Cassie Wilson can pinpoint the moment her daughter Melanie became her son, Tom. They were in the supermarket and Melanie, then two and a half, said: â€œI donâ€™t want to be a girl any more â€“ Iâ€™m going to be a boy, and Iâ€™m going to be called Tom.â€
â€œThat was that,â€ Cassie tells me. â€œI said: â€˜Come on, then, Tom.â€™ He could have said he was called anything and I would have thought, great, fine, letâ€™s get on with the shop.â€
â€œI was wearing my Spiderman costume,â€ Tom, now five, remembers.
â€œYes, you were,â€ Cassie nods.
But it didnâ€™t end when they left the shop. â€œThe next day, when Tom woke up, I said: â€˜Morning, Melanieâ€™ and he said: â€˜I told you yesterday! My name is Tom!â€™ It just went on from there.â€
Cassie and I are sitting at the dining table in her home in the north-east, while Tom charges about in a Batman costume, brandishing a sword. Cassie, 30, is a single mother to Tom and his sister Carla, whoâ€™s just turned two. Side by side on the shelves near us are two framed photographs: on the left is Melanie in a white dress, with a cascade of blond ringlets; and on the right is Tom, still the same bright blue eyes, but with a boyâ€™s short hair.
Tom loves dressing up. â€œNormally as a superhero,â€ Cassie says.
â€œBatman and Superman,â€ Tom adds. â€œAnd Wolverine!â€ He also likes to play cowboys or policemen with his best friend, Charlie. â€œSometimes we arrest people. Remember when we did it yesterday to the dog?â€ He grins. â€œHe wasnâ€™t putting the ball down.â€ He shows me his bedroom. Thereâ€™s his treasured Playmobil pirate ship, his Marvel poster featuring Ironman, Captain America and the Hulk, and his pencil case shaped like a football boot.
Cassie says she knows that Tom is very young to be transgender, but he is just one of a striking number of children who have been referred to the Tavistock and Portman NHS Trustâ€™s Gender Identity Development Service in London over the past five years. A multidisciplinary clinic where all British transgender children are assessed, the service has seen referrals increase by 50% every year, from 97 new cases in 2009 to 697 in 2014. Young children such as Tom are unusual, but not rare: last year alone, close to 100 of those referred were aged 10 or younger.
Cassie tells me this was clearly â€œmore than just a little phaseâ€. Until that trip to the supermarket, Melanie had always been â€œquite tomboyish â€“ I hate that phrase nowâ€. But ever since that day, he has been Tom consistently, never faltering, even though at first he still dressed as a girl. But he always wanted to be called Tom, and to be referred to as â€œheâ€ and â€œhimâ€. If anyone used a female pronoun, he would get furious.
â€œOn numerous occasions we would have to leave the park because someone would say: â€˜Let that little girl have a turn.â€™ Weâ€™d get out of the park and heâ€™d absolutely sob his heart out. It was the end of the world. Heâ€™d say: â€˜Mummy, why canâ€™t people see that Iâ€™m really a boy?â€™ This was before he was three.â€
He still has girlsâ€™ clothes in his drawer. Cassie says he can choose to dress as a girl if he wants, but he never does any more.
When Cassie took three-year-old Tom to the barber for the first time, she wept. â€œThat was the final thing. If I let him get his hair cut short, that was me accepting he is a boy.â€ The hairdresser was bemused. â€œI was crying and I had this little boy with me who had hair down to his arse. She asked him: â€˜Has your mummy never let you get your hair cut?â€™ And he loved it, because she thought he was a boy with long hair.â€ After that, Tom never got mistaken for a girl, and became much happier.
â€œGranny still calls me â€˜sheâ€™. My teacher still calls me â€˜sheâ€™ sometimes.â€ Tom scowls as he nibbles a chocolate-covered rice cake. Heâ€™s about to go into his second year of primary school, where heâ€™s fully transitioned: a male pupil. While the teachers have done everything possible to make things easy for Tom, the staff who have known him since nursery often get confused, because he was enrolled as a girl. â€œIt used to make you upset but now youâ€™re more grown up,â€ Cassie tells him, deliberately.
Like most parents of transgender children, Cassie learned about gender dysphoria from Google. Before sheâ€™d heard of the Tavistock or even visited her GP for a referral, she found Mermaids, a support group for transgender children and their families. â€œThe Mermaids website is quite negative,â€ she says. â€œEvery time I went on it, it made me worryâ€¦ I knew from reading other peopleâ€™s posts that I was going to struggle with my GP, because it seems to be a standard thing that they say no, we donâ€™t believe in this.â€ She went to her GP armed with a printout of the NHS websiteâ€™s page on gender dysphoria, prepared for a fight. Her doctor told her that she, too, had children, and that she needed to be tougher: tell her sheâ€™s a girl, and thatâ€™s the end of it. Tom was initially referred to child and adolescent mental health services, and then the Tavistock. Heâ€™s having annual appointments there, with his second coming up in a few weeksâ€™ time.
