Transgender and Gender Non-Conforming Youth: Other Disorders

IACAPAP Textbook of Child and Adolescent Mental Health
Chapter
OTHER DISORDERS H.3
TRANSGENDER AND GENDER
NON-CONFORMING YOUTH
2018 edition
Jack L Turban, Annelou LC de Vries, Kenneth J Zucker &

Shervin Shadianloo
Jack L Turban
Division of Child & Adolescent
Psychiatry, Massachusetts
General Hospital, Boston, MA,
2114, USA
Conflict of interest: none
declared
Annelou LC de Vries
Department of Child and
Adolescent Psychiatry, Center
of Expertise on Gender
Dysphoria, VU University
Medical Center, Amsterdam,
The Netherlands.
declared
Kenneth J Zucker
Professor, Department of
Psychiatry, University of
Toronto, Toronto, Ontario,
Canada
declared
Photo Gillian Laub, Le Monde, 10.12.2014
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks to
describe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authors
and may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines and
laws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked to
illustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2018. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and
the use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Turban JL, de Vries ALC, Zucker KJ, Shadianloo S. Transgender and gender non-conforming youth. In Rey
JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2018.
Transgender and gender non-conforming youth H.3 1

T
ransgender and gender nonconforming youth include children and Shervin Shadianloo
adolescents who experience a marked incongruence between the gender Department of Child and
Adolescent Psychiatry, Center
assigned at birth and their gender identity (American Psychiatric for Transgender Care, Hofstra
Association, 2013). Over the past decade, there has been a remarkable Northwell School of Medicine,
75-59 263rd St Glen Oaks, NY
increase in attention to transgender issues across the lifespan. Television has 11004, USA
begun to highlight transgender individuals from childhood to adulthood (Zucker, Conflict of interest: none
2007; Morrison, 2010). News outlets from The New York Times Magazine to Le declared
Monde have explored the life experiences of transgender youth (Padawer, 2010; This chapter was adapted with
Rosin, 2008; Chayet, 2014). Legislative bodies have examined transgender rights revision from the chapter entitled
Gender Dysphoria & Gender
through restroom access, hate crime legislation, insurance regulations, and anti- Incongruence in the 5th Edition
of Lewis’s Child & Adolescent
discrimination policies, with physicians playing key roles in these discussions Psychiatry: A Comprehensive
(Schuster et al, 2016). These initiatives have ranged from protection of rights Textbook written by Jack L. Turban,
Annelou L.C. deVries, and Kenneth
for transgender patients to discriminatory policies that put the wellbeing of Zucker.
transgender children at risk. In India, The Rights of Transgender Bill 2014 was
recently introduced. The Canadian Senate passed Bill C-16 to expand anti-
discrimination laws to cover transgender individuals. Legislation in the United
States has fluctuated between Obama-era protections for transgender patients and
Trump era restrictions, most recently a proposed ban on transgender service people
in the military.
Parallel to this growing attention, there has been a marked increase in the
establishment of specialized gender identity clinics for children and adolescents
in North America and in Europe (Hsieh & Leininger, 2016), which likely reflects
the marked increase in referrals that has been noted internationally (Aitken et
al, 2015; Chen et al, 2016). The scientific literature on gender incongruence has
expanded as well, with an influx of new studies on co-occurring psychological
functioning, long-term follow-up studies, biological correlates, and outcomes of
medical interventions. Practicing child and adolescent psychiatrists should be
familiar with the basics of this field to appropriately assess and help these patients.
TERMINOLOGY AND DEFINITIONS

Terminology in this specialized area is continuously evolving. This section
describes terms and definitions that are in common usage in 2018, but different
regions, cultures, and families may have their own preferred terminology (see
Table H.3.1).
The term gender assigned at birth refers to a newborn’s gender (boy, girl,
indeterminate), as generally declared by a medical professional. Other relevant
terms include natal sex and birth sex. The term biological sex is somewhat vague, as
it is unclear whether it would be based on karyotyping of the sex chromosomes,
internal reproductive structures, the configuration of the external genitalia, etc.
The vast majority of newborns are assigned the gender of boy or girl through
prenatal diagnostics or, at birth, based on genital anatomy. A small number of
newborns may be classified as having a “disorder of sex development” or what
others have called “differences of sex development” (Hughes, 2006), congenital
conditions in which biological parameters of sex (e.g., the sex chromosomes, the
gonads, the configuration of the external genitalia, etc.) are incongruent with
one another. These conditions include complete or partial androgen insensitivity
syndrome, mixed gonadal dysgenesis, 5-alpha-reductase deficiency, penile
agenesis, and congenital adrenal hyperplasia, among others. Such patients may

experience gender identity issues different from those experienced by individuals

