Factors shaping gender incongruence and gender dysphoria, and impact on health services

DOI: https://doi.org/10.58248/PB53

Warning: This briefing discusses issues around suicide which some readers may find distressing.

Background

In the 2021 census for England and Wales 45.7 million people (94% of the population aged 16 or over) answered the question: “Is the gender you identify with the same as your sex registered at birth?”. Of the people who answered the question, 262,000 (0.54% of people aged 16 and over) said their gender identity and their sex registered at birth were different. However, the reliability of this data has been questioned and the Office for Statistics Regulation is undertaking a short statistical review.  

The evidence about why some people develop distress associated with gender incongruence is generally limited and poor quality. Stakeholders with varied perspectives may interpret the same research in different ways.  Distress can be described as occurring at distinct levels, including individual (distress associated with one’s body); interpersonal (distress associated with social interaction); or social (distress associated with living as a transgender or non-binary person in society). The presence and relative importance of each of these factors is unique to each individual. 

The demand for gender identity services has increased for children and adults. Healthcare services in England do not have the current capacity to meet this significantly increased demand in a timely way. There are long waiting lists between approximately 40 and 60 months and there are concerns that waiting times are contributing to distress experienced by children and adults. 

Specialist NHS services for children and adolescents are the subject of an independent review (the Cass Review). The review was commissioned by NHS England and NHS Improvement to explore how services could be improved, and to ensure that the NHS can commission safe and effective services. There were concerns that overall service design was not subjected to some of the normal quality controls that are typically applied. 

The way the medical community defines gender incongruence is changing. The World Health Organisation moved “gender incongruence” from a mental health to a sexual health classification in the International Classification of Diseases and Related Health Problems (ICD) 11th edition. This may have potential future implications for the way gender is recognised in legislation.  

Overview of key points 

• The Office for National Statistics collected data on the number of people identifying as transgender in the 2021 England and Wales census. This is the first time nationally representative data for this population has been collected. The Office for Statistics Regulation is reviewing the reliability of the data. 
• Referrals to specialist child and adolescent gender identity health services increased from 210 per year for 2011-12 to over 5,000 per year for 2021-22. 
• There has been a notable increase in the number of adolescent birth-registered females being referred for specialist care. The reasons for this are poorly understood. 
• There is less publicly available data for adults, but research suggests more are seeking support, with larger increases amongst younger adults.
• These patterns in increased care seeking have also been reported in Western Europe and North America. 
• Some stakeholders understand this to be a result of increased societal awareness and acceptance of people with transgender and non-binary identities.
• Other stakeholders state there may be other biological, psychological, or cultural factors that could explain this.
• Health service provision has not kept pace with the rapid increase in referrals.
• NHS England and NHS Improvement commissioned an independent review (the Cass Review) of specialist NHS services for children and adolescents. 
• The way the medical community defines gender incongruence is changing and this has implications for the way gender is recognised in legislation.  
   

Acknowledgements

POSTbriefs are based on literature reviews and interviews with a range of stakeholders and are externally peer reviewed. POST would like to thank interviewees and peer reviewers for kindly giving up their time during the preparation of this briefing, including: 

• Members of the POST Board*  
• Cassie Barton, House of Commons Library*  
• Felix Lane, Stonewall*  
• Dr Lisa Littman, Institute for Comprehensive Gender Dysphoria Research*  
• Dr Una Masic, The Tavistock and Portman NHS Foundation Trust*  
• Dr Azer Mohammed, London Child and Adolescent Mental Health Services*  
• Office for National Statistics (for census 2021 statistical aspects)*  
• Dr Sean Pert, Indigo Gender Service*  
• Professor Ivanka Savic-Berglund, University of California, Los Angeles*  
• Dr Tara Suchak, TransPlus, 56 Dean Street*  
• Dr Claudia Zitz, Gender Plus*  
• Department of Health and Social Care*  
• Mermaids*  
• Trans Learning Partnership*  
• Transgender Trend*  
• Bayswater Support*  
• International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) – Europe  
• The Cass Review Team* 

* denotes people and organisations who acted as external reviewers of the briefing.