No one can agree on what causes gender dysphoria, why so many children now say they are experiencing it, or even what it is, exactly: the idea that some people are just â€œborn in the wrong bodyâ€ doesnâ€™t do justice to the range of feelings transgender people express. Gender itself is difficult to define, with a mix of social, medical and individual interpretations. The little research that exists on gender dysphoria is patchy and often fiercely contested. Some claim it has a biological basis; others argue it is a psychological state. Some say it must be genetic or created in the womb; others see it as learned behaviour, or a combination of nurture and nature. Whatever it might be, for the families of transgender children it is undeniably real.
â€œTom is telling me what he wants and this is who he is, so I have to respect that even though heâ€™s five. He knows his own mind,â€ Cassie says. â€œIt could be that he changes his mind and goes back to being Melanie. But I canâ€™t see it happening.â€
The available evidence suggests most young children with gender dysphoria will not go on to be transgender adults. The Tavistock quotes research claiming that, while the majority of post-pubescent teens with gender dysphoria continue into adulthood with the same feelings, only 16% of prepubescent children do. (This figure comes from taking data from several different studies, with a total sample size of 246 children.)
Transgender children now have the opportunity to delay puberty by taking hormone â€œblockersâ€ that inhibit the development of their secondary sexual characteristics, such as breasts, periods, a broken voice or facial hair. They can stop taking the blocker at any time and their own puberty will kick in, albeit at a later stage. But if they choose to proceed with the transition, they can then take cross-sex hormones from 16 years old, which will bring on the puberty of the gender they want to be. After they turn 18, they can opt for sex-change surgery through the NHS.
â€œHand on heart, I do think that Tom will be trans when heâ€™s older. He talks about â€˜when I start having medicine to make me grow a willyâ€™,â€ Cassie says. But she is making sure he knows his options are always open. â€œWhen heâ€™s 18, he might be really mortified that this ever happened. But the message deep down is still going to be the same: itâ€™s OK to be the person that you feel you are, and if that changes, thatâ€™s all right as well. You want your children to be happy.â€
Meanwhile, the NHS is proceeding carefully with this explosion of child transgender referrals. Some parentsâ€™ groups claim it is too slow, too cautious and putting the wellbeing of young people at risk. â€œMedical intervention is very important, especially for teenagers who are already in puberty,â€ says Susie Green, chair of Mermaids and mother of a trans daughter. â€œItâ€™s absolutely vital. If they feel their body is changing against their will, thatâ€™s when we get a lot of suicidality, self-harm, lots of young people talking about wanting to be dead. Weâ€™re trying to help the parents to help their children to get to a better place, and a lot of that is about navigating services and getting timely intervention â€“ which unfortunately is not really happening as much as it should.â€
Green became involved with Mermaids 16 years ago, after she got in touch about her daughter, Jackie, who was then six. â€œThis is biological, definitely. Itâ€™s too widely pathologised as being a psychiatric issue, when itâ€™s not,â€ she says. â€œThe level of understanding within the NHS is appalling. If youâ€™ve got a child whoâ€™s suicidal and self-harming because their body is changing against their will, nothing is done to fast-track or deal with that need. Thatâ€™s why weâ€™ve got families going abroad.â€ (This tends to be to the US, Germany and Holland.) Green reels off shocking figures from a 2014 study by the mental health charity Pace which surveyed 2,000 young people with gender issues: 48% attempt suicide, 58% self-harm. â€œItâ€™s really common.â€ She pauses. â€œYou can see why weâ€™re worried.â€
In the back garden of her Northamptonshire home, eight-year-old Julia King leaps on the trampoline with her 12-year-old brother, Dylan. Sheâ€™s tiny and delicate, a pink hairband just holding her shoulder-length, white-blond hair from her face, her pink-framed glasses somehow staying put.
Iâ€™m in the living room, drinking tea with Juliaâ€™s parents: Annie is on the sofa, Daniel lying on the carpet on his side, propped up by a cushion. They finish each otherâ€™s sentences as they tell me what can happen to transgender children like Julia.
â€œDepression. Isolation,â€ Annie says.
â€œSelf-harming. Substance abuse,â€ Daniel says.