without a disorder of sex development (Meyer-Bahlburg et al, 2016). “Until I was about four or
five I didn’t know I wasn’t
Experienced gender or gender identity refers to one’s sense of self as a boy, a girl, to be honest with
as a girl, or some alternative gender that is different from the traditional boy-girl you. One of my earliest
dichotomy (e.g., “gender fluid,” “agender,” or “non-binary”). Other terms include memories, about five years
affirmed gender (typically used for individuals who have transitioned socially to old, was being yelled at by
a teacher for going to the
living as the desired gender). For the majority of individuals, experienced gender toilet with the girls. About
matches the gender assigned at birth. These individuals are referred to as cisgender. the same age I realised I
For some patients, experienced gender is opposite to the gender assigned at birth, was different to these other
boys. At the age of nine
and are referred to as transgender. I refused to have my hair
Gender expression refers to the way in which one presents to the outside cut. I didn’t have it cut until
I was 16, because having
world in a gendered fashion and may include pronoun use, clothing, and other it cut was such a torment
external markers. Gender nonconformity refers to a person’s gender expression that to me.
differs from socially anticipated gender expressions, which are binary in many School was extremely
cultures. These anticipated gender expressions vary from culture to culture and difficult. I got bullied a lot.
may vary from time to time within a single culture. Gender expression is different I was picked on for being
from gender identity in that an individual may carry and express themselves in a too thin, for being feminine,
for not liking football, for
way that is not expected in their culture but continue to identify as their gender hanging round with girls,
assigned at birth. for having long hair. They
mocked everything they
This may also be part of the psychosexual development of a child before, could think of in terms of
during and after puberty. The term gender role is also used in a similar way to gender and sexuality.”
gender expression but may be limited to behavior and is less inclusive than gender The Guardian
expression.
Transgender and gender variant identities are sometimes used as terms for
individuals whose experienced gender does not strictly match the gender assigned
at birth. Persons who experience psychological distress in relation to their gender
identity may be referred to as gender dysphoric. “Gender dysphoria” is the diagnostic
term adopted in the DSM-5 (see below) (American Psychiatric Association, 2013).
Sexual attraction or sexual orientation is a separate concept from gender
identity. Sexual orientation refers to the type of individuals toward whom one is
romantically or sexually attracted. Terms such as androphilia (attraction to males),
gynephilia (attraction to females), biphilia (attraction to males and females), and
aphilia (attraction to neither males nor females) have become more common, slowly
replacing older terms such as heterosexual, bisexual, homosexual, and asexual,
though this terminology can also be confusing as it does not explain if individuals
are attracted to a specific gender assigned at birth, a specific gender identity, a
specific gender expression, etc. In the scientific literature, the sexual orientation
of individuals who identify as transgender has been described in relation to their
experienced gender or their gender assigned at birth. For example, an adolescent
female who identifies as male and is sexually attracted to females may be described
as “heterosexual” in relation to experienced gender but as “homosexual” in relation
to birth sex (Lawrence, 2010). From either a clinical or research perspective, it
is critical to identity the frame of reference when describing a patient’s sexual
orientation. Most individuals who identify as transgender will describe their sexual
orientation in relation to their gender identity, not their gender assigned at birth
(e.g., a transgender woman who is attracted to men would likely consider herself
to be heterosexual).

Figure H.3.1 The “Genderbread Person”
The “genderbread person” is a tool designed by Sam Killermann to explain the distinctions between experienced gender
(termed gender identity here), gender expression, gender assigned at birth (termed biological sex here), and sexual or
romantic orientation. This educational tool may be useful for students new to the field and when explaining these phenomena
to families with gender nonconforming and gender dysphoric children. These terms are further described in table H.3.1.
The “genderbread person” has been developed as an educational tool to

clarify the distinctions among gender assigned at birth, experienced gender, and
sexual orientation (Figure H.3.1). Note that as a published educational instrument,
this graphic diverges somewhat from the contemporary terminology we describe.
Nonetheless, this tool has proven useful for introducing this terminology to families
and students new to the topics of gender and sexuality. The gender unicorn is
another popular graphic that highlights the dimensional aspects of gender identity,
gender assigned at birth, and sexual or romantic attraction.
UNDERSTANDING GENDER IDENTITY AND

GENDER NON-CONFORMITY AROUND THE WORLD
Most of the current literature regarding gender non-conforming, gender
variant and transgender youth is predominantly from Western countries. Given
the intangible nature of gender, gender identity and its expression, cultural
differences in how gender is understood and expressed may effect the approach
to these individuals. National Geographic recently tackled the complex topic of
gender in a special issue.
To work with gender non-conforming, gender variant and transgender
individuals from different cultures, or to apply current practice guidelines in
different cultures, various factors need to be taken into consideration. Gender may
be defined differently based on the language spoken. Language is the major mode
of creating and describing concepts as well as the emotions associated with them.

