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Managing Gender Dysphoria in Young People – The National Association of Practising Psychiatrists Guide

by | Dec 1, 2023 | Media Release, News

Gender dysphoria/incongruence in young people is a contested area of medical practice.  The National Association of Practising Psychiatrists (NAPP) Guide avoids political, social, religious and ideological positions.

The NAPP approach to developing guidelines for 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.  The NAPP Guide prioritises the best interests of the child in accordance with human rights obligations under the United Nations Convention on the Rights of the Child [3].

Specifically, this Guide:

While respecting young people’s views about their gender identity, it does so as part of the totality of their developmental and holistic clinical picture, and incorporates these into the clinical formulation.  The NAPP Guide requires that a comprehensive bio-psycho-social assessment of the young individual and their family be conducted before recommending specific treatment.

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 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].

Understands 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 [2] of desire and behaviour that indicates the person insists they are a gender different to their biological sex and natal gender.

Recognises that gender dysphoria/incongruence can be a manifestation of complex pre-existing family, social, psychological or psychiatric conditions or predisposing factors [6].  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 psycho-social interventions (e.g. psychoeducation, individual psychotherapy, school-home liaison, and 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 apply a range of psychological interventions to assist the young person clarify and resolve these contributory factors.  Such approaches are consistent with established principles of comprehensive and systemic youth health care [7].  They should be undertaken before any consideration of the use of puberty-blocking drugs [9] and other medical interventions (e.g. cross-sex hormones and sex reassignment surgery) that should only be done in the context of Human Research Ethics Committee (HREC) approved clinical research conditions.

Psychotherapy for gender dysphoria in children and adolescents is a respectful, supportive and exploratory process that does not seek any particular outcome in relation to gender identity [10].  It seeks to understand the nature and meaning of the young person’s gender distress and the context in which it has arisen.  Psychotherapy addresses the multiple factors that contribute to the young person’s difficulties, helping to address issues that resolve distress and support ongoing development and maturation. Conversion therapies, on the other hand, aim to achieve a pre-determined outcome such as gender normativity or heterosexual orientation.  Psychotherapy for gender dysphoria must NOT be conflated with conversion therapies [11].

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, 12, 13, 14, 15, 16, 17, 18].

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.  Systematic reviews have consistently concluded that the evidence for medical gender affirming interventions is low to very low quality [19].  It is unclear whether young people receiving gender-affirming interventions are better or worse off.  Furthermore, there is no evidence that these interventions reduce the risk of completed suicide [19, 20].  The argument that these treatments are a medical necessity is not based on evidence. 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 psycho-social adjustment [21, 22, 23, 24].

There are increasing reports of individuals who have undergone hormonal and surgical treatments subsequently experiencing regret and a wish to de-transition [25].  They describe significant psychological and physical suffering, including loss of fertility and sexual function as a consequence of decisions made when younger [26, 27, 28].  The advent of de-transitioning individuals claiming earlier inappropriate care raises serious ethical and iatrogenic issues for the medical profession [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 in children under age 18 years both parents have not agreed to puberty suppression and cross-hormone treatment;
  • if gender affirming treatment is not preceded by a comprehensive psycho-social assessment, that considers and excludes alternate diagnoses; and/or
  • if the patient was not informed of all the risks of puberty-blockers and cross-hormone treatment including their experimental nature [9].

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 treatment advisory bodies in Finland, Sweden, Norway, France and the United Kingdom that recommend treatment methods for gender dysphoria in minors [30, 31, 32, 33, 34].  In Finland, the recommendation is that among young people with gender dysphoria and significant psychiatric comorbidity, no conclusions can be drawn on the stability of the gender identity of the child [30].  In Norway, the recommendation is that puberty delaying treatment (puberty-blockers) as well as hormonal and surgical gender confirming treatment for children and young people should be regarded as experimental [33].  A more cautious approach to the use of puberty blockers, gender affirming hormones and sexual reassignment surgery for youth with gender dysphoria has now been adopted in Denmark [35].

In the UK, the one specialised clinic in England (Tavistock Clinic) offering an affirmation approach to management of gender dysphoria in children and adolescents has been closed and replaced by regional clinics offering a more holistic model of care [34]. The author of the report that led to this decision (Dr Hilary Cass) raised substantial concerns about the effect of puberty-blockers on developmental maturation and decision-making [36].

As Dr Hilary Cass notes [37], the diagnostic process required by doctors who prescribe treatment for young individuals with this condition must include a diagnosis and differential diagnosis:

“I have also noticed some debate around the inclusion of the need for a diagnosis and differential diagnosis, and whether that means we are pathologising gender identity or seeing it as a mental health problem. I think it is worth clarifying what is meant by these terms.

