	1346	79.8	339	20.11
	Cancelled by young person	225	73.2	82	26.7
	Cancelled by Trust	32	82.1	7	17.9
	Referral rejected	369	66.8	183	33.1
	Discharged	917	72.3	350	27.6

Table 3.

Attendance at first appointments for all referrals to Gids between 2017 and 2020 (n = 9555).

First appointment attendance	(n)	%
Attended	4223	44.19
DNA	408	4.27
Awaiting first appointment	2459	25.73
Cancelled by young person	398	4.16
Cancelled by Trust	49	.51
Referral rejected	626	6.55
Discharged	1392	14.56

Note. N = 9360. The overall sample referred to GIDS between 2017 and 2020 was 9555. However, 195 (2%) of the sub sample did not identify themselves as assigned male or female at birth and therefore were not included in this crosstabulation. Children were categorized as 12 years and under, and adolescents as 12–18-year-olds to explore group differences of referrals made to GIDS between 2017 and 2020. DNA: Did Not Attend; n: subsample; %: percentage. The age range for the sample was 1–18-year-olds, M = 14.05; SD = 2.5.

Discussion

The present research provides an update of reported referral demographics to the largest and sole clinical child and adolescent gender service in Europe between 2017 and 2020, extending previous literature (de Graaf et al., 2018b; Kaltiala-Heino et al., 2020; Morandini et al., 2022). A number of clinically relevant trends were observed in line with, and expanding, previous findings. A larger proportion of assigned female young people were referred than assigned male young people overall (both under- and over 12-year old), with the majority of referrals across assigned gender made during adolescence. The majority of the sample referred (83.4%) reported a White British ethnicity overall and this statistic was even more pronounced for White ethnicity (92.7%). First appointment attendance closely matched the demographics of those referred, and only 4% in this sample DNA a first appointment. Indeed, our data supports previously reported referral trends to specialist gender services documented in the last 5–10 years (de Graaf et al., 2018b; GIDS, 2019; Thompson et al., 2022; Wiepjes et al., 2018) with referrals to the GIDS increasing by 5409 young people in 2017–2020 since de Graaf et al. (2018a) who reported 4506 referrals between 2009 and 2016.

As predicted, the majority of referrals to the GIDS in 2017–2020 were assigned female young people (71.4%) as compared to assigned male young people (26.6%) in line with the literature (Arnoldussen et al., 2020; de Graaf et al., 2018b; Khadr et al., 2022; Thompson et al., 2022). This trend was found across children and adolescents. However, interestingly, only marginally more assigned female children were referred than the previously reported patterns of larger proportions of assigned male children referred to services in childhood (de Graaf et al., 2018a). Indeed, of the 17.3% children referred, 60.7% child referrals were assigned female, and 39.3% assigned male in the present research where de Graaf et al. (2018a) noted this as 56.7% assigned female children, and 43.3% assigned male children respectively. Most referrals received consisted of adolescents (82.7%), with the majority of the sample assigned female at birth adolescents (75.5%). This cohort differs to reportage in gender-diverse community samples, which indicate a more balanced spread of assigned gender (Turban et al., 2022).

As noted, some hypotheses have been proposed to explain the rise in assigned female referrals to services, for instance, reduced stigmatization allowing assigned female young people to feel more able to express their gender identity (Arnoldussen et al., 2020). However, and it is not clear why reduced stigmatization should be specific to assigned female young people (Marianowicz-Szczygiel, 2022). Others suggest that the distress of an earlier puberty of an unwanted gender in assigned female young people may explain this increase in referrals to services (Aitken et al., 2015). Although this hypothesis does not explain previous referral trend data, which shows higher proportions of assigned male children (<12 years old) attending services (de Graaf et al., 2018a). Overall, there are a range of sometimes competing hypotheses put forward and there is insufficient evidence to conclude why this trend is being observed. It must be noted that researching the efficacy of conjectures put forward is difficult, as it suggests generalization and does not consider the individuality and unique nuance of access, acceptance, culture, society, and each young person’s experience, and how this relates to their gender identity. It seems likely that there is not one explanation for this observation and that we need to think more widely about potential explanations including the possibility of under-representation of assigned male young people.