â€œSuicide,â€ Annie adds. â€œThey kill themselves, you know. And I want a happy daughter, not a dead son.â€
Like Cassie, the Kings have learned a lot about gender dysphoria from Mermaids. The whole family has taken part in the organisationâ€™s residential get-togethers, where families meet and share information. Last time, Annie found out that Julia was telling people she was only there in support of her transgender brother.
â€œSheâ€™s cheeky. Sheâ€™s funny. Sheâ€™s quickâ€ â€“ Annie snaps her fingers â€“ â€œvery quick. Sheâ€™s into everything. My Little Pony, Moshi Monsters. Her friends. Parties, hair, nails. Clothes! She can change her clothes three, four times a day.â€
Julia was born Callum, but as soon as she could talk, she said she was a girl. From two or three years old, she refused to answer if people called her by her birth name.
â€œShe used to draw herself as a girl as soon as she could hold a pencil,â€ Daniel says. â€œIâ€™ve never seen her draw herself as a boy, ever.â€
Unlike Tom, there was no single turning point when Callum became Julia. â€œIt just â€“ from a little, little age â€“ happened,â€ Annie says, brushing her pink, dip-dyed fringe from her eyes.
Daniel nods. â€œIt evolved.â€
At nursery, she was always in the dressing-up box, choosing the girlsâ€™ costumes. When Julia was given her first dress, at two and a half, she would wear it to bed. â€œShe wore it until it was falling apart. We had to buy a new one because she was growing out of it.â€
Julia still had a boyâ€™s haircut at the time, and they didnâ€™t let her wear her dresses outdoors. â€œShe would ask: â€˜Why? Why?â€™ And Iâ€™d say to her: â€˜People arenâ€™t used to seeing boys in dresses.â€™
â€œWhen she was around four, she started asking questions. â€˜When will I have a baby in my tummy? Why do I have a winky when Iâ€™m a girl? Will I have boobies one day? When will I grow into a girl?â€™â€ Annie winces. â€œThese arenâ€™t normal questions. Dylan never asked them.â€
Dylan comes in. Heâ€™s tall with square shoulders, his hair shaved at the sides with a floppy quiff on top. Juliaâ€™s having her picture taken and heâ€™s not interested in watching her pose.
Whatâ€™s Julia like as a sister, I ask. â€œJust a sister,â€ he shrugs. â€œI donâ€™t see her as a boy or a girl. Sheâ€™s just my sibling.â€
Julia never wanted Dylanâ€™s little cars, his action figures or his Star Wars toys. Her Christmas list, aged three, was full of Barbies. Annie and Daniel had never heard of people who were transgender at that point, and didnâ€™t know how to respond.
â€œI struggled, initially,â€ Daniel says. â€œI had a big issue, not with her, but with the fact that Iâ€™ve got a boy and Iâ€™ve got another boy who wants to be a girl.â€ Daniel works in uniform, in a very conventionally male world. â€œI wasnâ€™t ashamed, but thereâ€™s something in you, your pride or something, where you think, this isnâ€™t what men do.â€ Now, he says, heâ€™s incredibly proud of his daughter. When they changed her name by deed poll a few weeks ago, he toasted her with champagne.
Juliaâ€™s grandparents have found it harder to accept. â€œMy mum said: â€˜You wanted a girl, thatâ€™s why this is happeningâ€™,â€ Annie says. She thinks itâ€™s a fad. â€œSheâ€™s said: â€˜This is all some American thing.â€™â€
When Julia was five, social services rang. â€œThey said weâ€™ve had an anonymous call, that youâ€™re making your son Callum wear dresses,â€ Annie tells me. â€œI went ballistic. I said, â€˜You are more than welcome to come to my house, because when you go in Callumâ€™s bedroomâ€¦â€
Julia comes in with a plate of cocktail sausages.
â€œâ€¦heâ€™s got pink walls, heâ€™s got princess castles, heâ€™s got Barbiesâ€¦â€™â€ Annie continues.
â€œHe?â€ asks Julia, indignant.
â€œâ€¦he wears princess dresses.â€ Annie throws her hands up. â€œI donâ€™t care what anybody thinks.â€
â€œWhoâ€™s he?â€ Julia frowns.
Upstairs, Juliaâ€™s bedroom is meticulously tidy. Her shelves are stacked with boxes of loom bands, a Shimmer â€™n Sparkle nail kit and books with titles such as Love Lessons and The Illustrated Mum. She sits on her bed, twisting foam flowers on to a pipe cleaner to make a ring.
â€œWhen people say â€˜heâ€™ it makes me feel nervous,â€ she says gently. â€œThat theyâ€™re going to forget and call me it from now on. That it might go back to how it was. All my friends call me Julia now. They never say C-A-L-L-U-M.â€ She canâ€™t bring herself to say it.