Table H.3.1 Terminology
TERM DEFINITION
• Gender assigned at birth
Gender assigned to an infant at birth, generally based on observed physical
• Natal sex
characteristics (genitalia etc.)
• Birth sex
• Experienced gender
Individuals’ psychological understanding of their own gender
• Gender identity
Individuals’ psychological understanding of their own gender, typically referring
• Affirmed gender
to living socially as that understood gender
• Sexuality Refers to the type of individuals towards whom one is romantically and/or
sexually attracted
• Sexual orientation
Refers to individuals whose gender assigned at birth and gender identity do
• Gender incongruence
not match
• Gender role A characteristic that is considered “male” or “female” by a particular culture
An individual’s outward presentation of their gender identity. Typical examples
• Gender expression
include, but are not limited to, clothing, hairstyles, and activities
Refers to individuals whose gender identity is incongruent with that assigned
at birth. This term is often used for individuals who are transgender in a binary
• Transgender
fashion but may also be used as an umbrella term for persons with any gender
identity other than cisgender (see below).
Typically used to refer to individuals who desire medical interventions to
• Transsexual align their anatomy with their gender identity. This term has been used
synonymously with transgender by some and has largely fallen out of favor
A transgender individual who identifies as male (typically with a female gender
• Transman
assigned at birth)
A transgender individual who identifies as female (typically with a male gender
• Transwoman
assigned at birth)
Refers to psychological distress in relation to one’s experienced gender; is
• Gender dysphoria also the classification used in DSM-5 (when fulfilling certain clinical criteria).
Note that not all patients with gender incongruence will experience dysphoria.
Refers to individuals whose experienced gender matches the gender assigned
• Cisgender
at birth
Refers to variation from developmental norms in gender role behavior that
• Gender non-conforming may be considered as non-gender stereotypical. This may include identifying
as both genders or identifying with neither, among others. Some transgender
• Gender variant individuals who identify on the gender binary (i.e., male or female) also identify
with these terms.
This term refers to the estrogen or testosterone treatment that induces the
• Cross-sex hormones
development of female and male secondary sex characteristics respectively
Refers to treatments aimed at supporting a patient in that patient’s gender
• Gender affirming care identity. This may include mental health, medical, legal, and surgical aspects
of care.
Refers to a process in which a patient is allowed to explore gender identity.
Treatment should not have a gender identity (cisgender, transgender, or
• Gender identity exploration
otherwise) as a goal of therapy. Rather, patients should be permitted to
explore the different possibilities to better understand the best fit for them

Gender, being a core feature of identity, is influenced by the language spoken. In

some languages the words for sex and gender are the same. This may make it harder
to differentiate between gender identity versus anatomical sex. It is important to
also note that some languages are grammatically gendered and some are not. In
languages that are grammatically gendered (e.g., Spanish), use of pronouns can be
an important topic and become a milestone in transitioning; however, this may
vary if the language spoken is non-gendered. About one quarter of the world’s
languages are grammatically gendered. In these languages each noun is assigned to
one gender, typically, masculine, feminine, neuter. Most cultures appear to have
followed a binary anatomical sex and created their language and culture based
on this presumed dichotomy. In contrast, other cultures have specific words to
describe aspects of gender identity that may fall outside of a binary concept of
gender such as hijra in India, two-spirit in some Native American tribes, and men-
women in Balkan communities.
Historically, Middle Eastern, North African and European cultures
recognized and had terms for transgender people. This includes hijra in India,
Mukhannath in Islam and Arabic cultures, Phrygia in ancient Greek, and Cybele
in ancient Roman. These individuals were often intersex people or natal males
castrated for religious or other reasons. It is important to note that the recognition
did not necessarily protect these individuals from stigma and marginalization, and
in some places like India, Hijras, although believed to have power to remove a “bad
spell” from newborns, were highly stigmatized. Meanwhile there have been new
movements to support and protect transgender people in this region. The Rights of
Transgender Persons Bill, which provisions anti-discrimination and employment
Click on the picture to
for transgender people, was introduced in 2014 in India; it may result in positive access Mermaids, UK site
changes in the future. Another example is the Fatwa from the Iranian Supreme that provides information
Leader, Ayatollah Khomeini, after the 1979 Islamic Revolution, that allows and support for children
transgender people to transition to their identified gender. and teenagers with gender
identity issues
It is beyond the scope of this chapter to review the concept of gender identity
in all different cultures; we bring these examples to highlight the cultural variation
about how gender identity is understood. There are many countries that have no
literature on the care of gender non-conforming, gender variant, and transgender
people. Transgender identity and gender non-conformity continue to be highly
stigmatized around the world. In East Asia alone, perspectives vary significantly.
Thailand has the highest number of gender affirming surgeries in the world. In
China, there are limited if any services for transgender people.
Working with children and youth presenting with gender issues requires
knowledge of the child’s psychosexual development, cultural aspects of gender and
its expression in that specific society and family unit, as well as their exposure
and understanding of the expanding information and media awareness around
gender non-conformity and transgender identity. In the case of working with
immigrant families, understanding the interaction of the host and home cultures
is also important.
HISTORY OF GENDER IDENTITY AND MEDICINE

John Money (1921-2006) was a psychologist and sexologist whose empirical
and theoretical contributions regarding gender identity, gender role, and gender

development were innovative and of great influence, beginning in the 1950s.