The majority of referrals to the GIDS were for adolescents, reflecting previous findings from the service (de Graaf et al., 2018a) and elsewhere (Morandini et al., 2022). This may be owing to puberty advancing and difficulties associated with this (e.g., shifts in social expectations) exacerbating feelings of GD (Steensma et al., 2018). Indeed, clinically referred gender-diverse adolescents report higher rates of mental health co-morbidities than children (Holt et al., 2016).

Of note, only 4% of children and young people DNA their first appointment at the service. This indicates the clear clinical need for specialist child and adolescent gender services, and their utilization by service users. Attendance figures matched referral demographics, with more assigned female children and young people (particularly in adolescence) attending first appointments. This distinction is important as referral demographics only reflect those initially seeking to access support, and using only these figures is not representative of clinical samples attending services, particularly where waiting lists to access may be long. Comparing those referred to those attending could be useful in identifying whether systematic issues in reaching services are present. Where there is parity in referral and attendance demographics, as in the present sample, assurance can be given that demographic information is not being conflated.

The mean age of referrals made in 2019 were marginally younger compared to other referral years, with oldest age of referral noted as 2018, only a .2 year mean age difference. This indicates a general consistency in referral age across the years assessed and matches international data on referral age to services (Expósito-Campos et al., 2023). We also note that that there was a lower rate of referrals made in 2020 which is likely owing to the imposed lockdown in the UK due to the COVID-19 pandemic. During this time, access to NHS services across the UK was affected. Indeed, some research indicates that gender-diverse individuals reported significantly reduced care and increased socioeconomic insecurity during the pandemic across the world (Jarrett et al., 2021).

With respect to ethnicity characteristics, the majority of young people referred were of a White ethnicity (92.7%), mirroring previous research in the GIDS (de Graaf et al., 2019; Manjra et al., 2022). These figures do not reflect the spread of ethnicities found in the general population, and are lower than those found in CAMHS (de Graaf et al., 2019; Manjra et al., 2022). Barriers such as cross-cultural variations in the conceptualization of gender may elicit feelings of shame and stigma and affect the seeking of specialist gender services for ethnic minorities (de Graaf et al., 2019). Further research is required to understand what these perceived barriers to access are (Manjra et al., 2022) and how they can be overcome. For intervention purposes, service providers ought to consider how to improve the accessibility of their services to different ethnicities and on how to work alongside different ethnicities and recognize where the bias lies (Beck & Naz, 2019).

Limitations and future directions

The present research builds on considerations around the potential changing needs of clinically referred gender-diverse young people through understanding shifts in referral demographics (de Graaf et al., 2018b). A number of limitations of the research must be considered. The data assessed was quantitative, restricted to demographic characteristics and only applies to Great Britain. Thus, only limited conclusions can be drawn to explain the trends found. Nevertheless, owing to the similar trends reported worldwide, the present data provides further insight. Future research should include qualitative data capture, exploring the young person’s hopes and wishes from the service to gain an initial understanding, as well as subsequently capturing young people’s pathways through gender services (Wright et al., 2021) using a longitudinal design to further understand if patient pathways through the service differ in relation to service user demographics. Such work from the GIDS has only been reported in young people accessing medical treatment pathways (Butler et al., 2022; Masic et al., 2022), reflecting limited representation of gender diversity. But work is underway to gain a wider picture understanding of gender-diverse people in Great Britain (Kennedy et al., 2021). Additionally, 2% of young people had an unrecorded “sex assigned at birth” and a further 36.6% did not have a listed ethnicity at referral.

