hello, good morning. tuesday was welcome to bbc news — broadcasting to viewers another record—breaking day, and in north america and around the globe. temperatures today will be very my name is mike embley. our top stories: similar. today, though, likely to be once more with feeling — the last of the dry, warm and sunny donald trump and kim jong—un arrive in vietnam ahead of days for quite sometime. chilly start this morning, though. temperatures in a few rural areas will be close to freezing, and there a bit on this tenfold around in the their second summit. it's 3:303m, incredibly enough. morning across southern england, the you're up to date with the headlines. midlands, the vale of york again and now on bbc news, panorama. more and more young people around the murray firth. tending to are questioning their gender. lift, though, in the morning, being trans isn't a choice. we are hours away from talks you but sunshine developing far and wide. a when people see me on the street, bit more cloud at times for northern what talk is there regarding i want to be perceived as a woman. ireland, the far north and west of scotla nd ireland, the far north and west of scotland and for the irish sea. but on the whole dry and sunny day, progress of the denuclearisation of the number of under—18s seeking help north korea? from the nhs has risen sharply another very warm one. temperatures theresa may admits britain's in the last five years. departure from the eu well above average, 19, 20 around could be delayed as her government warns of a severe impact if the uk the london area. but thursday looks leaves without a brexit deal. donald trump's former fixer very different. not only will it be testifies in washington. already jailed for lying this isn't some frivolous choice cloudy and it will be rather misty, to congress, he says he welcomes that kids are making the chance to tell the truth. and there may be some patchy mist without thinking about it. health professionals and there may be some patchy mist and fog, there will also be some pakistan warns india, "we will act at a time are feeling under pressure. rank into wales, the midlands, southern england and perhaps the north—west of england as well a few i've become increasingly concerned about the large number of patients spots of rain in the north—east of who want physical treatment scotla nd as quickly as possible. spots of rain in the north—east of scotland where temperatures are nine for others, there degrees, 12 or 13 further south. is no time to waste. quite a change from recently. we get lots of children

who are already in puberty, who are very distressed, "please, stop me developing any further, i cannot bare this." there are calls for better regulation in this new area of medicine. we urgently need a new regulator. tonight, we ask, do we know enough about the care offered to transgender children? is there an impact on brain development that has longer—term implications? we don't have the answer to that. i am faye kirkland — i am a journalist and also a family doctor. for young people questioning their gender, gps can be the first port of call. it's relatively new area of medicine, and i want to find out how much we understand about the care available.

i am in leicester to meetjade. being trans is not something you choose, it is something you choose to act on. when people see me on the street, i want to be perceived as a woman. jade, 18, is biologically male. during rehearsals for a school nativity play, she realised she did not feel like a boy. i wanted to be cast as an angel, and the teacher said no, that was my first inkling. when teachers ask what you want to be when you grow up, what career, ijokingly say i want to grow up to be a girl. as she grew up, she became more and more unhappy. puberty, like, started, and ijust felt this huge disconnect. i was growing taller and broader, and i wasn't having any of it,

but i never talked about it, i knew that it wasn't right, i sort of knew that it wasn't normal. similar stories are shared online by transgender bloggers. for as long as i can remember, i have always felt incorrect. puberty made me feel like there was something really wrong with me. i want to scream at the thought of not being able to wear the clothes that i wanted to wear. gender dysphoria is a feeling of intense distress around a physical body that does not fit in with one's sense of one's gender identification. it is a profound experience for many young people, and it is exceedingly distressing. polly carmichael runs the only nhs service offering child gender medicine to under—18s in england and wales. based at the tavistock centre in london, it sees many young people with gender dysphoria. often, young people will wish to be read of the secondary sex characteristics, or afraid of them developing,

if you like, which don't match the sense of themselves. with the onset of puberty, children experiencing gender dysphoria may fear the beginning of periods, the growth of facial hair, or breast development. for the first stage of medical intervention, it would be in the early stages of puberty, so we would start with a puberty blocker. the use of medication to block puberty, to put it on pause, was pioneered 18 years ago by this clinic in amsterdam. we started for the first time treating adolescents to actually create time and rest for transgender adolescents. it was considered fully reversible treatment, so they had the time to make

