No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Importance of being persistent. Should transgender children be allowed to transition socially?
Abstract
Studies suggest that the majority of gender diverse children (up to 84%) revert to the gender congruent with the sex assigned at birth when they reach puberty. These children are now known in the literature as ‘desisters’. Those who continue in the path of gender transition are known as ‘persisters’. Based on the high desistence rates, some advise being cautious in allowing young children to present in their affirmed gender. The worry is that social transition may make it difficult for children to de-transition and thus increase the odds of later unnecessary medical transition. If this is true, allowing social transition may result in an outright violation of one of the most fundamental moral imperatives that doctors have: first do no harm. This paper suggests that this is not the case. Studies on desistence should inform clinical decisions but not in the way summarised here. There is no evidence that social transition per se leads to unnecessary medical transition; so should a child persist, those who have enabled social transition should not be held responsible for unnecessary bodily harm. Social transition should be viewed as a tool to find out what is the right trajectory for the particular child. Desistence is one possible outcome. A clinician or parent who has supported social transition for a child who later desists will have not violated, but acted in respect of the moral principle of non-maleficence, if the choice made appeared likely to minimise the child’s overall suffering and to maximise overall the child’s welfare at the time it was made.
... The initial stage of the therapeutic process, known as the 'social transition, ' involves permitting the adolescents to live in their own affirmed gender, informing individuals within the child/adolescent's social circle about their decision to embark on a gender transition. During this phase, the individual may select a name corresponding to their gender identity and adopts the social role associated with that gender, including clothing and behavior [20,52,55]. ...
... The timing for commencing this social transition should be agreed upon collaboratively between the healthcare professionals and the family, taking into consideration individual sensitivities and prioritizing the overall psychophysical well-being of the individual [55]. Based on the high desistence rates, some advise being cautious in allowing young children to present in their affirmed gender. ...
... A survey-based study on 20,619 transgender adults in the USA found that those who received puberty suppression had lower odds of lifetime suicidal ideation compared to those who desired puberty suppression but did not receive it [70]. While the majority of adolescents with GD who start GnRHa subsequently initiate GAHT, GnRHa use is not associated with increased subsequent GAHT use [55]. Additionally, a small percentage of cases discontinue GnRHa therapy, mostly due to remission of GD, highlighting the therapeutic value of this option in facilitating informed decision-making for adolescents [71,72]. ...
Background
In response to the imperative need for standardized support for adolescent Gender Dysphoria (GD), the Italian Academy of Pediatrics, in collaboration with the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine and Italian Society of Child and Adolescent Neuropsychiatry is drafting a position paper. The purpose of this paper is to convey the author's opinion on the topic, offering foundational information on potential aspects of gender-affirming care and emphasizing the care and protection of children and adolescents with GD.
Main body
Recognizing that adolescents may choose interventions based on their unique needs and goals and understanding that every individual within this group has a distinct trajectory, it is crucial to ensure that each one is welcomed and supported. The approach to managing individuals with GD is a multi-stage process involving a multidisciplinary team throughout all phases. Decisions regarding treatment should be reached collaboratively by healthcare professionals and the family, while considering the unique needs and circumstances of the individual and be guided by scientific evidence rather than biases or ideologies. Politicians and high court judges should address discrimination based on gender identity in legislation and support service development that aligns with the needs of young people. It is essential to establish accredited multidisciplinary centers equipped with the requisite skills and experience to effectively manage adolescents with GD, thereby ensuring the delivery of high-quality care.
Conclusion
Maintaining an evidence-based approach is essential to safeguard the well-being of transgender and gender diverse adolescents.
... Abel explored the positives and negatives of gender-affirming hormones through the lens of autonomy, beneficence, and nonmaleficence, 55 while Drescher and Pula attempted to explore both positive and negative arguments around GAC through posing, but not answering, various questions, such as what are the ethical implications of social transitions or should parents be told ''transsexualism'' can be prevented. 56 Of the remaining three articles, two articles argued in favor of GAC, with one article by Giordano endorsing social transition, 57 and another article by Priest advocating for state sponsored access to puberty blocker treatment. 3 The final article, by Laidlaw et al., argued against GAC in favor of a form of watchful waiting that differs from the standard model, stating that children younger than 16 years did not have the mental or emotional capacity to make such choices. ...
... Fifteen articles referred to desistance as the disappearance of the diagnosis of GD after the start of puberty or during adolescence, not related to social or medical interventions. 5,29,32,52,53,[56][57][58][61][62][63]69,71,74 Only three of these included the absence of GD in adulthood as well, again not related to social or medical interventions. 29,52,61 Eleven articles used desistance to indicate a change in gender identity from TGE to cisgender. ...
... An almost equal number of articles referred to desistance as the disappearance of GD as did articles that referred to desistance as the change of a transgender identity to a cisgender identity. Disappearance of GD and a change in gender identity are two concepts that, while 59 Explicit ''Children who transitioned in childhood, but discovered at an older age that they preferred to live in the gender role of their natal sex again'' 2 Singh (2012) 52 Inferred Children with GID who do not have GID in adulthood 1 Daniolos (2013) 60 Explicit Those who in time are able to ''settle'' into their natal gender 2 Hembree (2013) 70 Inferred When the dysphoria that occurs due to variance between natal sex and gender no longer exists after puberty 1 Steensma (2013) 53 Inferred No longer meeting criteria for GD for the respective age group 1 Abel (2014) 55 Explicit ''While many young children will ultimately decide to revert to their natal genderknown as desisting'' 2 Drescher (2014) 61 Inferred GD that does not continue into adolescence and adulthood 1 Drescher (2014) 56 Explicit ''The gender dysphoria of the majority of children with GD/GV does not persist into adolescence, and when it does, the children are referred to as 'desisters''' 29 Inferred Children with GD in childhood, who did not have a ''developmentally equivalent adolescence or adulthood diagnosis'' 1 Giordano (2019) 57 Explicit ''Gender diverse children whose feelings of gender dysphoria desisted into adolescence OR Gender diverse children who do not have a desire for medical gender-affirming treatment after they enter puberty'' 1 Laidlaw (2019) 5 Inferred Children who are no longer dysphoric after puberty 1 Priest (2019) 3 Explicit ''transgender children who revert back to their natal gender'' 2 Butler (2020) 68 Inferred Children who begin undergoing a gender transition and then choose to stop this journey 2 Hruz (2020) 73 Inferred Children who ''express gender discordance.and experience reintegration of gender identity with biological sex by the time of puberty'' 2 Explicit definitions are in bold. ...
