Gender dysphoria/incongruence in young people is a contested area of medical practice. This approach avoids political, social, religious and ideological positions.
This approach to developing a guide for managing gender dysphoria  or gender incongruence  in children and adolescents aims to protect and safeguard the health, safety and welfare of the child. This guide prioritises the best interests of the child in accordance with human rights obligations under the International Convention of the Rights of the Child .
- While respecting young people’s views about their gender identity, this guide does so 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.
- It acknowledges that childhood and adolescence is a time of rapid physical and psycho-social growth and profound personal development, during which young people may question their identity, sexual orientation and gender. As the child matures and progresses through puberty this questioning usually resolves, and in the majority of cases the young person who has gender incongruence issues accepts his/her biological sex and adult body [4, 5].
- It is based upon an understanding that gender dysphoria/incongruence can be both a symptom and a syndrome. For a young person to have the syndrome of gender dysphoria/incongruence there must be a significant, established and prolonged pattern  of desire and behaviour that indicates the person insists they are a gender different to their natal (birth assigned) gender.
- It recognises that gender dysphoria/incongruence can often be a manifestation of complex pre-existing family, social, psychological or psychiatric conditions . A holistic approach to assessment includes a comprehensive exploration for these potential conditions in order to more fully understand a child presenting with gender dysphoria/incongruence [7,8]. Where these conditions are presenting as gender dysphoria/incongruence, the treatment of the underlying condition is a priority.
Individualised psychosocial interventions (e.g., psychoeducation, individual therapy, school-home liaison, family therapy) should be first-line treatments for young people with gender dysphoria/incongruence. Exploratory psychotherapy should be offered to all gender questioning young people to identify the many potential sources of distress in their lives in addition to their gender concerns. Clinicians can provide a range of ethical psychological interventions (e.g., supportive psychotherapy, CBT, and dynamic psychotherapy) to assist the young person to clarify and resolve these contributory factors. Such approaches are consistent with established principles of comprehensive, systemic youth health care . They should be undertaken before experimental puberty-blocking drugs  and other medical interventions (e.g., cross-sex hormones, sex reassignment surgery) are considered.
Medical interventions to block puberty and cross-hormone treatment to achieve feminisation and masculinisation 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 [9,10,11,12,13,14,15,16,17,18].
Currently, while some individuals report a successful transition, we are not aware of published long-term prospective 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 puberty-blocking drugs, cross-sex hormones or sexual reassignment surgery lead to better future psychosocial adjustment [17,18,19,20,21,22].
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 [23,24,25,26,27,28,29].
Medico-legal considerations must be fully appreciated in this area of clinical practice. Health professionals are exposed to significant legal risk:
- If a child or adolescent is found not to have been competent to give an informed consent,
- If gender affirming treatment is not preceded by a comprehensive psycho-social assessment, that considers and excludes alternate diagnoses, or
- If the patient was not informed of all the risks of puberty blockers and cross-hormone treatment including their experimental nature .
Clinicians should therefore reflect carefully before recommending treatments for gender dysphoria/incongruence.
The still unproven risks and benefits of gender reassignment interventions make it imperative that parents and children under 18 years and young people over 18 years are made aware of the current evidence of potential harm regarding gender transition and provide fully informed consent before potentially damaging and irreversible treatment is commenced.
This cautious approach is also mirrored in general clinical guidance by national advisory bodies in Finland  and the Karolinska Hospital in Sweden  that recommend treatment methods for gender dysphoria in minors.
In preparing this guide, advice was obtained from a number of senior medical specialists in child and adolescent psychiatry, adult psychiatry, forensic psychiatry, and clinical psychology and from physicians and other clinicians who have cared for young people experiencing gender dysphoria/incongruence, and legal practitioners who have experience in this field. Contributors to this guide include Dr Philip Morris, Dr Roberto D’Angelo, Dr George Halasz, Dr Cary Breakey, Prof Dianna Kenny, Dr Carlos D’Abrera, Dr Vivienne Elton, and Dr Ron Spielman.
Dr Philip Morris
President National Association of Practising Psychiatrists
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