But then she says something I wasnâ€™t expecting. â€œSometimes I say to my friends â€“ because they were born a girl â€“ â€˜Would you be a boy for a day to see what it feels like?â€™ And they say yeah, but Iâ€™m like: â€˜I donâ€™t have to because Iâ€™m both.â€™â€
Do you really think youâ€™re both, I ask, or do you think youâ€™re a girl?
â€œIâ€™m both. Itâ€™s all right if Iâ€™m both. I want my mum to take me to football lessons.â€ But then the next minute she says she never feels like a boy, even though being a girl can be tough. â€œWhen youâ€™re a boy you fall out and then the next day youâ€™re friends, but with girls you fall out for months. Itâ€™s easier when youâ€™re a boy.â€ She talks me through her collection of figurines. Thereâ€™s Slimer from Ghostbusters, Raven from Teen Titans Go, Predator, and Anna from Frozen. â€œI donâ€™t really like Frozen. I like horror films,â€ she grins. â€œMy favourite film is Chuckie. For Halloween, Iâ€™m going to be Chuckieâ€™s bride.â€
Back downstairs, I tell Annie and Daniel what Julia said. â€œShe knows the trans world better than we do,â€ Annie says. â€œWill there always be confusion in her mind?â€ she asks herself.
But is it confusion, or can you just be both?
â€œShe can be whatever she wants to be, however she sees herself. Sheâ€™s just our little girl at the moment.â€
Julia is enrolled at her Catholic primary school as Callum. The school had suggested she finish the year as Callum and come back in the autumn as Julia, and the Kings had planned a big coming-out party for her over the summer â€“ but Julia made it happen more quickly, insisting on wearing a skirt to school earlier this year.
â€œI said, â€˜Do you really want to wear this?â€™â€ Daniel says. â€œShe said, â€˜Dad, Iâ€™m scared, but I want to because I have to.â€™â€
â€œWhen she does things like this, you realise she doesnâ€™t have the choice,â€ Annie adds. â€œShe will put herself in the most awkward position. We donâ€™t hold her back.â€
They wonâ€™t hold her back when it comes to medical intervention, either. â€œWe need to get these hormone blockers,â€ Annie says. â€œI wouldnâ€™t want people to think that Iâ€™m pushing for something she doesnâ€™t want, but Iâ€™m very aware of those years that could damage her future if sheâ€™s going to live the rest of her life as a woman. If we can get them at 10, 11, 12, brilliant. All the decisions are hers. We make her aware of what is out there, what they do, how she takes them, what she can have â€“ even operations.â€
At a Mermaids residential meeting, the Kings learned how other countries treat transgender kids. â€œThey said that places like Germany and Holland are ahead of the UK in relation to giving the blockers,â€ Daniel says. â€œAnd I told the Tavistock, if thereâ€™s any blocking [of Juliaâ€™s treatment] Iâ€™ll remortgage and Iâ€™ll take my child over straight away. Thereâ€™s no way Iâ€™ll stop my childâ€™s happiness because of your restrictions.â€
â€œWe have made that quite clear to everyone,â€ Annie adds.
At the Tavistock, they are taking a more cautious approach. I meet Dr Polly Carmichael, the consultant clinical psychologist who leads the Tavistockâ€™s Gender Identity Development Service, in her office in a leafy corner of Belsize Park, north London. A stone Sigmund Freud sits deep in thought in a corner of the car park. Carmichael is concerned that physical intervention is being seen, unrealistically, as a panacea.
â€œWhen the idea of the blocker being available to younger people was being pushed forward, I think that inevitably â€“ understandably â€“ there were quite simplistic arguments that if you have the blocker then all the problems disappear. In our experience, all the problems do not go away.â€
The blocker can be therapeutic in itself, because it takes away the anxiety that comes with going through the â€œwrongâ€ puberty. It also gives young people much-needed time and thinking space. â€œThe idea was, if you could reduce that distress, then there would be room for young people to really explore the less reversible interventions: cross-sex hormones,â€ she explains. â€œBut thereâ€™s also a lot of pressure to introduce cross-sex hormones at a younger age. Itâ€™s currently at 16. For some, thereâ€™s a real wish to bring it down to 14.â€ When I ask who she means, she says Mermaids and the Gender Identity Research and Education Society (Gires), a transgender advocacy charity based in the UK. â€œReally big changes like that should not be considered outside proper research protocols. We just donâ€™t have the evidence.â€
Carmichael says itâ€™s very important for young people to experience some of their own puberty. â€œThe blocker is said to be completely reversible, which is disingenuous because nothingâ€™s completely reversible. It might be that the introduction of natal hormones [those you are born with] at puberty has an impact on the trajectory of gender dysphoria.â€ Even though the idea of experiencing any â€œnaturalâ€ puberty might horrify the Kings and the Wilsons, by inhibiting it completely Tom and Julia might be denied the chance to explore fully who they are.