decisions about more irreversible parts of treatment. it was another ten years before the tavistock centre began prescribing blockers to children in the early stages of puberty. many of their patients are aged around 15. how do you, on the one hand, accept and support a young person's self identification, whilst at the same time leaving things open? for us as a clinic, what it means is working on a case—by—case basis. jade was a patient at the tavistock centre two years ago, when she was 16. she hasn't taken puberty blockers. there is so much thinking to be done before any life—changing decisions about hormone blockers, when there are so many changes

happening in your body and life. the drugs are said to be reversible, but there is emerging evidence they may have more long—lasting effects in other parts of the body. they are fully reversible in the sense that if you stop taking the puberty blocker, then your preprogrammed sex hormones will resume, and you will continue to develop. is there an impact on brain development in some way that has longer—term implications? and we don't have the answer to that. doctors do their best to advise patients are making important choices about their care, based on the best available evidence. you know, gender dysphoria is a distressing condition. one of the key issues is to be able to say to parents and children

that it is an informed decision based on the evidence. i am in oxford to visit the university's centre for evidence—based medicine. panorama asked the centre's director to review the most up—to—date research from across the world into outcomes for children and adolescents. what does the medical evidence actually show? he began by posing some basic questions. what does it say about the benefits, what does it say about the harms? have we got a sufficient sample size? the answer is no. based on all that, can we make an informed decision? the answer is no. three different areas where you look at the evidence and you say it is not fit for purpose. puberty blockers have long been used to treat children with a condition that means they start puberty way too early. less is known about the long—term safety of their use in transgender medicine. if you ask me about puberty

blockers, what can you tell from the evidence? very little, apart from they give you the intended effect in terms of blocking and suppressing puberty. ten years ago, doctors concerned about this lack of evidence asked professor neil evans to study the effects of puberty blockers in sheep. we could see differences in the size of different areas within the brains, associated with whether they had gone through puberty or not. having the blockers changed the anatomy of the brain? absolutely, yes, so we are increasingly realising that at the time of puberty, our brain changes quite a lot. if we change the hormone environment, we have to think about long—term changes in how the brain is able to work.

puberty resumes if the drugs are stopped, but professor evans can't be sure how significant the changes he observed in sheep are. so fully reversible — we are not sure? we don't know, there are a variety of different reasons why these treatments are acceptable at this point in time, but we don't know what is going to happen, so it is in some ways a live experiment. the tavistock centre agrees there should be more research but say they also have to manage risks. there are questions around risk, but there is a reason why people have even begun to think about using something like a puberty blocker in young children, and so what you have is a real phenomenon, and that phenomenon is young people who are hugely distressed around their gender identity, and so some of the evidence that is important is that young people and families who have gone forward for this treatment are exceedingly positive about it.

over the past five years, the number of children referred to the tavistock centre has risen from 468 to 2500, an increase of more than 400%. most of the children seeking help are biologically female but identify as male. no—one knows why this is. perhaps there is something about the role of women in our society, and in some ways it's preferential to have a male role, rather than a female role? they have also been arguments around sexuality, and whether for some of these young people in the future the outcome would be around sexuality rather than gender.

she ran like a boy and walked like a boy from the earliest possible age. she wouldn't entertain anything feminine or pink, and she actually said that she wanted to be a boy, that she was a boy. fiona — not her real name — says her son experienced gender dysphoria from an early age. at 11, he was living as a boy and being treated with puberty blockers at the tavistock centre, but he was still distressed. my son noticed that his friends at school were progressing through puberty naturally, the bodily changes, voice changes, and he wasn't. comments would be made, he felt incredibly uncomfortable and sank into a deep depression. aged only 12, he wanted to begin treatment with the male

hormone testosterone, the start of a journey towards irreversible changes to his body. he wanted more than anything in this world to be prescribed hormones in order to progress through puberty with his peers. hi, guys, today i am doing a video on how i got onto testosterone... i'm officially six years on testosterone... not all trans people go on hormones, but i fought very hard to get it... the nhs advice is that only young people who have been taking blockers for a year and are aged around 16 can progress to hormone treatment with testosterone or oestrogen. the tavistock centre told fiona her son was too young, so she looked elsewhere. i managed to find a private doctor, helen webberley, who was prepared to hear us out.

