The issues facing transgender young people are indicative of the society in which we live. While numbers of children and teenagers unhappy with their gender identity are increasing the stigma and prejudice around them remain (Rivers et al, 2018). Pathologising transgender young people also leads to poor outcomes (Roen, 2019). School nurses have an important role to play in supporting transgender young people and embracing diversity in ways that encourage tolerance and inclusion in school communities.
Statistics about the mental health of young people who are lesbian, gay, bisexual, transgender or who have other sexual identities (LGBT+) demonstrate profound need (Salkind et al, 2019). There are higher rates of depression, anxiety, eating disorders, substance use, self-harm, and suicide in the LGBT+ population.
In 2017, a UK-based survey of 3713 LGBT+ young people found that 61% reported self-harm and 22% a previous suicide attempt in the LGB cohort. Of the transgender cohort, 84% reported self-harm and 45% a previous suicide attempt (Stonewall, 2017). The disproportionately high rates have been linked to factors including homophobia, biphobia or transphobia and being unable to disclose being LGBT+.
There is no prevalence data for the number of transgender young people in the UK. The UK's Office for National Statistics does not collect information on gender identity (Salkind et al, 2019). Estimates from a 2007 survey found that 1% of the UK population were gender variant (Department for Communities and Local Government, Race, Cohesion and Faith Research Unit and National Centre for Social Research, 2019). This lack of accurate data is indicative of the neglect of this population in terms of resources.
The concept of being transgender has existed for centuries and is multi-cultural. It is thought that transgender identities existed in prehistoric times. Graves of transgender people in Europe and America have been identified from 4 500 years ago, and likely depictions found in art around the Mediterranean from 9 000 to 3 700 years ago. In Ancient Greece, Phrygia and Rome, there were trans-female galli priests, and records of women dressing as men to vote, fight or study. The Roman emperor Elagabalus (d. 222) preferred to be called a lady not a lord, sought sex reassignment surgery, and has been identified as an early trans figure (Stryker, 2008). The Hijra of India, the Fa'afafine of Polynesia, the ladyboys and the tomboys of Thailand and the Takatāpui of New Zealand define trans people from those countries. Its apparent deviance from the norm is what has defined it.
A sense of gender identity may emerge at a young age. Two-year-old children label themselves as boy or girl and 4-year-olds understand that gender is a stable part of their identity (Kohlberg, 1966). Gender identity is highly complex and dependent on genetic, hormonal and environmental factors (Rosenthal, 2016). Acknowledgement of this complexity presents diversity as an option and could support transgender children and young people. The mix of influences on gender identity is an opportunity for tolerance and understanding to be promoted in society.
Case study
All names and identifying details have been changed in this case study.
Tom is a 14-year-old teenager who attended a school nurse run drop-in over a period of a year. He describes himself as ‘very dysphoric’. Gender dysphoria is a recognised medical condition. It is the distress caused by a mismatch between a person's biological sex and gender identity (NICE, 2016). Tom's sense of unhappiness in his own skin has resulted in low mood and self-harm. The lack of acceptance by his father is a constant source of tension. Tom lives with his dad, Ben. Tom has had an unsettled life from an early age. His parents have struggled to bring up their two children and their relationship has been unsettled. His mum, Paula left to move in with her boyfriend 4 years ago. Amy who is 12 wanted to be with her mum. Tom is in touch with his mum but she now lives in Norfolk with her partner and two children. Emily is 3 and Sean is 1.
Tom has described himself as ‘trans’ for the past year. He wants to be known as Tanya as he does not feel comfortable with his masculine identity. Tanya wears make-up, jewellery and paints her nails. Tanya is finding it difficult at home and school. She is constantly arguing with her dad about her name and clothes. He says she shouldn't label herself and can't come to terms with her desire to be identified as a girl. He calls her Tom. Paula is much more understanding and wants Tanya to come and live in Norfolk. Tanya is caught between the two as she does not want to leave her dad. At school Tanya feels everyone is looking at her and talking about her behind her back. She is anxious going into lessons and can't sleep at night. In the past she has self harmed but hasn't done this recently. She has talked to her form teacher who is very supportive. Tanya also goes to the LGBT meetings in school and remains adamant that she wants to be a girl. She hates going in the boys' toilets and changing rooms in school and will do everything she can to avoid PE. Tanya wants to do psychology at university but her grades are beginning to slip. She says she is having difficulty concentrating in lessons. She feels unhappy with her identity and heard that you can get hormone treatment to change sex. Tanya's father did not agree to this.
