Read the practice review ‘Assessment and support of children and adolescents with gender dysphoria’ in the Archives of Disease in Childhood
There has been a large increase in the number of children and adolescents who question conventional gender expectations and seek recognition and acceptance of their gender diversity, wishing to develop a body that is congruent with their gender feelings. Professionals may be unsure how best to provide supportive care, how to access the national Gender Identity Development Service (GIDS) for children and adolescents, or how to deal with a transgender young person presenting with another clinical problem unrelated to their gender transition.
Faced with very distressed young people, they may feel under pressure to initiate physical intervention without consultation with psychosocial colleagues. It is important that all professionals are aware of the care pathway for transgender children that may be of relevance in a range of paediatric settings. The purpose of this practice review is to present an up-to-date perspective on the care of transgender children and adolescents to guide management and to enable the provision of a practical, evidence-based approach to their support.
Most empirical studies around mental health of gender variant young people show that adolescents are at higher risk of other co-existing difficulties than the general population (Coates & Spector Person, 1985). Adolescents, who present with gender dysphoria and cross-gender identification well after the onset of puberty, are more likely to also have significant psychopathology and broader identity confusion than gender identity issues alone (Kaltiala-Heino et al. 2015).
Yet it is also true that many young people who present to gender services are not necessarily distressed. Young people who are well supported by their family and receiving ongoing psychological support, seem to cope well with their gender incongruence (de Vries et al, 2015). Similarly, suicide is extremely rare.
Internalising problems (such as anxiety and depression) seem to be more common in adolescents with GD than externalizing difficulties (such as ‘oppositional defiant disorder’ or outward aggression) (de Vries et al, 2010). Within GIDS, the three most common associated difficulties at the moment of coming to the service were bullying (47%), low mood/depression (42%) and self-harming behaviour (39%) (Holt et al, 2014).
The percentages for associated difficulties and self-harm appear to be in line with young people from the LGB population (Stonewall, 2012) and increasing with the general population (Whitlock, 2010). The Stonewall (2012) survey for instance states that gay young people who experience homophobic bullying are significantly more likely to harm themselves than those who aren’t bullied (61 per cent compared to 50 per cent). In comparison to the general population, NSPCC estimates that between 1 in 15 and 1 in 10 young people in general deliberately harm themselves, and this figure is increasing.
Young people with GD are more likely to be at risk of prejudice, stigma, transphobia, individual, institutional, and societal discrimination and violence (Hendricks & Testa, 2012), which suggests the importance of the work of schools and local mental health services in supporting at-risk young people.
Autistic Spectrum Conditions
There seems to be a higher prevalence of autistic spectrum conditions (ASC) in clinically referred, gender dysphoric (GD) adolescents than in the general adolescent population. Holt, Skagerberg & Dunsford (2014) found that 13.3% of referrals to the service in 2012 mentioned comorbid ASC (although this is likely to be an underestimate). This compares with 9.4% in the Dutch service; whereas in the Finnish service, 26% of adolescents were diagnosed to be on the autism spectrum (Kaltiala-Heino et al. 2015).
Why there is a higher prevalence of ASD in GD young people is still unknown. A review of the literature by Van Der Meisen et al (2016), groups underlying hypotheses into biological, social and psychological assumptions.
- Biological: Extreme Male Brain Theory - ASD as a result of Extreme Male Brain. Prenatal testosterone may not only lead to a higher disposition towards ASD but also GD as an expression of extreme male characteristics- explains why girls with ASD would be more susceptible to develop GD.
- Social: Poor understanding of social relationships, which is a characteristic of individuals with ASD, suggests that GD could develop as a consequence of difficulty in social interactions. E.G boy with ASD who had been bullied by other boys might have developed a feeling of belonging to female sex out of aversion to male gender. Parkinson (2014) described 2 birth-assigned men who had feelings of being different and interpreted these feelings as GD and therefore requested gender reassignment therapies.
- Psychological: ASD - link with GD. From the literature review, we can conclude that knowledge on the co-occurrence of GD and ASD is far from complete. More research is needed to find out which factors are important in this co-occurrence. Despite the limited current literature on GD and ASD, there is now some replicated evidence of an over-representation of co-occurring GD and ASD compared to what would be expected by chance based on the prevalence in the general population. It is plausible that not only one suggested hypothesis but multiple suggested hypotheses may play a role in the GD-ASD co-occurrence. Alternatively, of course, the two may be present without being related to each other (Ristori and Steensma 2016).
How many people continue with their transition?
There are various papers and debates around gender identity development relating to whether an individual’s gender dysphoria may or may not change over time: often labelled by scientific papers (i.e. Steensma et al, 2013) as ‘persistence and desistence’.