dr webberley runs gender gp, the only private clinic in the uk offering this treatment to young people. to many in the nhs, she is a controversialfigure. the nhs sau you have to be around the age of 16 to have gender altering hormones, and i think our uk children, some of them find it very difficult. i think children should be allowed the second stage of treatment, hormones, when it is right for them and the family and their situation, and that might be before 16. following consultations, counselling and tests, dr webberley prescribed testosterone to fiona's 12—year—old son. he would come home from school on cloud nine, saying, mum, my friends say my voice has dropped. but not everyone was so pleased. complaints about cases such as these have led to dr webberley‘s suspension from the medical register.

she cannot practice as a doctor, but others in how clinic can. what would you say to critics who say you are assessing people too quickly, giving medication a way that the nhs does not? what makes you think you are right? because of all the patients we have treated telling us that what we do is right, the outcomes are good. this is not brand—new, but what is developing is a much more gender affirmative approach, and what australia and america are using very successfully. i would feel concerned about introducing a less reversible treatment that has long—term implications at a much younger age. for us, it's about ensuring that there's time and space for proper exploration before taking any irreversible steps.

with more and more young people seeking referrals to the tavistock centre, waiting times can now be anything up to 18 months. it creates pressure for families and their children. a lot of people assume that once you come out, that's — the hard part is over. rubin transitioned when he was 24. jade has been going to his support group in leicesterfor years. it still can be incredibly frustrating for young people, can't it? i think particularly if you've waited a long time already to come out, because if your family aren't going to be supportive or it has taken you a long time to find the courage to come to this decision, to move forward, and you're like, i'm ready to start my life now,

and then you find out that there's this potentially two—year wait, it can be quite crushing. there are many transgender children who come to us already in puberty, because they've been waiting a long time on the nhs, or they've just been referred to the nhs, but the waiting time is going to be up to two years, who are very distressed, who are saying, please stop me developing any further. i cannot bear this. what would you say to people who are on the waiting list now? i think, you know, of course we can always support people better, and ideally there wouldn't be the waiting lists. it's not a simple bastion of more funding. but unfortunately, with the best will in the world, you can't magic up specialists in a highly specialist area. local services need to be skilled up to be supporting young people. make some noise forjade!

it's distressing to hear that, like, you'll have to wait more than a year to be seen. but i understand the wait, because it gave me a lot of time to think about what i wanted from tavistock. jade waited a year to be seen by the tavistock when she was 15. she had had a traumatic childhood, and thinks the time helped her process her feelings and prepare for counselling. therapy helped me talk about not just gender stuff at tavistock, but talk about everything. i took a lot of time playing with my identity, which i think is an important thing to do, especially for young people, because it gave me that time to realise that, like, i live my life as a feminine guy, but that wasn't it. there was something more to it.

but i have spoken to parents who fear waiting, worried about what might happen if their children go through puberty in the wrong gender. my son was prepared to take his own life, because he wasn't living the life he was meant to be, or who he was. i think for parents, there is this idea that, "if my child comes out as trans, they're automatically going to start self—harming, their life will be doom and gloom", when that is not necessarily the case. the more we do to support them, the less likely they make it that they'll have those horrible experiences. although there are some research suggesting that young transgender people are at an increased risk of suicide, the tavistock says current statistics should be treated with caution.

i think the figures around self—harm, suicidal ideation, and indeed suicide, need to be interpreted with great caution. i think for families who have a child experiencing gender dysphoria, often, the way in which statistics can be presented can lead perhaps to an assumption that the panacea to this, if you like, is to start physical treatment as quickly as possible. and our experience would be that thatjust isn't the case. the relationship between gender identity and mental health issues can be a complex one. i had a parent come to me quite recently and say, "my child has been self—harming", and they told me they were trans, and i don't understand it, but i supported them. and then the self—harm hasn't stopped. why hasn't it stopped? i'm still struggling with depression, anxiety and gender dysphoria. i'm still — i'm not coping. i'm not self—harming as much.

