Managing gender dysphoria/incongruence in children and adolescents: a perspective for debate

  1. This approach to managing gender dysphoria [1] or gender incongruence [2] in children and adolescents aims to
    protect and safeguard the health, safety and welfare of the child. These guidelines prioritise the best interests of the
    child in accordance with human rights obligations under the International Convention of the Rights of the Child
    [3].
  2. Gender dysphoria/incongruence in young people is a debated area of medical practice. This approach avoids
    political, social or religious ideological positions.
  3. As health professionals this approach acknowledges and respects young people’s views about their gender
    identity, as part of the totality of their developmental and holistic clinical picture, and incorporates these into the
    clinical formulation. This approach requires that a comprehensive bio-psycho-social assessment be conducted
    before recommending specific treatment.
  4. The approach appreciates that childhood and adolescence is a time of rapid physical and psycho-social growth
    and profound personal development. It is characterised by examining many aspects of identity, including sexual
    orientation and gender. As the child matures and progresses through puberty this questioning usually transforms
    and resolves and the young person, in the majority of cases, accepts his/her biological sex and adult body [4,5].
  5. The approach recognises that gender dysphoria/incongruence can often be a manifestation of complex preexisting
    family, social, psychological or psychiatric conditions. A holistic approach includes a comprehensive
    exploration for these potential conditions in order to more fully understand a child presenting with gender
    dysphoria/incongruence [6].
  6. Extensive assessment of family, social, psychological and psychiatric factors is an essential step in effective and
    safe management of children and adolescents presenting with gender dysphoria/incongruence.
  7. The approach proposes that psychotherapy should be a first-line treatment for young people with gender
    dysphoria/incongruence. This intervention should be undertaken before medical interventions (puberty-blocking
    drugs, cross-sex hormones, sex reassignment surgery) are planned.
  8. The approach is aware that medical interventions to block puberty and to achieve feminization and
    masculinization according to the young person’s perceived gender are not fully reversible and can cause significant
    adverse effects on physical, cognitive, reproductive and psychosexual development [7,8,9,10,11,12,13].
  9. Currently, while some individuals report a successful transition, we are not aware of published long-term
    outcome studies that have followed up adults who have undergone childhood or adolescent transition that show
    substantial benefit. As a consequence, there is no consensus that medical treatments such as the use of pubertyblocking
    drugs, cross-sex hormones or sexual reassignment surgery lead to better future psychosocial adjustment
    [14,15,16,17].
  10. Increasing numbers of individuals who have undergone hormonal treatment and surgical interventions
    subsequently report experiencing regret and a wish to de-transition. They describe significant psychological and
    physical suffering, including loss of fertility and sexual function as a consequence of decisions made when younger
    [18,19,20,21,22,23].
  11. Clinicians should therefore reflect carefully before contemplating or recommending treatments for gender
    dysphoria/incongruence, including irreversible medical interventions.
  12. The still unproven risks and benefits make it imperative that parents and children and adolescents are made
    aware of the current evidence regarding gender transition and provide fully informed consent before potentially
    damaging and irreversible treatment is commenced.
  13. This cautious approach is also mirrored in general clinical guidance by national bodies that recommend health
    services for public funding [24].

In preparing this statement advice was obtained from a number of senior medical colleagues in child and adolescent
psychiatry, adult psychiatry, forensic psychiatry, and from physicians who have cared for individuals experiencing
gender dysphoria/incongruence.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
    Arlington, VA: Author.
  2. World Health Organization. (2018). International classification of diseases for mortality and morbidity
    statistics (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en
  3. UN Commission on Human Rights, Convention on the Rights of the Child., 7 March
    1990, E/CN.4/RES/1990/74, available at: https://www.refworld.org/docid/3b00f03d30.html [accessed 3 November
    2020]
  4. Entwistle K. Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child
    Adolesc Ment Health. 2020. doi:10.1111/camh.12380
  5. Ristori J, Steensma T. Gender dysphoria in childhood. International Review of Psychiatry. 2016;28(1):13-20.
    doi:10.3109/09540261.2015.1115754
  6. Kosky R. Gender-disordered children: does inpatient treatment help? Medical Journal of Australia
    1987;146:565-69 (June 1, 1987). doi: 10.5694/j.1326-5377.1987.tb120415.x
  7. Vlot MC, Klink DT, den Heijer M, Blankenstein MA, Rotteveel J, Heijboer AC. Effect of pubertal
    suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density
    (BMAD) in transgender adolescents. Bone. 2017;95:11-19. doi: S8756-3282(16)30333-7 [pii].