Applying medical thinking to gender identity isn’t required until and unless a young person needs treatment. The regulations are particularly tightly defined when a doctor is considering prescribing medication, and especially medication that may have some life-long effects. Doctors then have a professional obligation to go through a process of ensuring that it is appropriate for the health needs of the individual, which means making a positive diagnosis (what the condition is) and a differential diagnosis (what the condition isn’t). This applies in all areas of medicine.

The process of differential diagnosis is neutral in terms of outcome – it’s not about preferring one diagnosis over another; it’s just about getting it right. It isn’t about trying to rule out every conceivable explanation before confirming any particular diagnosis – only about ruling out other diagnoses that might be likely for that individual, or where getting it wrong and missing another diagnosis could have serious consequences. Achieving this involves taking a holistic, considered approach to each individual about the possible causes of their distress and identifying the most appropriate pathway for them. This must always be done with sensitivity and in partnership with the young person and their family.

This same requirement is reflected in the internationally developed Endocrine Society gender dysphoria/gender incongruence guidance which recommends that health professionals responsible for diagnosing gender dysphoria should meet a range of criteria including “the ability to make a distinction between GD [gender dysphoria] /gender incongruence and conditions that have similar features”.

The NAPP Guide adopts a personalised, non-ideological approach to the care of youth with gender dysphoria.

In preparing this NAPP Guide, advice was obtained from a number of senior medical colleagues in child and adolescent psychiatry, adult psychiatry and forensic psychiatry as well as from physicians and psychologists who have cared for young people experiencing gender dysphoria/incongruence and legal practitioners who have experience in this field.

References

  1. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association Publishing, Washington D.C., United States of American.
  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, 20th September 2022.
  3. UN Commission on Human Rights, Convention on the Rights of the Child. 7th March 1990, E/CN.4/RES/1990/74, available at https://www.refworld.org/docid/3b00f03d30.html [accessed 3rd November 2020].
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  8. 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.
  9. [2020] EWHC 3274 (Admin). https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock-Judgment.pdf.
  10. https://genderexploratory.com/wp-content/uploads/2022/12/GETA_ClinicalGuide_2022.pdf
  11. D’Angelo R. Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy. Journal of Medical Ethics Published Online First: 18 November 2023. doi: 10.1136/jme-2023-109282
  12. 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: 10.1016/j.bone.2016.11.008.Epub 2016 Nov 11.
  13. 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 Oct;34(10):1862-1872. doi: 10.1002/jbmr.3762. Epub 2019 Aug 19. PMID: 31099910; PMCID: PMC6852079.
  14. Schneider MA, Spritzer PM, Soll BMB, Fontanari AMV, Carneiro M, Tovar-Moll F, Costa AB, da Silva DC, Schwarz K, Anes M, Tramontina S, Lobato MIR. Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression. Front Hum Neurosci. 2017 Nov 14;11:528. doi: 10.3389/fnhum.2017.00528. PMID: 29184488; PMCID: PMC5694455.
  15. Auer MK, Ebert T, Pietzner M, Defreyne J, Fuss J, Stalla GK, T’Sjoen G. Effects of Sex Hormone Treatment on the Metabolic Syndrome in Transgender Individuals: Focus on Metabolic Cytokines. J Clin Endocrinol Metab. 2018 Feb 1;103(2):790-802. doi: 10.1210/jc.2017-01559. PMID: 29216353.
  16. Alzahrani T, Nguyen T, Ryan A, Dwairy A, McCaffrey J, Yunus R, Forgione J, Krepp J, Nagy C, Mazhari R, Reiner J. Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circ Cardiovasc Qual Outcomes. 2019 Apr;12(4):e005597. doi: 10.1161/CIRCOUTCOMES.119.005597. PMID: 30950651.
  17. Nota NM, Wiepjes CM, de Blok CJM, Gooren LJG, Kreukels BPC, den Heijer M. Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy. Circulation. 2019 Mar 12;139(11):1461-1462. doi: 10.1161/CIRCULATIONAHA.118.038584. PMID: 30776252.
  18. 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 2014. Accessed Nov 7, 2019.
  19. Clayton A. Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect-The Implications for Research and Clinical Practice. Arch Sex Behav. 2023 Feb;52(2):483-494. doi: 10.1007/s10508-022-02472-8. Epub 2022 Nov 14. Erratum in: Arch Sex Behav. 2022 Dec 13;: PMID: 36376741; PMCID: PMC9886596.
  20. Baker, K. E., Wilson, L. M., Sharma, R., Dukhanin, V., McArthur, K., & Robinson, K. A. (2021). Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review.Journal of the Endocrine Society, 5(4), bvab011.https://doi.org/10.1210/jendso/bvab011
  21. 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. PMID: 21364939; PMCID: PMC3043071.
  22. Bränström, R., & Pachankis JE. 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. Epub 2019 Oct 4. Erratum in: Am J Psychiatry. 2020 Aug 1;177(8):734. PMID: 31581798.
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  25. Littman, L. (2021). Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: A survey of 100 detransitioners. Archives of Sexual Behavior, 50(8),3353–3369.https://doi.org/10.1007/s10508-021-02163-w
    26. Vandenbussche E. Detransition-related needs and support: a cross-sectional online survey. Journal of homosexuality. 2021 Apr 30; 1-19. Doi: 10.1080/00918369.2021.1919479. Epub 2021 Apr 30. PMID: 33929297.
  26. Jorgensen SCJ. Transition Regret and Detransition: Meanings and Uncertainties. Archives of Sexual Behavior (2023) 52:2173–2184https://doi.org/10.1007/s10508-023-02626-2
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    http://dx.doi.org/10.1136/bmj-2022-073584 Published: 14 June 2023
  28. Halasz G, Amos A. Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice. Australasian Psychiatry. 2023;0(0). doi:10.1177/10398562231211130
  29. Council for Choices in Health Care in Finland (Palko/Cohere Finland) (2020). Recommendation of the Council for Choices in Health Care in Finland (PALKO/COHERE Finland): Medical Treatment Methods for Dysphoria Related to Gender Variance in Minors. Lingua Franca Translations (18 May, 2022), Certified English translation, Coconut Grove, Florida.
  30. Linden T, MD PhD Director/Government Chief Medical Officer. The National Board of Health and Welfare, Sweden 2022.
  31. National Academy of Medicine, France. Medical Care of Children and Adolescents with Transgender Identity. Unofficial translation by the Society for Evidence-based Gender Medicine (SEGM), March 2, 2022 – https://segm.org/sites/default/files/English%20Translation_22.2.25-Communique-PCRA-19-Medecine-et-transidentite-genre.pdf.
  32. https://ukom.no/rapporter/pasientsikkerhet-for-barn-og-unge-med-kjonnsinkongruens/sammendrag?utm_source=substack&utm_medium=email
  33. Cass, Hilary Dr. (2022) Independent review of gender identity services for children and young people: Interim report – https://cass.independent-review.uk/publications/interim-report/.
  34. https://ugeskriftet.dk/videnskab/sundhedsfaglige-tilbud-til-born-og-unge-med-konsubehag
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Co-authors of the National Association of Practising Psychiatrists Guide

