Introduction
‘Transgender is an adjective that is an umbrella term used to describe the full range of people whose gender identity and/or gender role do not conform to what is typically associated with their sex assigned at birth’ (American Psychological Association, 2015, p.863). The World Health Organization states that people who identify as transgender (hereinafter referred to as transgender person(s)/youth) have a prevalence rate of 0.3–0.5% (25 million) of the global population (Thomas et al. Reference Thomas, Pega, Khosla, Verster, Hana and Say2017). Gender dysphoria (GD), which is included in the umbrella term of transgender, is the American Psychiatric Association’s (APA) psychiatric diagnosis for the ‘distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender’, and the DSM-5 states that the rate of GD is 1:20 000 (APA, 2013, p.451). Irish research estimates GD at 1:10 154 male-to-female and 1:27 668 female-to-male individuals in the Irish population (Judge et al. Reference Judge, O’Donovan, Callaghan, Gaoatswe and O’Shea2014). It is important to note that these estimates are only based on individuals seeking medical intervention, and as the authors note, it is probably an underestimation.
Connolly et al. (Reference Connolly, Zervos, Barone, Johnson and Joseph2016) stated that research since 2011 has found that transgender young people have higher rates of depression, suicidality, self-harm, and eating disorders than their peers. In an Irish context, research by a non-profit organisation that supports the transgender community, ‘Transgender Equality Network Ireland’ (TENI) found that 78% of the adult transgender participants had considered suicide, with 40% having made at least one attempt, and 44% having self-harmed (McNeil et al. Reference McNeil, Bailey, Ellis and Regan2013). It is important to note that 58% had used mental health services for a reason other than gaining access to medical assistance for gender reassignment. In regard to transgender youth, McNeil et al. (Reference McNeil, Bailey, Ellis and Regan2013) found that of the 82% of participants who sought support in relation to their transgender feelings, a third did so between 11 and 20 years of age. Grossman et al. (Reference Grossman, D’Augelli, Salter and Hubbard2005) found in their study of transitioning adolescents, that at a mean age of 13 years male-to-female and 15.2 years female-to-male adolescents considered themselves to be transgender. They stated both the male-to-female and female-to-male adolescents reported feeling different from others at a mean age of 7.5 years. Hence, with high levels of psychological distress being reported and increasing numbers of transgender youth presenting to services (Alegría, Reference Alegría2016), it is extremely important that clinicians are familiar with issues and unique challenges faced by transgender youth so that they can appropriately assess and support them and their families.
The Irish public health service, the Health Service Executive (HSE) Quality Improvement Division (2016) published a report highlighting the important role of the Irish Child and Adolescent Mental Health Services (CAMHS) in supporting transgender youth. WPATH (2011) (Version 7, 2011) a non-profit interdisciplinary organisation that publishes transgender care guidelines identified psychology, psychiatry, social work, speech, and language therapy as disciplines which provide useful support for transgender people. These disciplines make up core CAMHS staff. Additionally, the HSE Quality Improvement Division (2016, p.31) notes that referral to the Gender Identity Development Service (GIDS) in the Tavistock and Portman Clinic (hereinafter referred to as GIDS), a UK-based specialised service for people who identify as transgender, has increased by 100% in the last 12 months, suggesting more people seeking support, and Irish services are responding to increasing demand with ‘minimal resources, [and] training’.
McNeil et al. (Reference McNeil, Bailey, Ellis and Regan2013) found ‘that many participants… [adults] …avoided mental health services due to prior negative experiences’ (p.6, 2013). One of the main barriers to using mental health services was mental health professionals’ lack of awareness, knowledge, and training in relation to transgender issues. Many studies throughout the literature have shown the lack of training for clinicians in transgender healthcare (Vance et al. Reference Vance, Halpern-Felsher and Rosenthal2015; Riggs & Bartholomaeus, Reference Riggs and Bartholomaeus2016; Torres et al. Reference Torres, Renfrew, Kenst, Tan-McGrory, Betancourt and López2015). A HSE report written by Crowley (Reference Crowley2015) stated that transgender people’s negative experience of the health service comes from the lack of experience and knowledge of clinicians. The report called for more training for professionals especially in mental health services and better signposting of services. Alegría (Reference Alegría2016) notes that clinicians may not be confident about working with transgender youth and their families, but argues that enhancing their knowledge and competence in posing appropriate questions and using appropriate terminology may increase their confidence.