The available evidence suggests that most prepubescent children with gender dysphoria will have a different outcome in adulthood, Carmichael says: â€œThe most common would be one around sexuality, rather than gender identity.â€ In her experience, they are more likely to be LGB than T.
When Carmichael took up her role in 2009, it was rare for children to be socially transitioned in primary school. Now itâ€™s becoming the norm. What are the implications if only a small proportion will end up as transgender adults?
â€œIf a lot has been invested in living in a gender role, then, potentially, it is difficult for young people to say: â€˜Well, actually I donâ€™t feel like that any more.â€™ Parents rightly want to support their child. Parents report that many young people who do make a social transition are much happier, that theyâ€™re functioning much better â€“ which is why there isnâ€™t a right and wrong. Itâ€™s about that child being able to carry on with general development, be in school. If transitioning facilitates that, then thatâ€™s positive, but how do we keep in mind a diversity of outcomes?â€ She pauses. â€œItâ€™s really hard, a real challenge.â€
The answer, she suggests, might lie in understanding gender as a spectrum, not a set of binary categories. â€œIt would be great if society were more open to a range of presentations. I think if we could break down some of the gender stereotypes around boys and girls being divided in school the whole time, then that would be positive.â€
Consultant clinical psychologist Dr Bernadette Wren works alongside Carmichael. Sheâ€™s concerned that gender is becoming increasingly polarised, at an ever younger age. â€œSome of these children are going into a school environment where they make gender choices all day long, and they shouldnâ€™t have to,â€ she says. We discuss how pupils have to choose what uniform to wear, what books to read, what sports to play, even what stationery to use, and I think of Julia insisting on wearing her school skirt, and Tomâ€™s football-boot pencil case. â€œItâ€™s not that you want everyone to be androgynous and gender fluid, you just donâ€™t want children to constantly have to make those choices. We need to preserve a space where children can explore their gender identity without having to make a commitment so early.
â€œThe younger ones can really, really want to be girls or boys, and then they can give that up and their relationship to their bodies can settle down quite comfortably. If we can help some of those young people through adolescence, they might make a different choice later.â€
What about the risk of depression, suicide and self-harm at puberty, cited by parents?
â€œIt troubles me that parents of very young children are already in terror that their child is going to kill themselves,â€ Wren says. â€œThe energy has to go into changing how these people are seen by their peers, not into physical intervention alone. You donâ€™t want these kids to have to make themselves over at a very early stage because otherwise theyâ€™ll be tormented to death.â€
But what about the young people who say that living in their body is itself a torment?
â€œWe have shifted to make the treatment available earlier and earlier. But the earlier you do it, the more you run the risk that itâ€™s an intervention people would say yes to at a young age, but perhaps would not be so happy with when they move into their later adulthood.â€
The argument over whether to intervene early or wait and see how a childâ€™s gender identity develops naturally is so polarised, with such potentially serious implications, that it can be baffling â€“ terrifying â€“ for the families caught in the middle. Whatever the correct balance, medical intervention alone cannot ensure that transgender children become healthy, happy adults. More than anything else, transgender children need resilience; even if their family accepts them, and however tolerant we are as a society, they will need enormous strength to manage the choices and challenges they will face as they grow up and form relationships.
The Kings have already had their first taste of those challenges. When we meet, itâ€™s the day after Juliaâ€™s school disco â€“ the first time sheâ€™s ever been properly dressed up for an occasion â€“ and Annieâ€™s telling me about it with tears in her eyes. â€œI watched her run in across the hall, and all the girls running to her. Last night she was one of them. And I knew how much it meant to her.â€ Julia danced with a boy called Luke, and theyâ€™re now boyfriend and girlfriend. â€œBut my worry is, whatâ€™s Lukeâ€™s mum saying when he goes home and says: â€˜Iâ€™m going out with Julia, Mumâ€™? I donâ€™t think society has come to terms with trans as far as parents letting their sons go out with a transgender female. Theyâ€™re fine to let them play together, to go to school together, to be best friends. But relationship-wise? Iâ€™m not sure.â€
Annie might not want Julia to know sheâ€™s worried, but Julia will learn the reasons for herself soon enough. â€œWeâ€™ve just got to be there, ready to catch, if anything falls apart.â€
â€¢ Some names have been changed.