Background:
Desistance is a concept that has been poorly defined in the literature, yet greatly impacts the arguments for and against providing gender-affirming care for transgender and gender expansive (TGE) youth. This literature review aims to provide an overview of the literature on desistance and how desistance is defined.
Methods:
A systematically guided literature review was conducted on March 27, 2020, using CINAHL, Embase, LGBT Life, Medline, PsychINFO, and Web of Science to identify English language peer-reviewed studies, editorials, and theses that discuss desistance concerning TGE pre-pubertal youth for a minimum of three paragraphs. Articles were divided based on methodology and quantitative data were quality assessed and congregated. Definitions of desistance were compiled and analyzed using constant comparative method.
Results:
One qualitative study, 2 case studies, 5 quantitative studies, 5 ethical discussions, and 22 editorials were assessed. Quantitative studies were all poor quality, with 83% of 251 participants reported as desisting. Thirty definitions of desistance were found, with four overarching trends: desistance as the disappearance of gender dysphoria (GD) after puberty, a change in gender identity from TGE to cisgender, the disappearance of distress, and the disappearance of the desire for medical intervention.
Conclusions:
This review demonstrates the dearth of high-quality hypothesis-driven research that currently exists and suggests that desistance should no longer be used in clinical work or research. This transition can help future research move away from attempting to predict gender outcomes and instead focus on helping reduce distress from GD in TGE children.
... To this date, the possible benefits or disadvantages of an "early" social transition for a child's future development are among the most controversially discussed topics in Transgender Health Care (Coleman et al., 2012;Giordano, 2019;Steensma & Cohen-Kettenis, 2015;Wong et al., 2019); especially bearing in mind the developmental trajectories of persistence versus desistence into adolescence and adulthood (Ristori & Steensma, 2016). Children with either a GD diagnosis or so-called gender nonconforming or gender variant experiences often do not continue to experience a clinical GD as adolescents and adults (Ristori & Steensma, 2016;Steensma et al., 2013). ...
... This developmental pathway is referred to as a desisting GD ("desisters"), in contrast to "persisters," whose GD continues to persist into adolescence and adulthood . This research has been criticized for including gender variant children despite not meeting the diagnostic criteria for a GD (Giordano, 2019;Temple Newhook et al., 2018). Furthermore, it has been argued that the number of desisters has been overestimated due to the timing of follow-up Giordano, 2019). ...
... This research has been criticized for including gender variant children despite not meeting the diagnostic criteria for a GD (Giordano, 2019;Temple Newhook et al., 2018). Furthermore, it has been argued that the number of desisters has been overestimated due to the timing of follow-up Giordano, 2019). In a response to these critiques, Steensma and Cohen-Kettenis (2018) have subsequently described limitations and also highlighted the possibilities for more than these two developmental pathways of either persisting or desisting. ...
Research provides inconclusive results on whether a social gender transition (e.g. name, pronoun, and clothing changes) benefits transgender children or children with a Gender Dysphoria (GD) diagnosis. This study examined the relationship between social transition status and psychological functioning outcomes in a clinical sample of children with a GD diagnosis. Psychological functioning (Child Behavior Checklist; CBCL), the degree of a social transition, general family functioning (GFF), and poor peer relations (PPR) were assessed via parental reports of 54 children (range 5-11 years) from the Hamburg Gender Identity Service (GIS). A multiple linear regression analysis examined the impact of the social transition status on psychological functioning, controlled for gender, age, socioeconomic status (SES), PPR and GFF. Parents reported significantly higher scores for all CBCL scales in comparison to the German age-equivalent norm population. Peer problems and worse family functioning were significantly associated with impaired psychological functioning, whilst the degree of social transition did not significantly predict the outcome. Therefore, claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.
... However, long-term follow-up studies suggest that over 80% of boys referred for clinical GD to GID services desisted from gender dysphoria in adulthood (16). The role of prepubertal gender social transition in increasing the likelihood of persistence is debated but may provide a means of support (17,18). Support for transgender children in their expressed gender identity appears to contribute to psychological well-being (19). ...
Gender issues have become a polarised and political subject in modern paediatrics and indeed, in broader society. These include the management of infants with disorders of sex development and transgender sports participation, but especially recently regarding the management of gender dysphoria. The European Academy of Paediatrics (EAP) acknowledges that there are deeply held beliefs about this issue based on conscience and social norms. Several European countries, led by the UK, have recently reviewed the management of gender dysphoria in children and young people. Recognising the need for far more research into treatments such as pubertal suppression and cross-sex hormones in children and young people, we review the current ethical and legal dilemmas facing children with gender dysphoria, their families and the clinical teams caring for them. We suggest an approach that maintains the child's right to an open future whilst acknowledging that the individual child is the crucial person affected by decisions made and must receive appropriate support in decision-making and care for any associated mental health or psychological issues. Noting that national approaches to this vary and are in flux, the EAP advocates a child-centred individual rights-based analytical approach.
... Likewise, we have witnessed this absence in our research, where we did not encounter participants who identified themselves as detransitioners (or an equivalent label). In fact, publications on this topic are very recent (Ashley 2019;Butler and Hutchinson 2020;Chen et al. 2018;Expósito-Campos 2021;Giordano 2019;Hildebrand-Chupp 2020;Temple Newhook et al. 2018;Vandenbussche 2021). ...