Tanya decided that she would not seek medical treatment until she was 16. She was not sure she would ever want surgery. She comes regularly to see the school nurse to talk through her feelings. The school nurse's role at this point is to foster and maintain a therapeutic relationship with the young person. Tanya has stopped self-harming and her mood is better. Her dysphoria still exists but she is happier in her own skin. Tom is called Tanya in the school environment and proudly wears an LGBT badge. Tanya's care shows how school nursing can help alleviate the pain and anguish caused by being a transgender young person in a heteronormative world.
Discussion
Added to the challenge of gender dysphoria comes everything to do with being an adolescent. Adolescents develop their sense of identity from their peers. Friends matter to teenagers more than at any other stage of life (Blakemore, 2018). Acceptance by their peer group is very important to adolescents. This has implications for school nurse practice as the practitioner must adapt their communication style and approach to their relationship with the client. This requires the practitioner to avoid being regarded as an overbearing adult while retaining their status as an authoritative advisor on health issues. If schools foster LGBT tolerance, transgender teenagers can function better (Coolhart and MacKnight, 2015). Peer rejection fosters a sense of lack of self-worth in young people which impacts on emotional wellbeing (Blakemore, 2018). Laboratory experiments have shown that teenagers display hypersensitivity to social exclusion. In one controlled experiment, teenagers, playing an online throw and catch game, were deliberately included or excluded by the computer-generated players. When excluded, the teenagers in the trial felt acute anxiety and experienced a low mood (Blakemore, 2018).
Gender conformity is particularly important for boys (Falomir-Pichastor et al, 2010). Peer culture appears to demand that boys conform to masculine stereotypes (Falomir-Pichastor et al, 2015). As a result, homophobia is linked to masculinity and LGBT school bullying leads to increased rates of depression and suicidal ideation (Russell et al, 2011). Overt displays of anti-bullying measures have been shown to reduce conflict behaviour and bullying in schools. Involving young people in designing anti-bullying resources added to their credibility and increased uptake of the interventions (Blakemore, 2018). Co-production of LGBT campaigns in schools between teenagers and school nurses could help foster tolerance.
Emotional wellbeing in LGBT young people is associated with safe and tolerant school environments (Willging et al, 2016). LGBT teenagers in protective school environments make fewer suicidal attempts and have less suicidal ideation (Eisenberg and Resnick, 2006). Effective anti-bullying policies, supportive staff and LGBT groups in schools contribute to transgender young people being able to connect with schools (Mitchell et al, 2014). School nurses are pivotal in advocating for gender affirming school environments and ensuring schools promote equality and diversity.
Education about LGBT issues is now a mandatory part of the national curriculum (Department of Education, 2019). Commitment to the Equality Act (2010) is embedded in the guidance. Schools can determine the content of lessons but it should be integrated into the curriculum (Department of Education, 2019). In order to minimise controversy, this should be comprehensive, age appropriate and evidence-based (Department for Education, 2019). Consultation with the school community should take place before the delivery of the lessons. School nurses could also contribute to co-production of lessons about LGBT issues in schools. They could return to the classroom and co-deliver these sessions with teachers. They are ideally placed to educate children and young people about sensitive identity and relationship issues (Day, 2009). This fits within the standards of proficiency for specialist community public health nurses (Nursing and Midwifery Council [NMC], 2004). However, this does not guarantee that such a programme will be acceptable to all in the school community. Recently hundreds of children in a Birmingham primary school were withdrawn by parents in protest at teaching about same-sex relationships. Parents felt that the lessons were not age appropriate and promoted gay and transgender lifestyles (Parveen, 2019).
While the school environment can help transgender teenagers, individual care planning is also required. Open access to a school nurse means holding a teenager's struggles with their identity. As school nurses, this encompasses the social model of health (NMC, 2004). However, knowledge of the medical model of care for transgender young people is also essential for good outcomes (NICE, 2017). It can be anxiety provoking for health professionals to work with young people in this emerging area of practice. School nurses may worry about using the wrong terminology, lacking knowledge and providing unwanted advice for teenagers who may be ambivalent about accessing support. This can be addressed through client-led education and training of school nurses. For example, in Sheffield a local charity called SAYiT (Sheena Amos Youth Trust) delivers a wide programme of educational and training activity.