These terms, however, are not entirely helpful, as they suggest that gender is binary, whilst gender instead is hugely varied, with a large number of gender options, which can shift over time.
Physical treatment studies
There are different options available around physical interventions. Some young people may decide not to access any form of physical intervention. For those who do, few people will choose to access the full range of physical treatments. Figures from the Scottish Trans Alliance Survey (2008) show that 24% (17/71) of the transgender respondents have not transitioned on a permanent basis from female-to-male or from male-to-female, but are either still living partly or fully as the gender they were labelled at birth or alternatively are living in a non-binary gender expression which is not clearly male or female.
Although hormone blockers and cross-sex hormone treatment are recommended in young people with GD and widely used across the board, it should be noted that the research evidence for the effectiveness of any particular treatment offered is still limited.
A Dutch research programme indicates that a treatment protocol including puberty suppression followed by cross-sex hormones and gender reassignment surgery, leads to improved psychological functioning in a selected group of transgender adolescents, who had persistent GD from childhood, lived in a supportive environment and had no serious co-morbidities. If the young people did not show persistent GD from childhood, live in a supportive environment or if they had serious co-morbidities, assessment was prolonged (de Vries et al 2014). The hormone blocker alone does not seem to alleviate feelings of GD, however, it does have a positive impact on adolescents’ psychological well-being by putting their pubertal development on hold (de Vries et al 2010). The Dutch authors conclude: ‘Clinicians should realize that it is not only early medical intervention that determines this success, but also a comprehensive multidisciplinary approach that attends to the adolescents’ GD as well as their further well-being and a supportive environment’ (de Vries et al 2014). Additionally, having good peer relationships and engaging in social interaction with other transgender people have both been shown to help build resilience and improve psychological well-being (Testa, Jimenez & Rankin, 2014; De Vries et. al., 2015).
Safety concerns remain regarding the impact of physical interventions. Although puberty suppression, cross-sex hormones and gender reassignment are generally considered safe treatments in the short term, the long-term effects regarding bone health and cardiovascular risks are still unknown (Cohen-Kettenis & Klink, 2015; Klink et al., 2015,).
Social transition age
The age at which adolescents socially transition has decreased in the last decade. Steensma & Cohen-Kettenis (2011) report that between 2000 and 2004, out of 121 pre-pubertal children, 3.3% had socially transitioned (clothing, hairstyle, change of name, and use of pronouns) when they were referred, and 19% were living in the preferred gender role in clothing style and hairstyle, but did not announce that they wanted a change in name and pronoun. Between 2005 and 2009, these percentages increased to 8.9% and 33.3% respectively.
However, quantitative and qualitative follow-up studies by Steensma et al (2011; 2013) present evidence to strongly suggest that early social transition does not necessarily equate to an adult transgender identity. The qualitative study reports on two girls who had transitioned when they were in elementary school and struggled with the desire to return to their original gender role. Fear of teasing and feeling ashamed resulted in a prolonged period of stress. One girl even struggled to go back to her previous gender role for two years.
As such, in our approach, we would encourage exploration of gender roles in this younger cohort, with a view to keeping options open and not having any pre-conceived ideas as the longer term outcome.
It is difficult to get an accurate idea of exactly how many people experience gender dysphoria across the world, not only because there are different criteria for treatment between countries but also because the term “gender dysphoria” is predominantly a white Western construct that may not necessarily translate easily to other cultures and societies. Estimates of the prevalence of gender dysphoria range from a lower estimate of 0.05% in the Netherlands and Belgium (Conway 2008) to 1.2% in New Zealand (Clark et al, 2014). These numbers are based on adolescents aged 15 years or older and adults who identify as transgender and who were treated at gender identity clinics.
The Endocrine Society (2009) and the World Professional Association for Transgender Health (2012) have published international guidelines for the treatment of children and adolescents with GD (add hyperlinks). According to the clinical management model for children with GD, a ‘watchful waiting’ approach is recommended, whilst carefully monitoring how their GD develops in the first stages of puberty. A proportion of adolescents experiencing GD choose to have (some) physical interventions. The guidelines recommend the use of gonadotropin-releasing hormone agonists (“hormone blockers”) in adolescence to suppress puberty, which can be followed by cross-sex hormone treatment from age 16 (Delemarre-van de Waal & Cohen-Kettenis, 2006). Young people can access these interventions if they fulfil eligibility and readiness criteria, such as onset of puberty (minimum Tanner Stage 2 required), but also psychological maturity, understanding and competence to make these decisions. The guidelines emphasize the importance of adopting a developmental approach, the involvement of the family and other social agencies as appropriate and that care should be provided within a well-integrated, specialist multidisciplinary team.