... En definitiva, preocupa la influencia que el estudio de las destransiciones podría ejercer sobre las prácticas sanitarias enfocadas en el tratamiento de la DG 134 . En esta línea, algunos autores han argumentado que el malestar asociado a la transición social y/o médica para aquellas personas que finalmente destransicionan no es significativamente comparable al malestar que genera demorar o desaconsejar la transición de género 40 , y que las destransiciones no invalidan el consentimiento informado ni atentan contra los principios hipocráticos de la beneficencia y la no maleficencia 126,150 , puesto que la recomendación inicial de transicionar buscaba maximizar el bienestar y minimizar los riesgos psicológicos asociados a la ausencia de tratamiento. Paralelamente, se han producido importantes discusiones sobre la posibilidad de dar un consentimiento verdaderamente informado, especialmente en el caso de menores, a la luz de la evidencia existente para el tratamiento médico de la DG y de su irreversibilidad, así como sobre otros aspectos éticos relacionados con la autonomía, la capacidad decisional y el equilibrio entre los riesgos asociados al tratamiento y los riesgos de no recibirlo 103,104,127,141,142,[151][152][153][154][155][156][157][158][159][160][161][162][163][164][165] . ...
Introducción. La destransición de género es el acto de detener o revertir los cambios sociales, médicos y/o administrativos con- seguidos durante un proceso de transición de género. Se trata de un fenómeno emergente de gran interés a nivel clínico y social.
Método. Se condujo una búsqueda sistemática en siete bases de datos entre 2010 y 2022, se rastrearon manualmente las referencias de los artículos y se consultaron libros especializados. Se realizó un análisis cuantitativo y de contenido.
Resultados. Se incluyeron 138 registros, 37% correspondientes a estudios empíricos y 38,4% publicados en 2021. Se identifican al menos ocho términos para hacer referencia a la destransición, con diferencias en sus definiciones. La prevalencia difiere en función del criterio utilizado, siendo menor para la destransición/arrepentimiento (0-13,1%) que para la descontinuación de la asistencia/tratamiento médico (1,9%-29,8%), y menor para la destransición/arrepentimiento tras cirugía (0-2,4%) que para la destransición/arrepentimiento tras tratamiento hormonal (0-9,8%). Se describen más de 50 factores psicológicos, médicos y socioculturales que influyen en la decisión de destransicionar, así como 16 factores predictores/asociados a la destransición. No se encuentran guías de abordaje sanitario ni legislativo. Los debates actuales se centran en los interrogantes sobre la naturaleza de la disforia de género y el desarrollo de la identidad, el papel de los profesionales con respecto al acceso a los tratamientos médicos y el impacto de las destransiciones sobre la futura accesibilidad a dichos tratamientos.
Conclusiones. La destransición de género es una realidad compleja, heterogénea, poco estudiada y escasamente comprendida. Se requiere un abordaje y estudio sistemático que permita comprender su prevalencia real, implicaciones y manejo a nivel sanitario.
... 2 Experts also disagree about how to factor in the attendant risk of regretting later in life the irreversible consequences of a medical intervention performed at a young age. 3 On the other hand, the decision not to offer any medical treatment may also lead to serious consequences for children's health such as higher rate of depression and suicide. 4 Since decisions have to be made at an age when trans minors might not yet have acquired full competence to consent, a great responsibility rests on the physicians and psychologists involved. ...
Increasingly, transgender minors are seeking medical care such as puberty-suppressing or gender-affirming hormone therapies. Yet, whether these interventions should be performed at all is highly controversial. Some healthcare practitioners oppose irreversible interventions, considering it their duty to protect children from harm. Others view minors, like adults, as transgender individuals who must be protected from discrimination. The underlying ethical question is presented as a problem of priority. Is it primarily relevant that minors are involved? Or should decision makers focus on the fact that they treat transgender individuals ? The paper explores the relevance for medical practice. We provide results of an interview study with German healthcare professionals. We discuss the general question whether prioritization among different group memberships of the same person is ethically defensible. We conclude that priority conflicts between group memberships of the same person can be deceptive and should be addressed by an intersectional approach. Eventually, we discuss practical implications.
... Studies suggest that the majority of gender-confused children (nearly 85%) revert to their birth sex when they reach puberty. 4 Some clinicians are also saying that in up to 98% of cases, children with gender dysphoria will outgrow this condition by adulthood. 5 The research question of this paper is twofold: Is it natural and normal to become transgender? ...
Introduction: The paper deals with gender dysphoria (gender identity) and helps the reader
understand that people are not born in wrong bodies thus linking the understanding with
unnatural behaviour. Methods: The second part compares transgenderism with a psychiatric
condition: clinical lycanthropy. We see a case of someone believing he was a bird and how
he was cured. Results: The author highlights similarities between the two conditions. In
both scenarios there could be delusions and the individuals are unhappy with their bodies.
The unshakeable belief in drastically changing one’s body is not normal and should receive
psychological or psychiatric treatment. Conclusion: A number of bioethical statements are
presented. The author reminds healthcare workers to adhere to the medical principle of ‘first
do no harm’ when considering gender affirmative treatment and advises that political decisions
should not be based on just palliative approaches. It is concluded that gender remains binary.
The transgender or third gender is a socio-political construct.
... For example, using a youth's chosen name and pronouns can reduce depression and suicidal ideation significantly (Pollitt et al., 2021;Russell et al., 2018). Social transition has been associated with improved mental health (Durwood et al., 2017;Wong et al., 2019), with no evidence that social transition itself further impacts someone's gender identity (Giordano, 2019). ...