Understanding the changes in demographic trends across child and adolescent gender services is vital as looking at trends over time globally can help to understand the shifting demographics and the potential changing needs of gender-diverse children and adolescents attending services (de Graaf et al., 2018b). Future research aimed at assessing these demographics alongside possible physical and/or mental health co-morbidities, which have been found to be more prevalent in clinic referred young people (Kaltiala-Heino et al., 2018; Karvonen et al., 2022) (e.g., social communication issues such as autism) (van der Miesen et al., 2018) may offer a richer understanding of the demography of cohorts globally, and may offer insights into service pathway navigation. It may be particularly useful to focus research on multiple factors together, considering how care can be tailored to include the additional home, cultural, and socio-economic context, alongside the many other complexities that may make up these young people’s lives.

Conclusions

The present research supports previously reported trends of referral demographics, with higher referrals from young people in adolescence, and more assigned female referrals overall. Shifts in marginally higher referrals of assigned female young people in childhood (<12 years old) were also noted, which has not been documented in clinically referred samples before. Demographics of those referred and those who attended were predominantly of a White ethnicity, pointing to the need to understand where barriers to accessing services are and how to ensure equitable access for all. Only 4% of first appointments were not attended over this 3-year period, indicating a clear need for specialist child and adolescent gender services, and the importance placed by service users to attend.

Supplemental Material

Supplemental Material - Demographics of referrals to a specialist gender identity service in the UK between 2017-2020

Supplemental Material for Demographics of referrals to a specialist gender identity service in the UK between 2017-2020 by Bibi Masala, Amy Love, Polly Carmichael and Una Masic in Clinical Child Psychology and Psychiatry

Footnotes

Acknowledgements

This work is not under consideration for publication elsewhere and its publication has been approved by all authors. If accepted, it will not be published elsewhere.

Author contributions

BM: Conception of design and research methodology, introduction, results, discussion, managed the submission process and engaged in the critical revision of the article. AL: Conception of design and research methodology methods, results and discussion. PC: Writing - review and editing and engaged in the critical revision of the article. UM: Conception of design and research methodology, writing - review and editing and engaged in the critical revision of the article. All authors reviewed the results, approved the final version of the manuscript and have agreed to be accountable for the work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Owing to the research being prospective and fully anonymized, exemption from ethical approval was granted.

ORCID iDs

Bibi Masala

Una Masic

Author biographies

Bibi Masala [BSc (Hons), MSc] graduated from King’s College London with an MSc in Mental Health Studies. She was a Research Assistant at the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust from 2020 until 2022, where she spearheaded and contributed to several projects. She is currently an Assistant Psychologist working within an adult inpatient acute and psychiatric intensive care unit. Bibi is also a Research Assistant at Equalab and has been since 2017. She was based in IAPT as an Assistant Psychologist.

Amy Love was a Research Assistant in the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust. She worked in the service from 2021 until 2023 and contributed to several research projects undertaken by the service during that time. Previously she worked in an IAPT service as a qualified Psychological Wellbeing Practitioner (PgCert) and has completed an MSc in Cognitive Development and Disorders at the University of Leeds. Currently, she works as a Mental Health Practitioner in an NHS CAMHS service.

Polly Carmichael is a Consultant Clinical Psychologist and Director of the Gender Identity Development Service (GIDS) for Children and Adolescents at the Tavistock and Portman NHS Foundation Trust. Dr Carmichael joined the GIDS in 2001 and was appointed Director of the service in 2009. Under Dr Carmichael’s Directorship the service has grown and developed into one of the largest in the world. The service is committed to equity of access with a second centre established in Leeds and regular outreach around the UK, including Birmingham, Bristol, and Exeter.

Una Masic is the head of research, data, and audit in the Gender Identity Development Service (GIDS) for Children and Adolescents at the Tavistock and Portman NHS Foundation Trust. Una has worked in the GIDS since 2018, after completing her Doctorate at the University of Sussex and post-doctoral work at the University of Liverpool. She leads a team of research assistants in the collection and dissemination of key data from one of the largest child gender services in the world as part of the GIDS’ continued responsibility to monitor the wellbeing of service users.

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