A six-year-old girl runs along a pier. The sun is shining, she has a lollipop, and she’s happy to be with her mother and two older sisters. Kelly has long brown hair and wears one of her favourite dresses. She appears happy, and nobody gives her a second glance.

Kelly wasn’t always so well adjusted. Less than two years ago this child was talking about how she could kill herself.

Her problems started the moment she was born, when her parents, Sarah and Conor, and the midwives looked at Kelly’s genitals and saw that she had male anatomy. After having had two daughters, Sarah and Conor received cards from friends, declaring: “Congratulations! It’s a boy!” They called their child Jake and imagined a future for their son.

From a very early age – almost as soon as she could talk – Sarah and Conor recognised that the child they knew as Jake was “a very girly boy”. Indeed, they worked hard to ensure that Jake had space to be “a very girly boy”. Still, the child showed signs of distress, crying in bed at night. Then, at the age of four, she told Sarah: “I’m really a girl inside. It’s not fair. I’ll never be who I want to be, because I’m stuck in this boy body.”

Psychological distress

Transgender children have always existed, everywhere. They are different from other children who fall under the umbrella term trans (which often appears as trans*, the asterisk denoting as inclusive a term as possible), which includes children who don’t conform to gender stereotypes or strongly identify as male or female.

Transgender children with gender dysphoria are distressed about their bodies and gender identities over a prolonged period. They often show signs of serious psychological distress, including self-harm, and may wish to transition, socially and sometimes medically, to their preferred gender.

A transboy, assigned female at birth, identifies strongly as male; a transgirl, assigned male at birth, identifies strongly as female. Although some indigenous societies have traditionally created space for trans people, they are, by and large, the most marginalised group in the world.

In the past, trans children spent a lifetime – often cut short by suicide – suppressing themselves; this continues today. With growing openness, however, the number of young people seeking treatment for gender dysphoria is rising.

Although it is a relatively new phenomenon for children as young as Kelly to transition, most trans people say they become aware of their gender identity between the ages of three and five but lack the vocabulary to express how they feel.

Sarah says she has connected online with hundreds of families who have young trans children. In the US, the actors Brad Pitt and Angelina Jolie have spoken publicly about how their child, who was female-assigned at birth, identifies as a boy, wears masculine clothes and wishes to be known as John; they have supported their child's identity.

One parent, referred to here as Clara, is attending therapy with her four-year-old daughter, Charlotte, who has identified as male since she could talk. Clara still uses female pronouns to refer to her child, as she feels she is too young to make a full transition, but has agreed to call her Charlie. She hopes Charlie will “grow out of it” but says she will back her child no matter what. “I think it would be harder if she was a little boy saying that he was a girl, whereas a girl saying she wants to be a boy is seen as kind of cute. Tomboys are rarely questioned.”

About three years ago adolescents began arriving at the endocrinology unit at Our Lady’s Children’s Hospital, Crumlin, distressed and in search of hormones to delay the onset of puberty, which they feared would drag them into the wrong body. Clinicians lacked clear guidelines and felt exposed and vulnerable. Since then the hospital has worked with the outreach arm of the Tavistock Clinic, in the UK, to provide a psychological and clinical treatment programme for six teens, which has often involved administering puberty blockers.

Prof Donal O’Shea is an endocrinologist at St Columcille’s Hospital, in Loughlinstown in south Co Dublin, which provides hormonal therapies for trans people. “In 2002 the average age at which people came from treatment was 34. Now it’s 23 – and continuing to fall,” he says. “I see people from the age of 16. I used to ask people if they had told their wife and children; now I’m asking secondary students whether they would rather transition during the year of their Leaving Certificate or wait till the exams are over. It is so much better if it can be addressed at an early age, before life becomes more complicated.”

International research points to about 1 per cent of the population feeling or expressing some form of gender variance. There is a wide spectrum of experiences for trans and gender-variant people. Not all who feel unease with their assigned gender (or “natal sex”) are uncomfortable with their bodies; those who are, however, may seek a diagnosis of gender dysphoria; the continued labelling of gender dysphoria as a mental illness is deeply controversial; trans advocates and clinicians often use it with reluctance, as it is the only way for trans people to access services.

There is a paucity of research on the long-term outcomes for trans people, both in Ireland and internationally, but in countries where gender reassignment – or gender confirmation surgery – is available, about 0.2 per cent of the general population medically transitions through hormones, surgery or both.

Trans teens

A more recent survey, of 8,000 secondary students in New Zealand, found that 1.5 to 2 per cent of teens identified as trans. It is at least three times more common for children who were assigned as male at birth to identify as female (transwomen) than it is for female-assigned people to identify as male (transmen), although transwomen, in support groups in Ireland, appear to be notably less visible.

Trans children can face enormous obstacles, including bullying, isolation and stigma, lack of support at school, family rejection and difficulty in accessing psychological and medical services. In 2013 an Irish transwoman called Nikita Keane took her own life at the age of 26, having never gained the acceptance of her parents; in the death notice they referred to her as their son. Last year the story of Leelah Alcorn – a trans teen in the US who took her own life at the age of 17 after her parents refused to accept her gender identity and instead sent her to Christian conversion therapy – gained international attention.

Gender Recognition Bill

All reputable medical and mental-health studies indicate that a person’s gender identity cannot be changed and that conversion therapies are hugely harmful. Against this background Irish politicians are discussing the Gender Recognition Bill, which seeks to address the fact that Ireland is the last country in Europe that does not permit legal recognition of transgender people.

The Bill has been criticised as it doesn’t allow recognition for children under 16 and imposes severe restrictions on 16- to 18-year-olds, including a requirement for diagnoses from two medical practitioners and parental consent in order for children to have their genders legally recognised.

Some families of trans children support and accept their child, although few families do not struggle at all. Sarah and Conor tried to reinforce boyhood on Kelly, but it wasn’t working. The child was telling everyone she was a girl, and becoming increasingly anxious. School was becoming increasingly difficult, and Kelly spoke of wanting to die. The choice was becoming stark: a dead son or a living daughter. They took Kelly to a play therapist, helping her to explore gender.

At first Kelly was in tears and curled up in a ball. But since then Kelly has transitioned. With the support of her family and clinicians she has thrived. “I hear about the overnight switch, where kids who have been self-harming for years just suddenly stop when they are afforded that recognition. That happened to Kelly,” say her parents.

For all the difficulties that trans children face, changing social attitudes, the availability of medical transition and the emergence of support and advocacy groups mean they are finding help. What was once unthinkable – that trans people could have anything but misery and rejection – is changing: more and more trans children are coming out the other side and leading full, healthy and often rich lives, especially when afforded recognition and respect.

The trans children we have spoken to have proven incredibly resilient and mature. They have been forced to understand themselves in a way that is unusual for anyone under 30, let alone a child.

All names have been changed