Objective: Transgender and gender diverse youth (TGD) are seeking psychological and medical care at an increased rate. Psychologists and other mental health providers, both on multidisciplinary teams and in the community, are being called upon to support these youth and their families. Evidence-based comprehensive care is imperative, which includes involving parents and caregivers. Moreover, parental and caregiver acceptance and support are one of the most important protective factors against anxiety, depression, and suicidality. By supporting parents and caregivers along their own journey, mental health providers can improve outcomes for the whole family. Method: This article summarizes key practices for mental health providers in working with parents and caregivers of gender diverse youth. Results: Best practices for working with parents and caregivers include (a) using a comprehensive, individualized, dynamic process for assessment, psychoeducation, and intervention; (b) assisting families in taking an informed and shared decision-making approach to care; (c) addressing parent and caregiver concerns from a risk/benefit perspective; and (d) understanding the parent and caregiver journey, including complex emotions and experiences of loss and grief. Conclusions: Working with parents and caregivers of TGD youth is an integral part of competent gender affirming care. While there is no one path that will be best for all families, using these best practices will assist mental health providers in supporting parents and caregivers as they adapt and support their TGD children and teens
... A second paradigm, 'delayed transition' , also known as 'watchful waiting' , puts age-based barriers on social transition, with an emphasis on delayed acceptance or affirmation of a child's identity, with children prevented from socially transitioning until a prescribed age, often around puberty (de Vries & Cohen-Kettenis, 2012;Ehrensaft et al., 2018;Giordano, 2019). The World Professional Association for Transgender Health (WPATH) published Standards of Care Version 7 (SOC 7) in 2011, in which it implicitly endorsed 'delayed transition' , through warnings against pre-pubertal social transition (Coleman et al., 2012). ...
Within transgender children’s healthcare there are two competing paradigms on appropriate support for pre-pubertal trans children, ‘affirmation’ and ‘delayed transition’. Parents of trans children accordingly face conflicting advice on the appropriate timing of ‘social transition’, where social transition connotes external acceptance and affirmation of a child’s identity. This innovative research brings experience-based insights from 30 UK-based parents (93% female), who supported 30 trans children to socially transition at an average age of seven years old (range 3–10 years old). Data were analyzed through inductive reflexive thematic analysis to understand interviewee experiences and perceptions related to the timing of social transition. Analysis highlights two broad themes; firstly, the influence of cisnormativity on delay, with parents revealing deeply embedded resistance to trans possibilities. Secondly, parental perception of delays causing distress, even in families who may be considered affirming. The study reinforces existing research on the importance of affirmation and family support. The study also highlights the support parents may need to overcome cisnormative barriers to supportiveness, and the distress, frustration and trauma that trans children may experience, even within affirming families. © 2022 The Author(s). Published with license by Taylor & Francis Group, LLC.
Importance
Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking.
Objective
To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting.
Design, Setting, and Participants
This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children’s Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022.
Exposure
Reidentification with birth-registered sex.
Main Outcomes and Measures
The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received.
Results
Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%).
Conclusions and Relevance
These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.
Introduction. Gender detransition is the act of stopping or reversing the social, medical, and/or administrative changes achieved during a gender transition process. It is an emerging phenomenon of significant clinical and social interest.
Methods. We systematically searched seven databases between 2010 and 2022, manually traced article references, and consulted specialized books. Quantitative and content analyses were carried out.
Results. We included 138 registers, 37% of which were empirical studies and 38.4% of which were published in 2021. At least eight terms related to detransition were identified, with differences in their definitions. Prevalence estimates differ according to the criteria used, being lower for detransition/regret (0-13.1%) than for discontinuation of care/medical treatment (1.9%-29.8%), and for detransition/ regret after surgery (0-2.4%) than for detransition/ regret after hormonal treatment (0-9.8%). More than 50 psychological, medical, and sociocultural factors influencing the decision to detransition and 16 predictors/associated factors are described. No health or legal guidelines are found. Current debates focus on the nature of gender dysphoria and identity development, the role of professionals in accessing medical treatments, and the impact of detransition on future access to these treatments.
Conclusions. Gender detransition is a complex, heterogeneous, under-researched, and poorly understood reality. A systematic study and approach to the topic is needed to understand its prevalence, implications, and management from a healthcare perspective.
Until recently, talking about transgender children was only accepted and described in medical terms as a pathology to be prevented and treated. Although this interpretative framework still prevails today, we are witnessing an important epistemological change that fosters the recognition of this experience as an expression of human diversity to be claimed first and foremost by families. From the sociological point of view, we are dealing with a new phenomenon. This is the first generation of parents who choose to support and accompany their transgender not just at home but in public, thus facing unexplored paths and heading to unknown destinations. This thesis aims to describe how parenting a transgender child takes shape from the voices of those directly involved: the families. My research takes place in the Catalan and the Italian contexts, which are very close in cultural, historical, and economic terms, but show remarkable differences when it comes to the object of this study. The world of associations, the current medical model, and the legislative instruments designed to protect young gender variant people are organized differently in Catalonia and in Italy and can deeply affect the way families attribute meaning to their children's experience and the way they accompany them. Ethnography is the method chosen to develop this work because it gives researchers closer access to the reality they want to describe and the opportunity to show the reality based on the meanings, language, and relationships of the social actors that constitute the subject of study. The analysis of the interviews, which is the central part of the thesis, highlights such elements as the emotions felt by the parents, their ethical reflections when confronted with the breaking of the gender norm by their children, the social meanings attributed to them by the available discourses and the practical strategies activated to create legitimate and socially recognized possibilities of existence.
Hasta hace unos años, hablar de infancia trans* era concebible únicamente dentro de un marco médico, que consideraba este tipo de experiencias una patología que había que prevenir y tratar. Aunque este sigue siendo hoy el principal campo de conocimiento desde el que se desarrolla el discurso sobre lo trans* en la infancia, estamos asistiendo a un importante cambio epistemológico que lleva a reconocer estas experiencias como una mera expresión de la diversidad humana que debe ser afirmada, ante todo, por las familias. Desde el punto de vista sociológico, estamos ante un fenómeno nuevo. Se trata de la primera generación de progenitores que opta por apoyar y acompañar a sus hijes trans* y que lo hace de forma pública, navegando por caminos hasta ahora inexplorados y de destinos inciertos. Esta tesis pretende describir cómo toma forma la crianza de criaturas trans* a partir de las voces de las personas directamente implicadas, las familias. He situado la investigación en dos contextos, el catalán y el italiano, muy próximos entre sí en cuanto a cultura, historia y economía, pero que presentan importantes diferencias por lo que se refiere al objeto de estudio de esta tesis. El mundo asociativo, el modelo médico actual y los instrumentos legislativos destinados a proteger a las pequeñas personas trans* se organizan de forma diferente en Catalunya y en Italia, y contribuyen a determinar el modo en que las familias atribuyen un significado a la experiencia de su prole, así como el modo en que la acompañan. La etnografía es el método elegido para desarrollar este trabajo por su capacidad de acercar a la persona investigadora a la realidad que desea describir, permitiéndole emerger a través de los significados, el lenguaje y las relaciones de los actores sociales que conforman el objeto de estudio. El análisis de las entrevistas, que constituye la parte principal de esta tesis, pone de relieve las emociones que sienten madres y padres, las reflexiones éticas que surgen cuando se enfrentan a la ruptura de la norma de género por parte de sus criaturas, los significados sociales que los discursos disponibles les atribuyen y las estrategias prácticas.