Therapeutic communication skills are generally helpful in having conversations with teenagers about deeply personal issues. Motivational interviewing encompasses the philosophy and approach which transgender young people have identified as supportive (Eisenberg et al, 2017). Adherence to the spirit of MI involves partnership, acceptance and compassion (Miller and Rollnick, 2013). It is a strengths-based approach and is rooted in client autonomy and self-efficacy. A research study suggests that an intensive and skills-based approach to teaching motivational interviewing has enhanced the therapeutic communication skills of SCPHN students (Day, 2018). A shift towards client-led consultations rather than advice giving is evident in the reported changes in practice (Day et al, 2018). In a study of treatment of substance misuse in transgender clients, acceptance of their sexual identity and sensitivity to their specific needs resulted in better outcomes (Lyons et al, 2015). Fostering an inclusive and affirming environment can make the difference between engaging with services or walking away and struggling to cope.
School nurses can make use of open questions, evoking a young person's story and validating feelings. Resisting the ‘righting’ reflex and avoiding fixing problems, which are important components of MI, are also likely to strengthen self-worth (Miller and Rollnick, 2013). The therapeutic value of MI has been demonstrated across a wide range of health behaviours such as sexual risk taking, alcohol and substance misuse and mental health issues (Naar-King and Suarez, 2011). This is relevant to a stigmatised and marginalised population of young people who are disproportionately represented in damaging health disorders.
Exploring a teenager's options can be difficult as it involves referral to specialist services (NICE, 2013). At present, nationwide specialist gender identity development services for children and young people under 18 are available through the Gender Identity Development Service at The Tavistock and Portman NHS Foundation Trust, London, and its satellite clinics in Exeter and Leeds. Children and young people should contact their GP in the first instance and may be referred to the Gender Identity Development Service at The Tavistock and Portman NHS Foundation Trust, London. Other professionals in Health, Social Services and Education departments as well as young people and their families can contact the service directly to discuss a possible referral.
For pubertal adolescents hormonal treatment can improve emotional wellbeing (Shumer, 2016). Gender dysphoria has been found to reduce in male transgender young people who take female hormones (Shumer, 2016). Male pubertal characteristics can be avoided through treatment in adolescence. In one study no transgender people who had undergone medical treatment regretted their decision (De Vries, 2014). Recent media reports have highlighted the controversy about treatment for gender dysphoria. An NHS England review of the use of hormone treatments for young people who want to undergo gender reassignment is to be conducted by experts. The review comes after a legal challenge to the Tavistock and Portman NHS foundation trust by a 23-year-old who was given hormone blockers and cross-sex hormones as a teenager. The case contests the way in which consent is obtained by the gender-identity development service (GIDS) for the treatment of children.
The young person's legal team told the high court that ‘the clinic's approach was unlawful because the potential risks of treatment were not adequately explained and that children could not give informed consent for this treatment’. The trust has said that it was not appropriate to comment on the legal proceedings at this stage, but that GIDS “is one of the longest-established services of its type in the world with an international reputation for being cautious and considered”’ (Savage, 2020).
Enabling young people to make life-changing decisions can challenge school nurses and cause emotional stress (Wakefield et al, 2010). Adopting a solution-focussed approach to client care has a major impact on nurses trained in the approach. Instead of a need to ‘“fix” things, it's released me from this awful feeling that as a nurse I have to put a plaster on and sort of send them away, so that's been useful to me’ (Bowles et al, 2001: 352).
NICE protocols for transgender clients are medicalised and convey little of the uncertainty of practice (NICE, 2013; 2016; 2017). In order to access support in this area of practice, school nurses could benefit from clinical supervision. Clinical supervision has been identified as able to increase nurses' sensitivity toward themselves and the families they care for (Jones, 2006). It enables time for reflection and emotional processing. Where nurses attend clinical supervision they have an increased level of satisfaction with their work environment, which increases job satisfaction and wellbeing (Begat and Serverisson, 2006). An RCT (Wallbank and Robertson, 2008) to examine the effectiveness of restorative supervision found that receiving clinical supervision allowed staff to process their workplace experiences, reducing their scores for burnout, compassion fatigue and subjective stress to non-clinical levels. Staff reported that the process assisted them in improving their own capacity to reflect and cope with their workplace experiences.
Conclusions
Supporting parents of transgender children and teenagers is vital in helping families come to terms with a major life change. Family rejection heightens the risk of poor mental health outcomes. Higher rates of attempted suicide, substance misuse and homelessness have been reported in transgender young people (McConnell et al, 2016). Lack of support at an early stage in adolescence increases the likelihood of mental health issues in adulthood. Conversely parental support has been shown to protect transgender teenagers from mental issues such as depression and reduces the negativity often associated with being transgender (Simons et al, 2013). Interventions for parents such as counselling support groups and education about LGBT communities decreases parental rejection and increases acceptance (McConnell et al, 2016). Family support has the effect of sustaining emotional wellbeing.