after the sessions, i was realising that talking about everything i have been through, it made me realise for myself, like, how strong a person i am. but some clinicians worry about patients who want to go straight to medication without talking first. i've become increasingly concerned about the large number of patients who want to be referred on for physical treatment, medical or even surgery, as quickly as possible. john, not his real name, is a child psychotherapist. he doesn't want to be identified, and says there is growing pressure not to question young patients. so they come with a variety of different presentations, very highly anxious, school—refusing, real difficulties with peer relationships, depression.

they don't want to explore that, and they feel that once their gender is sorted out, in their mind, that all of those problems will go away. i think what we see is a wider environment that's very negative about any exploration, and often see it as a delay. why are you asking that? i know exactly who i am, and how dare you ask that? over at the tavistock centre, some clinicians have resigned. they are worried about the impact of increased demand for the service, and the reliability of research in treatment and care on offer. former insiders who didn't want to go on camera claim they felt rushed into green—lighting medical interventions. this is what they told me. for some, i was fairly certain transitioning was the right course of action. but in the majority of cases, i was simply unsure how well things would work out for them in the future.

research is being conducted, but we are many years away from fully understanding the long—term outcomes from the interventions taking place today. counter to child development theory and knowledge, this service changes children's bodies, with the aim of improving their mental health, which mostly does not seem to work. so serious are the concerns that the tavistock centre ordered an internal review. its findings hadn't been published when we interviewed dr carmichael. you have had an internal review. are you able to share its findings with me? i think it's just about ensuring that the structures around the service are robust and supportive for staff working in the service, but also that we don't comprise on the care that we provide for the young people coming to the service. the review is due to be published next month, but some staff who have already seen

it say it doesn't go far enough, and they are demanding an external inquiry. gender clinics around the world are realising they need to do much more to find out what happens long—term to the children and young people who come through their doors. what we don't know is, how will they look back when they are in their adult years? do these adolescents, do these parents realise what sort of treatment they're getting, and how far—reaching the effects might be, lifelong? are they able to have long—term relationships? but also, what about their wish for children? that i think are really questions we haven't answered yet. the tavistock doesn't have all the answers, either. do you think tavistock has done enough? they haven't produced systematic data on the outcomes based on all children.

in the absence of evidence, ijust do not understand how they can inform children, adolescents and parents and families in a way that helps them make an informed decision. the tavistock centre now plans a new research project to record what happens to all its patients as they grow up, whether they're prescribed medication or not. we've just received a very large research grant, specifically to follow young people who come to the service through and forward, whatever their outcomes. and that's going to be really important information. but is that enough to make sure these life—changing decisions by children and their parents are based on the best possible evidence in the future? professor hennigan says this area of treatment and research needs regulating now. it's incredibly hard, when you're in these emotive situations, for people to take on board evidence. and we urgently need a new regulator

that has oversight to provide a more rigorous approach to the evidence to help inform decision—making. the department of health says it has no plans to introduce an independent regulator. nhs england says its policies are due for review and it will consider the most recent evidence available. while i've been making this film, i've been surprised by how many people don't feel able to speak openly about this important area of medicine. a lot of the time, people don't feel confident enough to speak up, because they feel like if they say anything remotely negative, they're going to be branded as a transphobic bigot, and anything remotely positive, they're going to be

branded as a leftie, liberal snowflake, social justice warrior. we're seeing the extreme sides of things, and it's meant that there's all this space in the middle, all this grey area that's not being explored. it can have a chilling effect on doctors. not every doctor that i know of really wants to be involved in this type of care. it's because there are so many opinions about it. it's delicate. people criticise the care we provide. so it's — yeah, you're sort of in politics as well. at the moment, there is a sort of febrile debate, it's fair to say, going on, and it has become more polarised. it's a really difficult space for families and young people to be part of and i really hope moving forward, that we can find some

way of debating some of these contentious issues. jade is now back on the waiting list at the tavistock, this time for the adult service. she says she feels ready for the next step in her transition. doing stuff like this helps, because it's like, if i can do this big thing, i can do a small thing like riding a bus or like going to class everyday. so it's doing big things to help conquer small things. i think that's what helps me. thank you. the future of care for young transgender people lies in the life stories of the young people themselves. it's only by following the journeys ofjade and others like her that we'll understand much more about the best ways to support them.