Introduction. This article presents a review of current concepts of gender identity under normal and pathological conditions.
Aim. To analyse the impact of the medical and social paradigm shift for clinical practice.
Results and discussion. The modern academic literature devoted to gender identity disorders is characterized by a variety of terminology, a shift in emphasis from clinical judgement to a socially beneficial normocentric approach and a relatively few advanced, evidence-based research. There is also a lack of evidence for the gender theory underlying the new approach, which raises serious doubts about the validity of the medical and social paradigm revision. In the same time, the position of Russian psychiatrists remains to be more clinically oriented.
Conclusion. Patients who declare the desire to reassign their gender have to be assessed by psychiatrists for differential diagnosis to exclude a mental disorder. In such cases, the destigmatization of mental disorders is more critical than the depathologization of gender identity disorders.
This is an online supplement to : 2. Byne, W. Karasic, D.H., Coleman, E., Eyler, A.E, Kidd, J.D., Meyer-Bahlburg, H.F.L., Pleak, R.R., Pula, J. (2018) Gender dysphoria in adults: an overview and primer for psychiatrists Transgender Health 3: 57–A3.
It addresses gender dysphoria in individuals somatic intersex conditions/differences of sex development
Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists
William Byne 1 2, Dan H Karasic 3, Eli Coleman 4, A Evan Eyler 5, Jeremy D Kidd 6, Heino F L Meyer-Bahlburg 7, Richard R Pleak 8, Jack Pula 9
PMID: 29756044 PMCID: PMC5944396 DOI: 10.1089/trgh.2017.0053
Free PMC article
Abstract
Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.
Keywords: assessment; gender dysphoria; gender transition; intersex; mental health; psychiatry; transgender.
The aim of this analysis is to explain the need to adapt Law 3/2007, of 15 March, regulating the register rectification of the entry related to a person’s sex, to following the judgements of the Constitutional Court of Spain (full bench) judgement 99/2019, 18 July 2019, and of the Supreme Court of Spain (full bench) judgement 685/2019, 17 December 2019, regarding the legitimacy to be granted to
transsexual minors (or, more correctly, «transgender»), among others. We will analyse certain issues pending resolution regarding the assessment of the maturity of minors and the stability of gender identity. In order to do so, we will mainly rely on the solutions provided by law on the legal recognition of gender identity, already adapted
to the principle of self-determination and «depathologisation». In our observations, when modifying an official identification, apdoslicable through a special registration procedure, we will try to find the balance between apdoslying the best interest of a vulnerable minor, the value of the apdoslicant’s declaration of will regarding the registry change and the legal certainty prevailing in the Registry Office
Both clinical literature and biographical accounts suggest that many transgender individuals experience shame or have experienced shame at some point in their life for reasons related to their gender identity. In clinical psychology, at least until the 1960s, shame has not received much attention; focus was on guilt and shame was regarded mainly as a 'by-product' of guilt. From the 1960s shame has been identified as an emotion not necessarily related to guilt and with unique features, and has been studied in connection with a number of situations, such as domestic abuse, trauma, illness, and sexual orientation. However shame has been studied less in connection with gender variance. Shame has however intrigued philosophers, writers and artists for a very long time. Yet, the importance of the contribution of various disciplines to the understanding of the experience of shame in vulnerable individuals has been overlooked. This paper attempts to explore the meaning of shame for transgender individuals, by making reference not only to clinical studies, but also to artworks and literary novels. Franz Kafka, named "the poet of shame" is particularly salient to the analysis of shame, and some of his works will enable us to shed light on the complexities of the experience of shame in transgender individuals which may defy clinical observation.
Temple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however , medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.
Having lived through both World Wars, Jung was aware of the dangers of what he termed “psychic epidemics.” He discussed the spontaneous manifestation of an archetype within collective life as indicative of a critical time during which there is a serious risk of a destructive psychic epidemic.
Currently, we appear to be experiencing a significant psychic epidemic that is manifesting as children and young people coming to believe that they are the opposite sex, and in some cases taking drastic measures to change their bodies. Of particular concern to the author is the number of teens and tweens suddenly coming out as transgender without a prior history of discomfort with their sex.
“Rapid-onset gender dysphoria” is a new presentation of a condition that has not been well studied. Reports online indicate that a young person's coming out as transgender is often preceded by increased social media use and/or having one or more peers also come out as transgender. These factors suggest that social contagion may be contributing to the significant rise in the number of young people seeking treatment for gender dysphoria.
Current psychotherapeutic practice involves immediate affirmation of a young person's self-diagnosis, which often leads to support for social and even medical transition. Although this practice will likely help small numbers of children, there may also be many false positives.
Objective
To update the “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2009.
Participants
The participants include an Endocrine Society–appointed task force of nine experts, a methodologist, and a medical writer.
Evidence
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.
Consensus Process
Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.