Money originally proposed a theory of “gender neutrality,” suggesting that gender “I have lived two thirds of
my life as female and a
identity was predominantly determined by social factors, including the gender third as male. I graduated
assigned at birth and subsequent socialization processes (Money et al, 1957). from high school as a girl
Money proposed that, for individuals with a disorder of sex development, early and from college as a guy;
surgical interventions to correct genital ambiguity were often needed so that a those five years were the
most difficult yet joyous and
child could then be supported with rearing in the gender assigned at birth. rewarding of my life.
Over the past few decades, Money’s original theory of gender neutrality at I was afraid to take this step
birth has been challenged by various lines of evidence suggesting the importance toward medical transition;
afraid I would lose
of biological factors, particularly patterns of prenatal hormone exposure, that everyone I loved, afraid
also contribute to gender identity formation and differentiation. For example, of what I would look like,
chromosomal females with congenital adrenal hyperplasia who were assigned afraid of what people would
female at birth are exposed to elevated levels of prenatal testosterone; many of say and what a freak they
would think I am. I thought
these girls are “behaviorally masculinized” and a higher percentage than the general I would have to move far
population develop gender dysphoria and transition from female to male (Dessens away and never talk to my
et al, 2005; Pasterski et al, 2015). parents, extended family, or
friends again. I am happy to
Perhaps the most widely cited case pertains to a biologically “normal” male say I was very wrong.
(one of a pair of identical twins) who, after a circumcision accident at the age of It has taken a lot of
7 months that led to penile ablation, underwent a vaginoplasty and was socially time, patience, and
re-assigned to female at the age of 17 months. Although this patient was described communication, but for
the most part I did not
by Money as a “tomboy” during childhood, subsequent follow-up revealed that lose anyone I love, and
the patient rejected estrogen therapy at the time of puberty and subsequently the people I did lose were
transitioned back to living as a male (Colapinto, 2000; Diamond & Sigmundson, not real friends in the
2004). Tragically, he committed suicide at the age of 38 (The Associated Press, first place. Nothing has
turned out like I thought it
2004). The “John-Joan” case, as it was called, has been used as evidence of the would when I first started
importance of biological factors in contributing to a person’s sense of gender transitioning; instead of
identity. A subsequent summary of seven similar patients reared as female after being shunned and vilified
traumatic loss of the penis have shown both male and female gender identities in by people from my past, I
have been received warmly
adolescence and adulthood, further complicating the picture (Meyer-Bahlburg, and lovingly. I have made
2005). many amazing friends
and had many incredible
In the 1960s, research into the developmental histories of adults with experiences along the way.”
“transsexualism” suggested that childhood cross-gender identification was The New York Times
common in these individuals (Green, 1974). This work was followed by research
It should be noted
with children who showed patterns of gender-related behavior similar to the that a large number of
recalled patterns of transsexual adults (Green, 1974). During this period, there transgender individuals are
was much less attention given to adolescents with a marked history of cross-gender rejected by their families.
identification. This leads to high rates
of homelessness among
By the late 1990s, however, more attention was given to adolescents with a them.
DSM diagnosis of gender identity disorder, including the possibility of treatment
with gonadotropin releasing hormone analogs, as reported by a research team in
the Netherlands (Cohen-Kettenis & van Goozen, 1998). This approach, described
below, was ultimately outlined in the 2009 Endocrine Society Guidelines for the
Treatment of Transsexual Persons (Wylie et al, 2009), and in the periodically updated
World Professional Association for Transgender Health (WPATH) Standards of
Care (Coleman et al, 2011). Research into these hormonal interventions has since
garnered significant attention, including increased NIH funding to study the long-
term benefits and risks of these treatments (Reardon, 2016).

DIAGNOSIS AND ASSESSMENT

Assessment of youth presenting with gender-related concerns requires a
developmental history that explores general psychological development, gender
development, and a careful analysis of the child’s environment and safety related
to expressed gender non-conforming behaviors. Various developmental theories
may provide assistance in understanding and categorizing children based on their
age in regards to gender development. The DSM-5 has criteria for diagnosis of
gender dysphoria in both children and adolescents. Gender dysphoria is a clinical
diagnosis and requires in depth and longitudinal evaluation of these youth.
Several scales have also been developed to help with the assessment of gender non-
conforming youth (The Utrecht Gender Dysphoria Scale, The Gender Identity/
Gender Dysphoria Questionnaire for Adolescents and Adults, among others),
though none of these alone can establish a diagnosis. The evaluation of gender,
in addition to the usual developmental and mental health evaluation of a child,
needs to include a thorough chronological history of the child’s gender expression
and identity from parents and caregivers as well as a developmentally informed
evaluation of the child’s gender individually. The evaluator may use tools such as
toys, books, drawing or playing materials to assist in the evaluation and gather
information about behavior at school, with peers and at home.
Families play a key role in the evaluation. A child’s gender variance has a
significant impact on the family dynamics and may lead to conflicts and disruption
of emotional attachments. It is important that these issues be identified and efforts
be made to include all parties involved in the child’s life regardless of the child’s
age.
Safety is a complex matter in the lives of gender non-conforming and
transgender youth. Mental health practitioners need to be aware and look for
overt and covert aggression and risk to the child due to being a sexual and gender
minority, in addition to the usual safety issues. Bullying, risk of being kicked out of
home, societal violence, and local legislation prosecuting or endangering a youth
need to be considered and documented.
CLASSIFICATION
Gender identity diagnoses first entered the DSM in its third edition with
three diagnoses: transsexualism, gender identity disorder of childhood, and
atypical gender identity disorder (American Psychiatric Association, 1980). The
essential feature of these three diagnoses was “an incongruence between anatomic
sex and gender identity” (American Psychiatric Association, 1980). Revisions in
the DSM-III-R were modest, though, in this edition, exclusion of individuals
with schizophrenia or a disorder of sex development was removed, noting that
individuals with either of these diagnoses could also have a “gender identity
disorder” (American Psychiatric Association, 1987).
In the DSM-IV, the three diagnoses from DSM-III were collapsed into
the overarching diagnosis “gender identity disorder,” with distinct criteria sets for
children versus adolescents and adults (American Psychiatric Association, 1987).
This edition also added a criterion stating “The disturbance causes clinically
significant distress or impairment in social, occupational, or other important areas
of functioning” (Vance et al, 2010).