Dr Philip Morris AM MBBS BSc(med) PhD FRANZCP FAChAM(RACP)
President National Association of Practising Psychiatrists

Dr Cary Breakey MB BS (Mon), FRACGP, DPM (Qld)
Consultant Child and Adolescent Psychiatrist

Dr Roberto D’Angelo Psy.D. FRANZCP, M.Med.(Psychotherapy), MBBS
American Psychoanalytic Association – Member
Psychiatrist and Psychoanalyst

Dr Vivienne Elton MBBS, FRANZCP
Vice-president National Association of Practising Psychiatrists

Dr George Halasz MBBS, BMedSc, MRCPsych, FRANZCP
Consultant Child and Adolescent Psychiatrist

Prof Dianna Kenny PhD, MA (Sch Couns), BA (Hons), Dip Ed, Grad Dip FDR, FAPs, MAPA
Consulting Psychologist, Psychotherapist, Couple and Family Therapist

Dr Alison Clayton MBBS MPM FRANZCP
Psychiatrist

Dr Jillian Spencer MBBS (Hons), BMedSc, FRANZCP, Cert. Forensic Psychiatry, Cert. Child and Adolescent Psychiatry
Child and Adolescent Psychiatrist

Co-signatories of the National Association of Practising Psychiatrists Guide

Dr Vanessa Spiller BA (Psych) (Hons), MPsych (Clinical), PhD
Australian Psychological Society (MAPS) (FCCLP)
Clinical Psychologist

Dr Dylan Wilson MBBCh MRCPH FRAC
Pediatrician

Guide content last updated 30 November 2023

https://napp.org.au/2022/03/managing-gender-dysphoria-incongruence-in-young-people-a-guide-for-health-practitioners-2/

Dr Philip Morris AM
President NAPP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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