Conclusion
Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person’s affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)—should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
Diane Ehrensaft Department of Pediatrics, University of California, San Francisco, CA, USA Abstract: Beginning with a case vignette, a discussion follows of the reformulation of theories of gender development taking into consideration the recent upsurge of gender nonconforming and transgender youth presenting for gender services and also in the culture at large. The three predominant models of pediatric gender care are reviewed and critiqued, along with a presentation of the recently developed interdisciplinary model of gender care optimal in the treatment of gender nonconforming youth seeking either puberty blockers or cross-sex hormones. Keywords: gender nonconforming, transgender, pediatric gender care, puberty blockers, cross-sex hormones
Analysis of data collected from behavioral paradigms has provided important information for understanding the etiology and progression of diseases that involve neural regions mediating abnormal behavior. The trace eyeblink conditioning (EBC) paradigm is particularly suited to examine cerebro-cerebellar interactions since the paradigm requires the cerebellum, forebrain, and awareness of the stimulus contingencies. Impairments in acquiring EBC have been noted in several neuropsychiatric conditions, including schizophrenia, Alzheimer’s disease (AD), progressive supranuclear palsy, and post-traumatic stress disorder. Although several species have been used to examine EBC, the rabbit is unique in its tolerance for restraint, which facilitates imaging, its relatively large skull that facilitates chronic neuronal recordings, a genetic sequence for amyloid that is identical to humans which makes it a valuable model to study AD, and in contrast to rodents, it has a striatum that is differentiated into a caudate and a putamen that facilitates analysis of diseases involving the striatum. This review focuses on EBC during schizophrenia and AD since impairments in cerebro-cerebellar connections have been hypothesized to lead to a cognitive dysmetria. We also relate EBC to conditioned avoidance responses that are more often examined for effects of antipsychotic medications, and we propose that an analysis of novel object recognition (NOR) may add to our understanding of how the underlying neural circuitry has changed during disease states. We propose that the EBC and NOR paradigms will help to determine which therapeutics are effective for treating the cognitive aspects of schizophrenia and AD, and that neuroimaging may reveal biomarkers of the diseases and help to evaluate potential therapeutics. The rabbit, thus, provides an important translational system for studying neural mechanisms mediating maladaptive behaviors that underlie some psychiatric diseases, especially cognitive impairments associated with schizophrenia and AD, and object recognition provides a simple test of memory that can corroborate the results of EBC.
Trauma memories - like all memories - are malleable and prone to distortion. Indeed, there is growing evidence - from both field and lab-based studies - to suggest that the memory distortion follows a particular pattern. People tend to remember more trauma than they experienced, and those who do, tend to exhibit more of the "re-experiencing" symptoms associated with post-traumatic stress disorder (PTSD). Our own research suggests that the likely mechanism underlying that distortion is a failure in people's source monitoring. After a traumatic experience, intentional remembering (effortful retrieval) and unintentional remembering (intrusive mental imagery) can introduce new details that, over time, assimilate into a person's memory for the event. We believe that understanding the role these factors play in distorting people's memories for traumatic experiences is both theoretically and practically important, particularly given their potential role in influencing people's recovery.
Treatment outcome in transsexuals is expected to be more favourable when puberty is suppressed than when treatment is started after Tanner stage 4 or 5. In the Dutch protocol for the treatment of transsexual adolescents, candidates are considered eligible for the suppression of endogenous puberty when they fulfil the Diagnostic and Statistic Manual of Mental Disorders-IV-RT criteria for gender disorder, have suffered from lifelong extreme gender dysphoria, are psychologically stable and live in a supportive environment. Suppression of puberty should be considered as supporting the diagnostic procedure, but not as the ultimate treatment. If the patient, after extensive exploring of his/her sex reassignment (SR) wish, no longer pursues SR, pubertal suppression can be discontinued. Otherwise, cross-sex hormone treatment can be given at 16 years, if there are no contraindications. Treatment consists of a GnRH analogue (GnRHa) to suppress endogenous gonadal stimulation from B2-3 and G3-4, and prevents development of irreversible sex characteristics of the unwanted sex. From the age of 16 years, cross-sex steroid hormones are added to the GnRHa medication.
Preliminary findings suggest that a decrease in height velocity and bone maturation occurs. Body proportions, as measured by sitting height and sitting-height/height ratio, remains in the normal range. Total bone density remains in the same range during the years of puberty suppression, whereas it significantly increases on cross-sex steroid hormone treatment. GnRHa treatment appears to be an important contribution to the clinical management of gender identity disorder in transsexual adolescents.
Dichotomous models of gender have been criticized for failing to represent the experiences of individuals who claim neither
an unambiguously female nor male identity. In this paper we argue that the feminist theoretical framework of intersectionality
provides a generative approach for interpreting these experiences of gender multiplicity. We review our previous research
on four young sexual-minority (i.e., nonheterosexual) women who are participants in a 10-year longitudinal study of sexual
identity development, applying the framework of intersectionality to understand their exploration of transgendered experience
and identification. Our analysis highlights the value of intersectionality as a framework for understanding not only multiplicity
across identity constructs (e.g.., race, gender, etc.) but also within identity constructs (i.e., female and male).
The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth's functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.
Childhood gender nonconformity has been associated with poorer relationships with parents, but it is unknown if childhood gender nonconformity is associated with childhood abuse or risk of posttraumatic stress disorder (PTSD) in youth.
We examined whether gender nonconformity before age 11 years was associated with childhood sexual, physical, and psychological abuse and lifetime risk of probable PTSD by using self-report questionnaire data from the 2007 wave of the Growing Up Today Study (n = 9864, mean age = 22.7 years), a longitudinal cohort of US youth. We further examined whether higher exposure to childhood abuse mediated possible elevated prevalence of PTSD in nonconforming children. Finally, we examined whether association of childhood gender nonconformity with PTSD was independent of sexual orientation.
Exposure to childhood physical, psychological, and sexual abuse, and probable PTSD were elevated in youth in the top decile of childhood gender nonconformity compared with youth below median nonconformity. Abuse victimization disparities partly mediated PTSD disparities by gender nonconformity. Gender nonconformity predicted increased risk of lifetime probable PTSD in youth after adjustment for sexual orientation.
We identify gender nonconformity as an indicator of children at increased risk of abuse and probable PTSD. Pediatricians and school health providers should consider abuse screening for this vulnerable population. Further research to understand how gender nonconformity might increase risk of abuse and to develop family interventions to reduce abuse risk is needed.