Table H.3.2 Summary comparison of diagnostic criteria for gender dysphoria in

children and in adolescents and adults according to DSM-5
GENDER DYSPHORIA IN ADOLESCENTS AND

GENDER DYSPHORIA IN CHILDREN
ADULTS
A marked incongruence between one’s

experienced/expressed gender and assigned
gender (one of which must be a strong desire A marked incongruence between one’s experienced/
to be of the other gender or an insistence that expressed gender and assigned gender, of at least 6
one is the other gender or some alternative months’ duration, as manifested by at least two of the
gender different from one’s assigned gender), following:
of at least 6 months’ duration, as manifested by
at least six of the following.
● In boys (assigned gender), a strong

preference for cross-dressing or dressing ● A marked incongruence between one’s experienced/
as female; or in girls (assigned gender), expressed gender and primary and/or secondary
a strong preference for wearing only sex characteristics (or in young adolescents, the
masculine clothing and a strong resistance anticipated secondary sex characteristics).
to wearing feminine dresses.
● A strong desire to be rid of one’s primary and/or
● A strong preference for cross-gender roles secondary sex characteristics because of a marked
in make-believe play or fantasy play. incongruence with one’s experienced/expressed
● A strong preference for toys, games, or gender (or in young adolescents, a desire to prevent
activities stereotypically used by the other the development of the anticipated secondary sex
gender. characteristics).
● A strong preference for playmates of the ● A strong desire for the primary and/or secondary sex
other gender. characteristics of the other gender.
● In boys (assigned gender), a strong ● A strong desire to be of the other gender (or some
rejection of masculine toys, games, and alternative gender different from one’s assigned
activities and a strong avoidance of rough- gender).
and-tumble play; or in girls (assigned ● A strong desire to be treated as the other gender (or
gender), a strong rejection of feminine some alternative gender different from one’s assigned
toys, games, and activities. gender).
● A strong dislike of one’s sexual anatomy. ● A strong conviction that one has the typical feelings
● A strong desire for the primary and/or and reactions of the other gender (or some alternative
secondary sex characteristics that match gender different from one’s assigned gender).
one’s experienced gender.
The condition is associated with clinically significant distress or impairment in social, school, or other
important areas of functioning.

DSM-5 renamed gender identity disorder as “gender dysphoria,” aiming to

decrease stigma associated with the diagnosis while maintaining a diagnosis that
could be used to secure access to care for those who needed it (Vance et al, 2010).
DSM-5 removed sexual orientation subtyping but noted in the text its relevance
in understanding variations in developmental trajectories, and for research on
biological factors and long-term outcomes (American Psychiatric Association,
2013). DSM-5 also made the childhood diagnosis stricter, requiring more than
just gender non-conforming behavior. The new criteria require that a child express
an actual desire or insistence in being of the other gender. The adolescent and adult
criteria simultaneously became more inclusive, allowing for non-binary gender
identities that would allow for gender variant, but not strictly binary, transgender
adolescents and adults to receive the diagnosis and subsequently access to care.
Current DSM-5 criteria for gender dysphoria in children require a marked
incongruence between one’s experienced/expressed gender and assigned gender,
of at least six months’ duration, as evidenced by at least six of eight criteria, one
of which must be a strong desire to be of the other gender or an insistence that
one is the other gender (or some alternative gender different from one’s assigned
gender). Additionally, the patient must experience clinically significant distress
or impairment in social, school, or other important areas of functioning as
introduced in the DSM-IV (see Table H.3.2). DSM-5 criteria for gender dysphoria
in adolescents and adults are similar, though with different requirements for the
manifestation of gender dysphoria. This diagnosis requires at least two of six
manifestations (see Table H.3.2).
Some have argued for use of the term “gender incongruence,” including
the Working Group on Sexual Disorders and Sexual Health for the forthcoming
11th edition of the International Classification of Diseases (ICD-11). This group
suggested that the term “gender incongruence” highlights that not all transgender
individuals experience dysphoria. The group notes that the term gender dysphoria
might increase inappropriate stigmatization and pathologization. The group
recognizes the necessity of diagnosis only for the purpose of preserving access to
medical care. The group additionally argues that this diagnosis be moved out of
the chapter on mental health and behavioral disorders and into another section, Click on the picture to access
the site of the Gender
provisionally termed “conditions related to sexual health” (Drescher et al, 2016). Identity Research and
though this brings up an additional issue of conflating gender identity with Education Society (GIRES)
sexuality, as described in the terminology section above.
EPIDEMIOLOGY
A range of methodological challenges including, but not limited to, shifting
terminology and stigma associated with self-identification, have made it difficult to
establish the true prevalence of gender dysphoria or gender incongruence.
Prevalence in Adults
In adults, most studies have used the number of individuals that seek
clinical care for gender affirming treatment as a proxy for determining prevalence
in a certain country or catchment area. A recent meta-analysis based on 21 studies
that applied this method concluded that the prevalence of transsexualism (the
definition used in most of these studies) was 6.8 trans women in 100,000 gender