There is a vast quantity of terminology and the use of language in relation to gender variance and identity continues to evolve. Carabez et al. (Reference Carabez, Pellegrini, Mankovitz, Eliason and Scott2015, p.3306) highlight the lack of knowledge about terminology and conclude the “critical need for education in gender identity” for those working with transgender clients. Furthermore, Alegría (Reference Alegría2011) emphasises the great importance of using the correct terminology with people who identify as transgender.
Whilst there is growing literature internationally on transgender care, there is a dearth of research published about transgender youth in Ireland. Ascertaining the training needs identified by CAMHS clinical staff is necessary in order to establish areas of clinical education required and provide insight into the methods of learning that is most acceptable to clinicians. As far as the researchers are aware, there is no research exploring CAMHS clinicians’ level of knowledge and confidence when working with transgender youth; nor on their preferences for support and training to enhance the effectiveness and quality of their work with transgender youth in Ireland. It is important for clinical staff to be knowledgeable and confident in order to provide best practice care, particularly as for many transgender youths, their CAMHS clinician may be the first mental health professional with whom they discuss their gender identity. Hence, the aim of this study is to assess the knowledge and confidence of clinicians in CAMHS and explore what clinical education they desire to assist them in their work supporting transgender youths.
Method
This research is a multi-method designed study. A survey, which included a quantitative scale, combined with qualitative and quantitative questions was disseminated, and six semi-structured interviews were conducted. The qualitative and quantitative research conducted was exploratory in nature and used an inductive analysis process for the qualitative data.
All participants were multidisciplinary mental health professionals who worked across five Leinster-based Irish CAMHS services. These clinicians were asked to volunteer to participate through their work e-mail between March and June of 2017. Seventy-one clinicians took part in the survey, which represents 76% of all staff (93). Fourteen males and 57 females completed the survey phase. This was representative of the gender profile of employees. Participants included the following professions: Psychiatry (14), Psychology (14), Occupational Therapy (6), Psychiatric Nursing (15), Social Work (12), Speech and Language Therapy (6), Social Care (3) and Other (1). The mean age was 41.42 with a s.d. = 9.8 with a range of 22–66 years old. Sixty-six practitioners completed the scale, and 61 participants responded to the survey in full.
The five services were contacted through their work e-mail to ask them to participate in a semi-structured interview. The interviewees included a clinician from Psychiatry, Psychology, Occupational Therapy, Psychiatric Nursing, Social Work, and Speech and Language Therapy. The first person from each discipline to agree to volunteer was interviewed. They represented all the disciplines with the exception of social care. Three were not seniors in their discipline, and the others had more senior positions making their quantity of experienced mixed. There also was a mix in the amount of knowledge they had as a group.
A literature review was conducted on Medline, PsychINFO, PsychArticles, etc. using terms such as transgender, knowledge, confidence, transgender youth, and clinician. Expert consultation was sought from two clinicians from the GIDS who specialise in gender identity care, a consultant psychiatrist who specialises in transgender care for clients aged 16 years and older, and an employee of TENI in developing the survey. The survey was distributed using an online platform, and the participants were assured anonymity.
