Writer and broadcaster

My 16 year old daughter is convinced she needs a sex change. The Guardian

Dear Annalisa

My daughter, who is 16, has a history of mental health issues. Her father is an alcoholic who left the family home when she was very young; she hasn’t seen him for some years and finds meetings with him upsetting. I am sure that this perceived rejection is at the root of her troubles as she suffers from very low self-esteem. She is overweight and was bullied at school, finally refusing to attend. She has been out of education since she was 12.

We have had some input from the Child and Adolescent Mental Health Services (CAMHS), but nothing has helped and she will no longer engage with them. She has never slept well and was prescribed melatonin. Then, last November, she was prescribed medication by a GP for persistent headaches and took a month’s supply in one go. To the family, this was the strongest example yet of her self-loathing and tendency to self-harm, albeit also perhaps a cry for help.

Following this, I had a telephone consultation with her psychiatrist, who raised the issue of autism – this has been a concern of mine, as she does display a number of traits associated with autism.

However, she is now convinced that she needs a sex change. Given that she has never previously shown any inclination to be anything other than female, it would appear that this is yet another form of self-harm and/or a cry for help.

I am worried that because of the amount of time she spends on the internet, she is being influenced to believing her intentions are correct.

She needs someone she respects sufficiently to listen to and open up to, who will dig deep enough to uncover the underlying issues, and help her to resolve them. I feel that, without such help, she will continue down her unhappy path, perhaps pursuing gender-change (without realising that this would not resolve any of her underlying issues), or leading to an even worse conclusion.

I contacted Neil Austin, head of child and adolescent psychotherapy at Great Ormond Street hospital for children. He felt it was really important not to give up on CAMHS, even if your daughter won’t engage at present. If she won’t attend herself (more of that later), they can help you to access specialist treatment.

Austin commented that, despite your best efforts, your daughter seemed to have a longstanding difficulty in expressing herself: rather, she seems to depend on an adult’s mind to make sense of her thoughts. I also notice that you don’t say anything about your relationship with one another and that’s really quite important.

“What your daughter really needs,” suggested Austin, “is somewhere she can safely explore and express who she is. A place where she could begin to bring all her emotions.”

You may feel that she has you to talk to, but children can find it difficult to open up to family members – and even friends – because they overthink the effect on the other person, or are fearful of the reaction. Often, paradoxically, the closer the person is, the less they can open up to them.

Austin added – and I think this is really important in your situation – “At this point, diagnosis isn’t as important as engagement: finding someone who can support your daughter with beginning to name her own thoughts and feelings within a safe and consistent setting. Only then can anyone begin to form a clear picture with her of what the real difficulties are and work towards an accurate diagnosis. You can’t begin to think diagnostically without a detailed assessment over several consultations, and this will only happen if your daughter feels engaged and starts to feel safe enough to open up.”

Don’t give up. You correctly surmise that what your daughter needs is someone to “click with”. “Child and adolescent psychotherapists do this kind of work,” says Austin, “and there are two members of this small NHS specialist profession in your area.” You can contact them directly (see the register at childpsychotherapy.org.uk, or email me again and I will send you the details).

When I asked Austin what you could do if your daughter refused to go to a new specialist, he said, “You [the mother] would go along, make the first link and consider how best to encourage your daughter. You might be able to take some pressure off her by saying something like, ‘It’s not just for you, we all need this as a family.’ When parents can be firm as well as considerate, this can have a very holding effect on both children and teenagers.”

I wouldn’t rule out anything at the moment, nor would I fixate on any particular diagnosis – there are just too many possibilities. Try not to bat away any theories your daughter brings up, however. This will all seem less frightening for you if you have proper support. Regarding the gender identity issues your daughter has expressed, this isn’t something children usually mention easily or lightly and sometimes adolescence is the first time they feel able to voice it. You may find these past Guardian articles helpful: Goodbye Katie, Hello Ben and I’m transgender and want my parents to know I’m their son, not a daughter.

“The priority,” concludes Austin, “is for your daughter to see someone who can offer her an open-minded exploration and for the work to be ongoing. You may need to hold out for a referral for longer term work, for at least a year. This is less readily available on the NHS these days, but there is no quick fix and continuity of care will be of the essence for your daughter, whose current situation and history are undoubtedly complex.”

This article first appeared in The Guardian Family on 14 August 2015.