at birth assigned males (1:14,705) and 2.6 trans men in 100,000 gender at birth
assigned females (1:38,461) (Arcelus et al, 2015). A time trend was also found,
with recent studies reporting higher prevalence rates. These studies are, of course,
limited by the fact that they do not include transgender individuals who do not
seek gender affirmative healthcare. Indeed, much higher prevalence rates—ranging
from 4.2 % having an ambivalent gender identity, to around 0.5 % identifying
as transgender and considering medical interventions—are suggested by recent
studies that have used broader definitions and probability samples (Conron et al,
2012; Kuyper & Wijsen, 2014; van Caenegem et al, 2015). A recent population-
based survey in the US found that 0.6% of adults self-identified as transgender,
with rates ranging from 0.3% to 0.8% in the states for which data were available.
Compared to older age groups, young adults aged 18 to 24 were more likely to
identify as transgender (Andres et al, 2016).
Prevalence in Children and Adolescents
Although formal epidemiological studies of gender dysphoria (previously

known as gender identity disorder) in children and adolescents have not been
conducted, looser or more liberal definitions of “caseness” have been examined
in several studies. In a random sample of 2,730 Grade 6-8 students from San
Francisco, Shields et al (2013) found that 1.3% self-identified as “transgender” in
response to the question “What is your gender?” with the other response options
being female or male. In a random sample of 8,166 high school students from
New Zealand, Clark et al (2014) found that 1.2% self-identified as transgender
and 2.5% reported that they were not sure about their gender, in response to the
question “Do you think you are a transgender?” which was followed by a definition
of the term. Interestingly, another 1.7% reported that they did not understand
the question. In a study of 80,929 American high school students from the 2016
Minnesota Student Survey, 2.7% self-identified as transgender or gender non-
conforming (Rider et al, 2018).
Gender Assigned at Birth Ratio
Of pre-pubertal children referred to gender identity clinics, the majority

has a male gender assigned at birth. Among 577 Canadian children referred to
a gender identity clinic between 1976 and 2011, the male-to-female ratio was
4.49:1 (Wood et al, 2013). This was significantly higher than the 2.02:1 ratio in
the Netherlands (Aitken et al, 2015). These differences are theorized, in part, to
be a reflection of increased parental anxiety regarding gender-variant behavior in
males compared to females, particularly in North America. For adolescents with
gender dysphoria, the gender ratio is much closer to 1:1 and appears to be more
consistent across nations (Aitken et al, 2015). However, it is of note that there
has been a recent temporal shift from more birth-assigned males prior to 2006, to
more birth-assigned females from 2006 to 2013, though the ratio remains closer
than 2:1 in either direction (Aitken et al, 2015).
BIOLOGICAL AND PSYCHOSOCIAL DETERMINANTS

The etiology of cross-gender identification and behavior continues to be
elusive. While psychological and social factors were once the main focus of study,
attention has shifted more recently to biological mechanisms. At present, the

evidence suggests that both psychosocial and biological elements are involved.
A single mechanism is unlikely and gender dysphoria most likely results from a
complex interaction between these factors (Steensma et al, 2013a).
Biological Factors
Twin studies suggest a strong heritable component with additional