This survey included demographic questions, a quantitative 14-item scale entitled the ‘Counselor Knowledge about Transgender Issues Scale’ with a Cronbach’s alpha of 0.75, Q–Q plots, and the Marlowe–Crowne Social Desirability Scale were used (Claman, Reference Claman2005). Each item on the scale was on a ‘True’, ‘False’, ‘Don’t Know’ response continuum. Two items were changed; the first to update it to fit with DSM 5 rather than DSM-IV, from ‘Gender Dysphoria is the proper DSM-IV diagnosis for individuals struggling with issues of gender identity (False)’ to ‘Gender Identity Disorder is the proper DSM 5 diagnosis for individuals struggling with issues of gender identity (False)’. The second to make the question relevant to Ireland rather than America, ‘Transgender legal rights relating to housing, public accommodation, and employment are protected in the majority of states (False)’ to ‘Transgender legal rights relating to housing, public accommodation and employment are protected (True)’. An additional question set about clinician clinical education, their confidence, and awareness of supports for transgender youth was included. Descriptive statistics were run using IBM SPSS Statistics 23 and Excel for the demographic data, the scale, and quantitative elements of the survey. Content analysis (Krippendorff, Reference Krippendorff2013) was completed on the qualitative survey questions. The responses from each qualitative question were treated as separate blocks of analysis and analysed separately. Six semi-structured interviews were recorded and thematically analysed together (Braun & Clarke, Reference Braun and Clarke2006). The principal researcher examined the data and coded the framework and researcher two examined the data and coded separately. Reliability between coders was compared, with any discrepancies discussed and used to adjust the coding framework accordingly until reliability was at an acceptable level.
Results
Seventy-six percent of all the clinical staff responded to the survey. As can be seen in Table 1, there is an evenly distributed amount of years of clinical experience, with the mode amount of clinicians having between 11 and 20 years’ experience. Table 1 displays that the mean number of transgender youth seen by clinicians is 5.38 with an s.d. = 10.10 and a mode of two transgender clients. At 51%, the mode duration of sessions was 1–10. The number of sessions delivered to transgender youth by individual clinicians ranged from 0 to 200+.
Table 1. Clinician experience in years and contact with transgender youth
Overall, 87% of clinicians did not believe that they had adequate clinical support (i.e. training/consultation/expert clinical supervision) to work with transgender youth effectively, with only 13% stating that they had adequate clinical support. Table 2 shows that the mode number of clinical staff rated their confidence, and the confidence of their colleagues, as ‘Unconfident’. On a Likert scale of 1–5, clinicians scored their confidence level as ‘Somewhat Confident’ (M = 3.36, s.d. = 0.90), and their colleagues’ confidence level as ‘Unconfident’ (M = 3.59, s.d. = 0.74) when working with transgender youth. Very few considered themselves (15%) or others (5%) to be ‘Confident/Very Confident’ and none of the participants rated CAMHS clinicians generally as ‘Very Confident’.
Table 2. Clinician confidence in caring for transgender youth
Table 3. The themes and subthemes from the thematic analysis
There were 174 incorrect responses, 198 ‘Don’t know’ responses, and 552 correct responses of a total of 924 responses received to the ‘Counselor Knowledge about Transgender Issues Scale’. Under two-thirds of the questionnaire were answered correctly. The mean score of all responses to the questionnaire was 8.65 out of a possible highest score of 14, which is 62% (s.d. = 2.97). From the scale, it is evident that the majority of clinicians, 77%, understood the definition for a transgender woman and 80% comprehended that the term transgender did not refer to sexual orientation. However, 56% answered incorrectly or were unaware of the current diagnostic term in use in DSM-5. A large percentage of participants, 42%, did not know if the following statement was correct or incorrect ‘FTM is proper terminology for a transsexual who identifies as female’. These responses highlight limited knowledge of transgender terminology. Additionally, 37% of participants either did not know or believed no professional guidelines for clinicians working with transgender clients existed.
When asked about the services or clinical pathways available to transgender youth, 49% of participants identified general medical hospital services, 36% listed CAMHS, and 32% stated the GIDS. When considering community resources, 18% of participants identified the organisation TENI as a service and 11% named BeLongTo, the LGBT+ support group. While 58% could list two or more different services, only 20% of clinicians explained a referral pathway. Twenty percent of participants stated that there are limited services available, whilst 38% reported that they were not aware of the services and clinical pathways available for transgender youth.
Sixty-nine percent of respondents said that CAMHS staff are not well informed about transgender issues. However, 20% of participants highlighted that there is variation in clinician knowledge on different areas such as terminology, discrimination, and service pathways, noting that those who have worked with transgender youth demonstrated more knowledge. Additionally, 18% of people said that the knowledge level of clinicians is growing.