  8. Vlot MC, Wiepjes CM, de Jongh RT, T’Sjoen G, Heijboer AC, den Heijer M. Gender-affirming hormone
    treatment decreases bone turnover in transwomen and older transmen. J Bone Miner Res. 2019;34(10):1862-doi: 10.1002/jbmr.3762 [doi].
  9. Schneider M, Spritzer P, Soll B et al. Brain Maturation, Cognition and Voice Pattern in a Gender
    Dysphoria Case under Pubertal Suppression. Front Hum Neurosci. 2017;11. doi:10.3389/fnhum.2017.00528
  10. Auer MK, Ebert T, Pietzner M, et al. Effects of sex hormone treatment on the metabolic syndrome in
    transgender individuals: Focus on metabolic cytokines. J Clin Endocrinol Metab. 2018;103(2):790-802. doi:
    10.1210/jc.2017- 01559 [doi].
  11. Alzahrani T, Nguyen T, Ryan A, et al. Cardiovascular disease risk factors and myocardial infarction in the
    transgender population. Circ Cardiovasc Qual Outcomes. 2019;12(4):e005597. doi:
    10.1161/CIRCOUTCOMES.119.005597 [doi].
  12. Nota NM, Wiepjes CM, de Blok, C. J. M., Gooren LJG, Kreukels BPC, den Heijer M. Occurrence of acute
    cardiovascular events in transgender individuals receiving hormone therapy. Circulation. 2019;139(11):1461-1462.
    doi: 10.1161/CIRCULATIONAHA.118.038584 [doi].
  13. Goodman M, Nash R. Examining health outcomes for people who are transgender.
    https://www.pcori.org/research-results/2013/examining-health-outcomes-people-who-are-transgender. Updated Accessed Nov 7, 2019.
  14. 22 Dhejne C, Lichtenstein P, Boman M, Johansson AL, Langstrom N, Landen M. Long-term follow-up
    of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS One.
    2011;6(2):e16885. doi: 10.1371/journal.pone.0016885 [doi].
  15. Bränström, R., & Pachankis, Reduction in Mental Health Treatment Utilization Among Transgender
    Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry.
    2019;177(8), 727- 734. https://doi.org/10.1176/appi.ajp.2019.19010080
  16. Correction to Bränström and Pachankis. American Journal Of Psychiatry. 2020;177(8), 734-734.
    https://doi.org/10.1176/appi.ajp.2020.1778correction
  17. Kalin, N. Reassessing Mental Health Treatment Utilization Reduction in Transgender Individuals After
    Gender Affirming Surgeries: A Comment by the Editor on the Process. American Journal Of Psychiatry.
    2020;177(8), 764- 764. https://doi.org/10.1176/appi.ajp.2020.20060803
  18. Lesbian Strength 2019 – Charlie Evans. YouTube. https://www.youtube.com/watch?v=-JazgA3AdUE.
    Published 2019. Accessed November 1, 2019.
  19. Female detransition and reidentification: Survey results and interpretation. archive Web site.
    https://guideonragingstars.tumblr.com/post/149877706175/female-detransition-and-reidentification-survey.
    Accessed Nov 7, 2019.
  20. Pique resilience project. PIQUE RESILIENCE PROJECT Web site. https://www.piqueresproject.com/.
    Accessed Nov 7, 2019.
  21. Subreddit survey update! : detrans. Reddit.com.
    https://www.reddit.com/r/detrans/comments/azj8xd/subreddit_survey_update/. Published 2019. Accessed
    November 1, 2019.
  22. Reddit.com. Has anyone been to gender therapy? What was your experience?: detrans.
    _yo ur/ Published 2019. Accessed November 1, 2019.
  23. Tumblr: Guide on raging stars. Female detransition and reidentification survey. Available:
    https://tinyurl.com/female-detrans-survey. Published 2016. Accessed November 1, 2019.
  24. https://palveluvalikoima.fi/documents/1237350/22895838/Summary+transgender.pdf/2cc3f053-2e34-39ce-
    4e21-becd685b3044/Summary+transgender.pdf
Season Greetings to all
Practical Guide to Gender Dysphoria