Court ruling uncovers knowledge gap in gender identity practice

A recent High Court ruling saw a seven-year-old boy who was living life as a girl removed from his mother's care after concerns were raised about her influence over his decisions.

In a written judgment in October, Justice Hayden said the boy, who was thought to have a gender identity condition, "dressed at all times like a girl" while living with his mother, but now lives as a boy and has "asserted his own masculine gender" since moving in with his father (see below).

Hayden criticised social workers for failing to properly investigate the mother's claims that the boy had been diagnosed with gender dysphoria, and ordered that they review how they handle such cases.

The widely reported case highlights the difficult challenge children's services and social workers face when responding to the growing issue of gender dysphoria in children and young people.

Gender dysphoria is a clinical condition where a person's emotional and psychological identity as male and female is opposite to their biological sex.

It was the subject of a recent Channel Four documentary calledKids on the Edge that illustrated the challenges faced by professionals when working with dysphoric children.

The documentary followed the work of the only NHS-funded unit for children with gender dysphoria, the Gender Identity Development Service (GIDS), run by the Tavistock and Portman NHS Foundation Trust.

Increase in referrals

Over the past five years, the number of under-18s referred to GIDS rose more than tenfold.

In 2010/11, 139 under-18s were referred to GIDS, but by 2015/16, that number had grown to 1,419. The majority of young people seen by the service are aged 14 to 17, but there have also been significant rises in under-10s and the 11 to 13 age bracket.

GIDS, which has clinics in London and Leeds, works with under-18s who develop gender identity difficulties providing counselling and treatment.

Dr Sarah Davidson, consultant clinical psychologist at GIDS, says the rise in referrals to the service reflect the fact that "an increasing number of young people are not happy with their gender".

Of the case in the recent High Court ruling, Dr Davidson says it highlights the fine line between a parent supporting a child and influencing their decisions.

"The idea I have is that the mother was very supportive of [the boy] presenting a wish of identification, but over time that [identity] had changed and the mother hadn't kept up with that," she explains.

"Frequently a young person presents saying they don't want to be in this body, and both parents support that.

"Sometimes you see parents respond in a very polarised way, where one will feel very strongly about supporting the child's wishes and the other will disagree."

Dr Davidson says that local authority social workers will often encounter "gender variant or diverse youth" when they are working with looked-after children, and she says that it is important for professionals to keep an open mind on how to best manage the kind of issues that may arise (see expert view).

Unlike the circumstances in the High Court case, the greater problem is that some social workers are not prepared to recognise gender dysphoria in children, particularly in under-10s, according to Susie Green, chief executive of Mermaids, a charity that raises awareness of gender identity issues.

"You get two different social workers: one is accepting and will be open minded, and others who think families must be making it happen," Green says.

"The younger the child, the more likely the family will get a social worker who doesn't recognise the issue."

Green says too often professionals make decisions based on personal opinions and instinct rather than knowledge. This creates the potential for practitioners to be influenced by often negative comments "seen in newspapers and on social media".

She explains that social workers often get involved in gender dysphoria cases where parents disagree over whether to support a child. If this leads to separation, one parent may report their concerns over the child's sexual identity to social services.

"If social services is informed that a child is being mistreated, they have to look at that, it can't be ignored," Green says.

"We have had parents who have been reported by their ex-partners and been investigated by social services. The threat of a social services investigation can be very scary. If a social worker is sceptical, the parent is placed in a difficult position over whether to support the child but [risk] being accused of abuse.

"A social worker's attitude can make or break a case."

Green is concerned that Justice Hayden's criticism of the social worker in the High Court ruling, and his recommendation for a review of how children's services manage gender identity cases, will lead to more professionals taking a sceptical stance in the future.

"The likelihood is that they will spend longer looking into somebody because of the judge's criticism," she says. "Professionals now may say ‘we need to look a bit closer', which means families will have greater scrutiny."

With most social workers not being trained in gender dysphoria, Green is concerned about the impact that closer scrutiny could have on children and young people struggling with their gender identity.

The answer, she says, is for those in practice and undergraduates on social work degree courses to be educated on the issue.