In relation to clinicians who had experienced sufficient clinical support, 59% stated that expert consultation (provided by GIDS) had been a useful support. Additionally, 59% reported that clinical education (i.e. in-house and external presentations, workshops, and conferences) had been informative and of benefit to their understanding and approach to working with transgender youth.
Sixty-seven percent of participants requested additional transgender care training and workshops. Transgender-specific supervision or expert consultation was requested by the largest number of clinicians (27%), whilst 11% felt that learning from ‘experts by experience’, specifically transgender people and their families, about how best to support transgender youth, would be of benefit.
Clinicians sought guidance on how to support parents and families of transgender youth (18%) and on how to support the emotional needs of this cohort and guidance on therapeutic input (9%). Eleven percent of clinicians reported an interest in learning about appropriate transgender terminology and 15% sought clarity on the clinical pathway.
Two major themes arose from the six semi-structured interviews; Clinician Awareness and Clinical Education, and Clinicians’ Opinions on the Needs of Transgender Youth.
Theme I: clinician awareness and clinical education
Subtheme (a): Knowledge Deficit around Transgender Terminology and Pathways
The majority of participants (5/6) discussed the lack of knowledge amongst clinical staff about transgender terminology. The participants reported the difficulties they experienced in knowing the correct pronouns to use with transgender youth and the terminological confusion that arises when writing in the person’s file. Further confusion may arise as the file may contain both the youth’s assigned name at birth and their preferred name.
P3: I think there’s probably huge confusion around ehmm he, she, when they’re in the process of transitioning. I think particularly when you’re documenting that that that can come up quite a bit.
The clinicians interviewed felt that clinical staff endeavoured both to keep abreast with, and be respectful about, using the appropriate terminology. However, they noted that terminology does not solely consist of clinical language, but it is also driven by the transgender community and online discourse which means it can make it challenging to keep up-to-date with the constantly evolving terminology.
P2: …very much driven by the trans community and, you know, emh as clinicians we try to keep up on that and be as respectful of that as we can…
P6: …the language is evolving on the internet rather than within clinical realms or fields so, yeah, so we’re always on the back foot
Two clinicians pointed out that they, or their colleagues, were surprised about the quantity of transgender terminology that exists. Another participant stated that some clinicians are not fully aware of how important terminology is within the transgender community.
P4: we had someone from BeLonG To come and speak to us and I realised there is so much more language than I would have initially known.
P5: I think that always causes surprise. I know in one of our department meetings recently we were looking at an article about it and a couple of the clinicians were really surprised.
P6: …people mightn’t ehm understand the gravity of it, they might understand that there’s different language and there’s different words that they mightn’t get how ehm fundamental that is to the young person…
Five participants stated that the referral pathways for transgender youth are not clear, and the sixth participant said that clinicians are not aware of the referral pathway. It was reported that the pathway is not well structured, there is a lack of signposting of services, and that there is, generally, a lack of services.
P5: I would say that it’s very confusing in CAMHS, it’s really not all that clear especially in Ireland like there is no pathway as far as we know really…
Subtheme (b): Sources of Knowledge Deficit
All six clinicians said that there is a lack of knowledge about transgender care and issues in CAMHS. However, four highlighted that knowledge has grown recently. The clinicians (5/6) pointed to insufficient training, clinical experience, or discussion about gender variance and dysphoria as the cause of the knowledge deficit.
P1: First of all training I don’t think we have enough training to deal with these complex issues.
P5: …little bit less confusion now than maybe there was a couple of years ago.
Subtheme (c): Awareness of Discrimination
All six clinicians thought that CAMHS clinical staff would have a general knowledge of discrimination experienced by transgender youth. Clinicians were aware of both societal discrimination (6/6) and discussed how this could cause distress, and two participants spoke directly to the unintentional discrimination within mental health services.
P6: …yeah I think they’re [clinicians] aware that these are young people who could be bullied or potentially discriminated against within schools…
P4: …we have male and female bathrooms beside our waiting area so again where does a young person go?