The author studied the outcome of 16 subjects who had exhibited feminine behavior as young boys. A structured interview, devised b culling from the literature those factors considered to be associated with gender identity disturbances, and a battery of psychological tests were administered. Six of the subjects showed markedly deviant gender identities; three were transsexuals, one a transvestite, and two homosexuals. There appeared to be two peaks for the age of onset of symptoms: before age six and after age ten. The data suggest that those with the earlier age of onset are more likely to develop severe gender identity disturbances.
The use of gonadotropin-releasing hormone analogs (GnRHa) to suppress puberty in adolescents with gender dysphoria is a fairly new intervention in the field of gender identity disorders or transsexualism. GnRHa are used to give adolescents time to make balanced decisions on any further treatment steps, and to obtain improved results in the physical appearance of those who opt to continue with sex reassignment. The effects of GnRHa are reversible. However, concerns have been raised about the risk of making the wrong treatment decisions, as gender identity could fluctuate during adolescence, adolescents in general might have poor decision-making abilities, and there are potential adverse effects on health and on psychological and psychosexual functioning. Proponents of puberty suppression emphasize the beneficial effects of GnRHa on the adolescents' mental health, quality of life and of having a physical appearance that makes it possible for the patients to live unobtrusively in their desired gender role. In this Review, we discuss the evidence pertaining to the debate on the effects of GnRHa treatment. From the studies that have been published thus far, it seems that the benefits outweigh the risks. However, more systematic research in this area is needed to determine the safety of this approach.
The aim of this qualitative study was to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. Twenty five adolescents (M age 15.88, range 14-18), diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood, participated in this study. Data were collected by means of biographical interviews. Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification. Although, both persisters and desisters reported a desire to be the other gender during childhood years, the underlying motives of their desire seemed to be different.
To establish the psychosexual outcome of gender-dysphoric children at 16 years or older and to examine childhood characteristics related to psychosexual outcome.
We studied 77 children who had been referred in childhood to our clinic because of gender dysphoria (59 boys, 18 girls; mean age 8.4 years, age range 5-12 years). In childhood, we measured the children's cross-gender identification and discomfort with their own sex and gender roles. At follow-up 10.4 +/- 3.4 years later, 54 children (mean age 18.9 years, age range 16-28 years) agreed to participate. In this group, we assessed gender dysphoria and sexual orientation.
At follow-up, 30% of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric. Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation.
Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality.
This article provides a selected overview of the literature on gender identity disorder and psychosexual problems in children and adolescents, with a focus on diagnosis, clinical course, etiology, and treatment.
This study provided information on the natural histories of 25 girls with gender identity disorder (GID). Standardized assessment data in childhood (mean age, 8.88 years; range, 3-12 years) and at follow-up (mean age, 23.24 years; range, 15-36 years) were used to evaluate gender identity and sexual orientation. At the assessment in childhood, 60% of the girls met the Diagnostic and Statistical Manual of Mental Disorders criteria for GID, and 40% were subthreshold for the diagnosis. At follow-up, 3 participants (12%) were judged to have GID or gender dysphoria. Regarding sexual orientation, 8 participants (32%) were classified as bisexual/homosexual in fantasy, and 6 (24%) were classified as bisexual/homosexual in behavior. The remaining participants were classified as either heterosexual or asexual. The rates of GID persistence and bisexual/homosexual sexual orientation were substantially higher than base rates in the general female population derived from epidemiological or survey studies. There was some evidence of a "dosage" effect, with girls who were more cross-sex typed in their childhood behavior more likely to be gender dysphoric at follow-up and more likely to have been classified as bisexual/homosexual in behavior (but not in fantasy).
Background: It has been widely suggested that over 80% of transgender children will come to identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans identity was a temporary “phase.” This statistic is used as the scientific rationale for discouraging social transition for pre-pubertal children. This article is a critical commentary on the limitations of this research and a caution against using these studies to develop care recommendations for gender-nonconforming children.
Methods: A critical review methodology is employed to systematically interpret four frequently-cited studies that sought to document identity outcomes for gender-nonconforming children (often referred to as “desistance” research).
Results: Methodological, theoretical, ethical, and interpretive concerns regarding four “desistance” studies are presented. The authors clarify the historical and clinical contexts within which these studies were conducted to deconstruct assumptions in interpretations of the results. The discussion makes distinctions between the specific evidence provided by these studies versus the assumptions that have shaped recommendations for care. The affirmative model is presented as a way to move away from the question of, “How should children's gender identities develop over time?” toward a more useful question: “How should children best be supported as their gender identity develops?”
Conclusion: The tethering of childhood gender diversity to the framework of “desistance” or “persistence” has stifled advancements in our understanding of children's gender in all its complexity. These follow-up studies fall short in helping us understand what children need. As work begins on the 8th version of the Standards of Care by the World Professional Association for Transgender Health, we call for a more inclusive conceptual framework that takes children's voices seriously. Listening to children's experiences will enable a more comprehensive understanding of the needs of gender-nonconforming children and provide guidance to scientific and lay communities.
Introduction:
The Australian standards of care and treatment guidelines aim to maximise quality care provision to transgender and gender diverse (TGD) children and adolescents across Australia, while recognising the unique circumstances of providing such care to this population. Recommendations are made based on available empirical evidence and clinician consensus, and have been developed in consultation with Australian professionals from multiple disciplines working with the TGD population, TGD support organisations, as well as TGD children and adolescents and their families. Main recommendations: Recommendations include general principles for supporting TGD children and adolescents using an affirmative approach, separate guidelines for the care of pre-pubertal children and TGD adolescents, as well as discipline-based recommendations for mental health care, medical and surgical interventions, fertility preservation, and speech therapy. Changes in management as a result of this statement: Although published international treatment guidelines currently exist, challenges in accessing and providing TGD health care specific to Australia have not been addressed to date. In response to this, these are the first guidelines to be developed for TGD children and adolescents in Australia. These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent's capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.