Mermaids runs training courses for groups of professionals aimed at raising awareness of gender identity. Cases are reviewed, agencies' responsibilities under the Equalities Act are outlined and practitioners discuss how to respond.

"What we try to do is get people to think what it must be like for families," says Green.

"Some people think it is a lifestyle choice, so we try to make them aware that children would not choose this. It's really difficult - that's why we have so many young people self-harming.

"Families often feel discriminated against by the very agencies that should be supporting them."

Improving knowledge

Other ideas Green has for helping improve social workers' knowledge include secondments and running residential weekends where professionals could spend time with families "who are accepting and supporting children at different ages" so that they can "learn about the issue as a whole rather than see it as a problem".

Ruth Allen, chief executive of the British Association of Social Workers, backed Green's call for social work degrees to include training on gender dysphoria because "issues of gender and sexuality are key to wellbeing".

She says gender identity issues are being spoken about more in social work, but accepts there is a risk that some practitioners "reflect prevailing social mores, however unconsciously, rather than really finding out what is right for a particular child".

"If we are uncomfortable and unconfident, we cannot do the best for service users," Allen says. "Talking to children about gender identity may feel alien to some social workers and approaching this with a young child may seem strange and almost inappropriate.

"But if the worker is trained, at ease and empathetic, this conversation can happen and we can make sure we are not seeing the issue through the eyes of the parents."

For Allen, the recent High Court case highlights the need for social workers to listen directly to children rather than parents.

She adds: "That is a primary source of information about child welfare for any social worker - or indeed judge."

Details of the recent high court ruling

In the High Court case, it was ruled that the mother of the seven-year-old boy was "absolutely convinced" that her son perceived himself as a girl and was determined to be one. By facilitating this, the mother believed herself to be fighting for her son's right to express himself as a girl.

But Justice Hayden ruled that the mother had caused her son "significant emotional harm". He concluded the child had been deprived of space for his gender identity to develop and instead was "pressed into a gender identification that had far more to do with his mother's needs and little to do with his own".

Despite concerns about the child's welfare being raised by his father and a number of agencies, Justice Hayden said social workers at the unnamed authority failed to properly investigate because "they did not wish to appear to be challenging an emerging orthodoxy".

The authority's Section 37 report said that assessments found there was nothing to suggest the boy was at immediate risk of harm and did not meet thresholds for intervention - a conclusion "entirely lacking in any logical analysis" according to the judge.

He said there had been a "wholesale acceptance" that the boy should be regarded as a girl, and that the authority had "consistently failed" to intervene appropriately when there were strong grounds to do so.

The deficiencies in the case were such that the judge asked the director of children's services to undertake a thorough review.

Expert view: What social workers need t0 know to support gender dysphoric children and young people

By Dr Sarah Davidson, consultant clinical psychologist at the Tavistock and Portman's Foundation Trust's Gender Identity Development Service (GIDS)

• Do not be fearful about engaging with young people over how they feel about themselves, their body and gender history.
• Know about specialist services, and that you can refer to GIDS directly. Flag up referrals to a GP and do not delay in referring a child, especially if they are distressed.
• Meet with the birth parents, foster carers and the child.
• It is more helpful to listen to a child's wishes and to support them than to doubt their authenticity or query how long they will last.
• If the child wants to be called ‘it' or ‘they' rather than ‘he' or ‘she', follow their wishes.
• Take extra care over how you use language. Where there are differences of opinion between birth parents, carers and the child, these have to be acknowledged. You cannot please everyone all of the time, but it is about talking respectfully and not insisting on taking on one point of view, especially when this silences one of the parties (and especially the young person).
• A young person's name is very important, particularly during important life events such as leading up to exams. Young people, even those under 16, can change their name through Deed Poll - that could be something that is really helpful for them.
• Body changes can be a real point of distress, such as when periods begin. It can be helpful to contact the GP to seek advice on whether periods can be halted for a while, for example. If the child's distress is so concentrated around that particular issue, it is worth knowing about what the options are and referring to the GIDS.
• Make contact with voluntary organisations - such as local LGBTQ groups (especially those that run groups for young Trans and gender diverse people), Mermaids, Gendered Intelligence, Intercom Trust and Allsorts Youth Project - who can offer professionals training and mentoring for young people.