Subtheme (d): Effect of Knowledge and Clinical Experience on Clinician Confidence
All six clinicians said that having knowledge and experience in working with a transgender youth or lack thereof, either respectively raises or lowers the confidence levels of clinicians.
P4: …some clinicians would have no experience whatsoever and others would have gained considerable experience and I think that’s really important too. [for confidence]
P6: I suppose confident eh enough in some ways but that’s because of the experience that I’ve had with young, with one young person…
Subtheme (e): Desired Clinical Education
All six clinicians stated that they, and clinical staff generally, would benefit from clinical education. All participants described in-house or external transgender organisations’ presentations as a good method of educating staff about supporting transgender youth.
P2: TENI Service ehh is very good and they have good speakers.
Three participants stated that it would be beneficial to hear from ‘experts by experience’.
P5: …having transgender youth who’re attending say ‘honestly like this was my experience and this is what I think would have helped’.
P2: I think it’s always helpful to hear the lived experience, you know. And particularly from adults I think that have been through it, you know, because that’s where our young people are aiming for…
The majority of participants (4/6) thought that further expert consultation from the GIDS would be useful.
P6: Tavistock are coming over and that does help….so they’re like experts in the field ….they’re kind of offering us a form of supervision, maybe once, twice a year, something like that but it is still really helpful so if we could get a little bit more of that it would be great.
Theme II: Clinicians’ Opinions on the Needs of Transgender Youth
Subtheme (a): Most appropriate Services for Transgender Youth
Five participants discussed that transgender youth attending CAMHS generally have mental health difficulties unrelated to gender identity.
P1: …the only time I’ve heard gender dysphoria mentioned is in association with those conditions or anxiety or depression…
Five said that they considered that if the young person does not have mental health difficulties that CAMHS would not be the most appropriate service. In these cases, those transgender youths who wish to medically transition would need to attend a Gender Identity Clinic.
P6: …some people, young people don’t need the mental health service at all, they just want to go ‘refer me to Crumlin, diagnose me and refer me…
One participant highlighted that, if there is no mental health difficulty, attending a mental health clinic is potentially stigmatising.
P3: …are we punishing them in a way for that choice in terms of going to a mental health setting?
Subtheme (b): Holistic, Individualised, and Needs-based Support
Five of the participants discussed the need to provide holistic support. All clinicians noted that transgender youth would be impacted by society, and as one of the clinicians remarked, part of clinician’s role is to enable transgender youth to adapt and understand their options.
P1: I really believe in supporting the person, the environment and the wider community cos all these problems happen out there as well…
P2: …they’re not kind of, you know stuck in one eh identity around it, you know, so it’s helping them kind of find their place in that I suppose is a role as well.
Furthermore, all clinicians highlighted that care should be individualised and needs-based as different transgender youth will require differing inputs and services.
P1: I think it has to be needs based…. it’s just case by case…
Discussion
Most clinicians reported experience of working with at least one transgender youth (83%). However, clinicians rated themselves and their colleagues most commonly as unconfident in providing care for transgender youth, and very few considered themselves to be confident. The majority, 87%, stated that they had insufficient clinical support. Therefore, this demonstrates that while clinicians are supporting this vulnerable cohort, the majority do not feel confident in providing this care and do not believe that they have adequate clinical education to care for transgender youth.
The clinician’s score (8.65 out of 14) on the ‘Counselor Knowledge about Transgender Issues Scale’ was lower than that of the original piece of research completed by Claman in Reference Claman2005 (10.1); however, she deemed her American based counsellor (psychologist, psychiatrist, social worker, and marriage and family therapists) participants as having a high level of knowledge. This score (8.65) reflects the qualitative responses that reported that significant gaps in knowledge exist. Importantly, the scale highlighted that many clinicians did not know or believed that there were no professional guidelines for working with transgender clients. It would be beneficial for clinicians to be aware of the WPATH Guidelines for international best practice guidelines on transgender healthcare as a potentially valuable resource.