From the moment a child is born, what happens to that child will be heavily based on gender predictions. What usually influences gender predictions is genital morphology. However, endocrinology and developmental psychology show that genital morphology is not always an accurate predictor of gender identity. This chapter reviews some of the recent literature on sex and gender identity development and shows that there seem to be not only two, but many sexes and genders. One related fact is that there is no set of biological markers that can allow us to determine whether an individual is a female or a male. If we accept these facts, we are led to ask how society as a whole should be organised, how parents should raise their children, how nurseries and schools should operate, and how society at large should function. This chapter does not advocate the abolition of sexes and genders: it instead proposes that they should be treated as broad approximations and illustrates some ways in which tolerance towards sex and gender minorities may be fostered.
Objective:
Social transitions are increasingly common for transgender children. A social transition involves a child presenting to other people as a member of the "opposite" gender in all contexts (e.g., wearing clothes and using pronouns of that gender). Little is known about the well-being of socially transitioned transgender children. This study examined self-reported depression, anxiety, and self-worth in socially transitioned transgender children compared with 2 control groups: age- and gender-matched controls and siblings of transgender children.
Method:
As part of a longitudinal study (TransYouth Project), children (9-14 years old) and their parents completed measurements of depression and anxiety (n = 63 transgender children, n = 63 controls, n = 38 siblings). Children (6-14 years old; n = 116 transgender children, n = 122 controls, n = 72 siblings) also reported on their self-worth. Mental health and self-worth were compared across groups.
Results:
Transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers (p = .311), and they reported marginally higher anxiety (p = .076). Compared with national averages, transgender children showed typical rates of depression (p = .290) and marginally higher rates of anxiety (p = .096). Parents similarly reported that their transgender children experienced more anxiety than children in the control groups (p = .002) and rated their transgender children as having equivalent levels of depression (p = .728).
Conclusion:
These findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. These findings lessen concerns from previous work that parents of socially transitioned children could be systematically underreporting mental health problems.
As part of the development of the eleventh revision of the International Classification of Diseases (ICD-11), WHO appointed a Working Group on Sexual Disorders and Sexual Health to recommend changes necessary in the classification of mental and behavioural disorders in ICD-10 that are related to sexuality and gender identity. This Personal View focuses on the Working Group’s proposals to include the diagnosis gender incongruence of childhood in ICD-11 and to move gender incongruence of childhood out of the mental and behavioural disorders chapter of ICD-11. We outline the history of ICD and DSM child gender diagnoses, expert consensus, knowledge gaps, and controversies related to the diagnosis and treatment of extremely gender-variant children. We argue that retaining the gender incongruence of childhood category is justified as a basis to structure clinical care and to ensure access to appropriate services for this vulnerable population, which provides opportunities for education and informed consent, the development of standards and pathways of care to help guide clinicians and family members, and a basis for future research efforts.
Gender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.
Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices presents an overview of the research, clinical insights, and ethical dilemmas relevant to clinicians who treat intersex youth and their families. Exploring gender development from a cross-cultural perspective, esteemed scholar Peggy T. Cohen-Kettenis and experienced practitioner Friedemann Pfäfflin focus on assessment, diagnosis, and treatment issues. To bridge research and practical application, they include numerous case studies, definitions of relevant terminology, and salient chapter summaries.
This is a long term follow-up of 55 boys with early effeminate behavior. It was possible to determine the outcome in sexual orientation in 38 of the boys, which included homosexuality or variants of it in 35 (63.6 per cent) of the total of 55 and heterosexuality in three (5.5 per cent). In 10 boys the outcome was uncertain, and seven were lost to follow-up. An analysis of the uncertain cases suggests that the overall outcome in terms of homosexuality may prove to have been higher than 63.6 per cent. These results agree with those of previous prospective and retrospective studies, which are reviewed. From both types of such studies, the prospective ones starting out with instances of early effeminate behavior and the retrospective with cases of established homosexuality, the conclusion is ventured that all male homosexuality begins with early effeminate behavior. This has implications for future research on homosexuality.
Nine of 11 boys with prepubertal discordance of gender identity/role have been maintained in follow-up until young adulthood.
All are known to be homosexual or predominantly so. None is known to be either a transvestite or transexual, though one formerly
began the real-life test for transexualism and quit after 6 weeks. All nine have completed some postsecondary education, and
all are well-achieved or better, occupationally. Secondary psycho-pathology in adulthood has not been obviously manifest.
There was a consensus in adulthood that the nonjudgmentalism of those responsible for their follow-up over the years had had
a strongly positive therapeutic effect on the boys' personal development.
Objective:
To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
Method:
The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
Results:
We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
Conclusion:
Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
Gender Identity Disorder (GID) is classified as a mental illness and included in the DSM-IV and ICD-1O. It will also be included in the DSM-V. The psychiatric diagnosis, in spite of some apparent advantages, has significant psychological and social adverse implications. This paper discusses some of the main epistemological reasons to consider gender variance as a mental disorder. It will also evaluate whether reasons of other kinds (pragmatic, rather than epistemological) may justify the inclusion of gender variance amongst mental illnesses.
Ten subjects who exhibited feminine behavior and cross-dressing as young boys are described. At follow-up, 8 to 10 years later, 4 are heterosexual, 2 are homosexual, 1 is transsexual, and the outcome is uncertain in 3. Of the eight who met DSM III criteria when evaluated, three are heterosexual, two are homosexual, one is transsexual, and the outcome is uncertain for two. Gender dysphoria appears to be a necessary but not sufficient factor in a transsexual outcome. The strength, rigidity, and persistence of cross-gender behavior through latency may be a good predictor of transsexual outcome.
This is a long term follow-up of 55 boys with early effeminate behavior. It was possible to determine the outcome in sexual orientation in 38 of the boys, which included homosexuality or variants of it in 35 (63.6 per cent) of the total of 55 and heterosexuality in three (5.5 per cent). In 10 boys the outcome was uncertain, and seven were lost to follow-up. An analysis of the uncertain cases suggests that the overall outcome in terms of homosexuality may prove to have been higher than 63.6 per cent. These results agree with those of previous prospective and retrospective studies, which are reviewed. From both types of such studies, the prospective ones starting out with instances of early effeminate behavior and the retrospective with cases of established homosexuality, the conclusion is ventured that all male homosexuality begins with early effeminate behavior. This has implications for future research on homosexuality.