environmental contributors. In a large-scale CBCL study of Dutch twins
(N=23,393) aged 7 and 10 (Coolidge et al, 2002), monozygotic (MZ) and dizygotic
(DZ) twins were compared; genetic factors contributed to 70% of cross-gender
behavior (as assessed via the two CBCL gender items). Another study of 314 MZ
and DZ twins (mean ages 9.4 and 10.1 years, respectively) roughly replicated this
finding, with genetic factors contributing up to 62% of the variance on a DSM-
IV-based gender dysphoria scale (Coolidge et al, 2002).
Many studies, both in animals and humans, have shown that differences in
brain anatomy and function in males and females underlie the sex differences in
their behavioral characteristics (Hines, 2011). Sex hormones play an important
role in these differences. The organizational effect, predominantly prenatally but
also during puberty, leads to the sex differences in brain structures (Ruigrok et al,
2014; Giedd et al, 2012). On average, males have larger brain volumes, more white
matter, gray matter, and cerebrospinal fluid than females, although when corrected
for total volume, females have more gray matter and a larger volume of the cortex
(Ruigrok et al, 2014; Guillamon et al, 2016).
The sexual differentiation hypothesis suggests that transgender individuals
may have brain structures and brain functioning more closely aligned with
their gender identity than with their assigned gender at birth (Swaab & Garcia-
Falgueras, 2009). Post-mortem studies have suggested a sex reversal in several
hypothalamic nuclei in transsexuals (Kruijver et al, 2000; Zhou et al, 1995).
More recent neuroimaging techniques have allowed the in vivo study of brain
morphology and functioning of larger numbers of adolescents and adults with
gender nonconforming feelings (Kreukels & Guillamon, 2016). Before they
received any medical gender affirmative treatment, brain anatomy with regard to
volume, gray and white matter, and cerebrospinal fluid did not differ compared to
their birth-assigned sex. Differences have been found with regard to white matter
microstructure showing that transgender individuals lie between males and females
(Guillamon et al, 2016). In the realm of functional neuroimaging, task-related
studies show that transgender people may have either similar reactions as those of
their experienced gender (e.g., smelling odorous steroids; Berglund et al, 2008)
or activity different from their assigned gender as well as their experienced gender
(e.g., mental rotation; Schoninget al, 2010), or not different from their assigned
gender (e.g., verbal fluency; Soleman et al, 2013). Overall, results in the realm of
neuroimaging are mixed.
In animal studies, where prenatal hormones can be manipulated, the
strong effect of prenatal testosterone on gender role behavior is clear (Hines,
2011). The effects on gender identity, however, can only be studied in humans.
Individuals with a disorder of sex development may be exposed to high levels of
prenatal testosterone, and individuals with two X chromosomes with congenital
adrenal hyperplasia (Merke & Bornstein, 2005) indeed have higher rates of gender
dysphoria and cross-gender identification (Pasterski et al, 2015). However, the

In the US, the Trump

administration withdrew in
2017 a federal guidance
issued by the Obama
administration in May 2016
requiring transgender
students to have unfettered
access to bathrooms and
locker rooms matching their
gender identity.
majority of female-raised individuals with congenital adrenal hyperplasia (~95%),

appear to develop a female gender identity (Dessens et al, 2005). Other evidence
for the importance of prenatal testosterone comes from studies in XY individuals
with complete androgen insensitivity syndrome who lack the receptors necessary
to respond to endogenous testosterone. The vast majority of these patients develop
a female gender identity, suggesting that downstream testosterone signaling may
be important for the development of a male gender identity (Mazur, 2005). Some
have noted that these patients were reared unambiguously as females and that social
factors may have played a strong role in their female identity formation (Hines,
2009). Some studies have shown that those with complete androgen insensitivity
syndrome have lower scores on female identity scales (Richter-Appelt et al, 2005)
and there are case reports of gender dysphoria ultimately leading in these patients
to gender affirming surgeries (T’Sjoen et al, 2011). This could be secondary to
the psychological stress of learning about the diagnosis, as well as the possibility
of undetected functional androgen receptors (Steensma et al, 2013a). Overall,
studies of gender identity in individuals with disorders of sex development, while
implicating androgens in the development of gender identity, have yet to show a
direct relationship.
Psychosocial Factors
Past literature has investigated the potential role of parental characteristics

on the development of gender dysphoria (maternal wish for a child of the opposite
gender, paternal absence, and parental psychological functioning, among others).
None of these hypotheses have been validated (Steensma et al, 2013a). Mothers of
gender dysphoric boys have been noted to have higher scores on the Beck Depression
Inventory and the Diagnostic Interview for Borderlines (Marantz & Coates,
1991), but these higher scores might be due to external pressures placed on these
parents by unaccepting social environments and such studies cannot determine the
direction of causation. One study noted that gender dysphoric boys were rated as
more feminine and “beautiful” by blinded college students (Zucker et al, 1993),
while another study of gender dysphoric girls showed that these girls were rated as
less “cute” (Fridell et al, 1996), raising the question of whether perceived physical
appearance and resultant social treatment may contribute to gender incongruence.
An alternative interpretation of this data is that those with a more male gender