The main services available to Irish transgender youth were mentioned in the survey responses. There was a greater emphasis on the services providing medical intervention, rather than community groups that provide support for transgender youth. It would be important to ensure clinicians are aware of community resources where transgender youth and their families can access support and become involved in the transgender community. Additionally, a large portion, 38%, said that they were unaware of the services or pathways available for transgender youth and 16% of participants stated that these services are very limited. This lack of clarity was corroborated in the interviews responses. Hence, there is a need to clarify pathways, educate clinicians about the service that currently exist, while simultaneously highlighting that there is a need for additional transgender services, and for them to be signposted more effectively.
Overall, most responses, 69%, indicated that clinicians were not well informed about supporting transgender youths. The clinicians interviewed explained that the lack of knowledge amongst clinical staff was due to inadequate training, lack of discussion, and insufficient experience working with transgender youth. This lack of training and limited experience in caring for transgender youth is evinced by the quantitative and qualitative data. As clinicians reported that lack of knowledge and experience makes them less confident, it makes sense that large percentages of clinicians reported a lack of confidence in supporting transgender youth. It was found from the content and thematic analyses that clinicians believed that increasing training and experience would lead to higher level of clinician confidence when supporting these youths.
Considerable variation of knowledge amongst clinicians was reported. Both sets of qualitative data indicate that those working with transgender youth seem to be the most informed across a range of topics. The interview data reported that transgender youths played a role in informing clinicians about relevant and current topics. A strong desire for greater understanding through clinical education was found across the data. Finding that clinicians want to deepen their understanding of the issues and concerns of transgender youth and their families is very positive for the future of clinician work with transgender youth.
In the quantitative questionnaire, a lack of knowledge around transgender terminology was found. A desire for more training on terminology was requested in the survey and the interviews (5/6). While clinicians appeared to be endeavouring to be respectful in using the most up-to-date appropriate terminology, it is clearly challenging to stay informed, as terminology is evolving rapidly and is frequently being driven by the transgender community. Furthermore, clinicians may not be aware both of the quantity of terms and the importance of terminology to the transgender community.
Clinicians are aware that some young people may experience discrimination at a societal level. Clinicians stated that an ideal service would support transgender youth holistically, assisting them to cope and flourish within their environments. This idea is promoted in the literature and the Royal College of Psychiatrists (2012) good practice guidelines. This approach would encompass family and school support and advocating for them. Research by Olson et al. (Reference Olson, Durwood, DeMeules and McLaughlin2016) concluded that socially transitioned transgender children who are supported have normative levels of depression and only minimal elevations in anxiety. It is to be hoped that with greater knowledge and confidence, clinicians as advocates for their transgender clients can address prejudices and contribute to the reduction of discrimination. A decrease in gender-based prejudice may assist in the reduction of suicide rates in this highly stigmatised population (Clements-Nolle et al. Reference Clements-Nolle, Marx and Katz2006).
It was discussed by 5/6 clinicians that most of the transgender youth who attend CAMHS have mental health difficulties, and their complex difficulties may require a specialist CAMHS intervention. This supports international evidence that finds transgender youth having higher risk of psychopathology then their peers and higher rates of self-harm and suicidal ideation (Veale et al., Reference Veale, Watson, Peter and Saewyc2017). Concern was expressed about the potential for stigmatisation of transgender youth without mental health difficulties attending CAMHS who are solely attending to receive a referral for a GD diagnosis. However, currently in Ireland, there are very little public services for transgender youth without co-occurring mental health difficulties. Overall, as found by McNeil et al. (Reference McNeil, Bailey, Ellis and Regan2013), there will be transgender people who need mental healthcare and it is vital for clinicians to be able to provide this with the necessary knowledge and confidence.
This research is limited by the fact that it was conducted solely in Lenister. A different experience or result may be found outside of Leinster. It is hoped that this research may be extended to different CAMHS services nationally to expand its explanatory power. It would have been useful for the research to be more specific in asking clinicians about the type of work they feel confident or lacking in confidence in, that is, assessment, intervention, etc. The ‘Counselor Knowledge about Transgender Issues Scale’ did include some outdated terms which were not ideal. Additionally, it would have been interesting to know the experience of those who did not respond to the questionnaire in order to make a comparison.
It would be beneficial for future research to be conducted with transgender youth in CAMHS services, in order to ascertain how they feel they can be best supported. Additionally, if there is a lack of knowledge and confidence amongst CAMHS clinicians, as found in this study, it would be useful to explore if this is also true for other professionals who work with young people as they may also need input to support them with their work. It would also be useful to quantitatively assess in a sample with more experience if knowledge and confidence increase with experience and if confidence increases with more knowledge.
In summary, clinicians in this study lacked confidence in supporting transgender youth, and there were some gaps in knowledge in this area, especially around terminology and referral pathways. A significant majority of clinicians stated that further education on transgender care is required. With the rising number of transgender youth presenting to mental health services for mental health difficulties, it is very important for CAMHS clinicians to have an understanding of transgender terminology, services, and their social experience and how best to support them. Clinicians requested different methods of learning (training, supervision, hearing the lived experience, etc.), and information and training on a range of topics (terminology, how to support the family, therapeutic support, and pathways, etc.). This research recommends that in order to optimise clinician learning, the identified educational needs of clinicians are addressed in the methods deemed most acceptable by staff. Increasing the capacity of CAMHS clinicians to provide appropriate support to transgender youth is vital to delivering best practice care to transgender youth and their families.
With increased training, access to information, and experience working with transgender youth, clinicians believed that greater confidence and knowledge will be engendered. With this enhanced clinician knowledge and confidence, it is hoped that the transgender youth’s journey through CAMHS may be a more positive and beneficial experience.
Glossary
Assigned sex at birth – Refers to the concept that sex is determined by external and internal physical characteristics at birth, with societal expectations of gender normative behaviours and interests in accordance with birth assigned sex.
Child and Adolescent Mental Health Services – CAMHS. A specialist service (secondary mental health equivalent) for children and adolescents with mental health difficulties.
Female-to-Male (FTM) – A person who was assigned female at birth who identifies as male; a transgender man (however, some men do not think of themselves as having transitioned from female to male because they always felt male).
Gender Dysphoria – A DSM-5 diagnosis referring to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.
Gender Identity – A person’s deeply felt identification as male, female, or some other gender. This may or may not correspond to the person’s physical characteristics or the sex they were assigned at birth.
Gender Identity Development Service (GIDS) in the Tavistock and Portman Clinic – A specialist gender identity development service for children, young people, and their families who experience difficulties in the development of their gender identity.
Gender Variant – People whose gender identity and/or gender expression is different from traditional or stereotypical expectations of how a male or female ‘should’ appear or behave.
LGBTQ+ – Lesbian, gay, bisexual, transsexual, queer, or questioning. The plus represents the many other sexual and gender identities not included in the initialism.
Male-to-Female (MTF) – A person assigned male at birth who identifies as a female; a transgender female (however, some women do not think of themselves as having transitioned from male to female because they always felt female).
National Gender Service – A specialised multi-disciplinary service, based in St. Columcille’s Hospital in Loughinstown, Co. Dublin, for people 18 years and older who want to transition. There is a gender service in the process of being established in Our Lady’s Hospital for Sick Children in Crumlin, Co. Dublin. At present, the gender service in Crumlin constitutes of an outreach service provided by the Gender Identity Development Service (GIDS) from the Tavistock and Portman Clinic in the UK and an endocrinology service.
The World Professional Association for Transgender Health (WPATH) – A non-profit interdisciplinary organisation devoted to transgender health and publishing standards of care in relation to the health of transgender people.
Transgender – an umbrella term used to describe the full range of people whose gender identity and/or gender role do not conform to what is typically associated with their sex assigned at birth.
Transgender Equality Network Ireland (TENI) – A non-profit organisation supporting the transgender community in Ireland. TENI provides advocacy, education, and support services.
Transition – Is a process whereby a transgender person begins to live as the gender with which they identify, rather than the one assigned at birth. Transition may include social, legal, medical, or surgical changes.
Financial Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
The authors SH, TB, MS, KM have no conflicts of interest to disclose.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the Trinity College Ethics Committee and the St. John of God Ethics Committee. The study protocol was approved by the ethics committee of both the Trinity and St. John of God ethics governance committee.