identity might alter their appearance to appear more “masculine” (e.g., culturally
masculine haircuts), while those with a more female gender identity alter their
appearance to look more “feminine” (McDermid et al, 1998). Some have suggested
that a lack of parental limit setting, particularly around cross-gender behavior,
is associated with gender dysphoria (Zucker & Bradley, 1995), though this does
not prove causation, as more insistence on cross-gender behavior (i.e., transgender
identity or stronger cross-gender behavior preferences) may make this limit setting
more difficult. Overall, there have been no proven causative psychosocial factors in
the development of gender incongruence
CLINICAL COURSE
Persistence of Gender Dysphoria from Childhood to Adolescence
The natural history of gender identity for children who express gender
nonconforming or transgender identities is an area of active research (Olson,
2016). To date, the long-term follow-up studies of clinic-referred children have
been based on samples that have included children who were either threshold or
sub-threshold for the gender identity diagnosis in DSM-III, III-R or IV and some
of the earliest studies began prior to the availability of formal diagnostic criteria.
These follow-up studies have classified participants as either “persisters” or
“desisters” with regard to gender dysphoria using various metrics (semi-structured
interviews based on DSM criteria for gender identity disorder, dimensional scores
on standardized questionnaires, etc.). Ristori and Steensma (2016) summarized
10 follow-up studies and reported that the percentage of participants classified as
persisters ranged from 2% to 39% (collapsed across natal boys and girls). In one
study (Wallien & Cohen-Kettenis, 2008), the percentage of natal girls who were
“persisters” was substantially higher than the percentage of natal boys (50% vs.
12%), but in two other studies from the same clinic the percentage was similar
across natal sex (Drummond et al, 2008; Singh, 2012).
One criticism of these studies is that either formal diagnostic criteria were not
used (because they were not available at the time of the study) or that subthreshold
cases were included. These subthreshold cases may have included individuals with
cross-gender interests or behaviors who did not actually identify as transgender.
It is perhaps not surprising that these patients did not identify as transgender at
follow-up. Some studies have found that threshold cases were more likely to be
classified as persisters (Steensma et al, 2013b), but other have not (Singh, 2012). It
has also been suggested that more recent cohorts (after the year 2000) have found
higher rates of persistence (12% to 39%) (Zucker & Bradley, 1995; Wallien &
Cohen-Kettenis, 2008; Drummond et al, 2008; Singh, 2012) than older cohorts
(2% to 9% prior to 2000) (Green, 1987; Zuger, 1984), suggesting that, as society
becomes more accepting of these individuals, fewer report “desisting,” which may
represent going back into the closet due to social pressures rather than a true
desistence of cross-gender identification. Comparisons of persisters with desisters
have found that the intensity of gender dysphoria (using dimensional metrics),
older age at the time of assessment in childhood, a lower social class background,
and having a female gender assigned at birth are associated with higher rates of
persistence (Steensma et al, 2013b). Despite this work, it remains difficult to

predict the likelihood of cross-gender identification persistence from childhood

into adolescence for an individual child (Steensma et al, 2013b).
Persistence of Gender Dysphoria from Adolescence to Adulthood
In contrast to the low rates of persistence from childhood into adolescence,

it appears that the majority of transgender adolescents persist in their transgender
identity (Cohen-Kettenis & Pfäfflin, 2003). In a study of 55 transgender adolescents
receiving gender affirmative care, 100% continued to identify as transgender in
young adulthood (deVries et al. 2014). Larger longitudinal studies such as this are
needed.
Childhood Gender Variant Behavior and Sexual Orientation
Childhood gender variant behavior has been found to be a strong predictor

of a same-sex sexual orientation in adulthood (using gender assigned at birth as a
reference point). In a study of 879 Dutch boys and girls, gender variant behavior
was assessed using the CBCL and sexual orientation was assessed 24 years later
(Steensma et al, 2013c). It was found that the prevalence of a same-sex sexual
orientation was, depending on the domain (attraction, fantasy, behavior, and
identity), between 8.4 and 15.8 times higher in the gender variant subgroup as
compared to the non-gender-variant subgroup. In summary, the current literature,
though limited, suggests that the majority of gender nonconforming pre-pubescent
children will grow up to endorse identification as cisgender individuals with either
a bisexual or a same-sex sexual orientation (Wallien & Cohen-Kettenis, 2008;
Singh, 2012; Green, 1987).
COEXISTING PSYCHIATRIC CONDITIONS

Children and adolescents with gender incongruence exhibit higher
internalizing and externalizing psychopathology compared to non-referred
controls, with internalizing psychopathology being more common, particularly in
birth-assigned boys (Steensma et al, 2014; de Vries et al, 2016; Wallien et al, 2007;
Skagerberg & Carmichael, 2013). One hypothesis is that this problem behavior
is a result of stress due to being a minority and dysphoria toward their gender
assigned at birth. These individuals are subjected to rates of peer bullying as high
as 80% (Holt et al, 2016; Kaltiala-Heino et al, 2015; McGuire et al, 2010), and
poor peer relations is one of the strongest investigated predictors for behavioral
and emotional problems in gender nonconforming youth (de Vries et al, 2016). In
a study of 105 gender dysphoric Dutch adolescents whose parents completed the
Diagnostic Interview Schedule for Children, 32.4 % had one or more psychiatric
disorders, with 21% suffering from anxiety, 12.4% from mood disorders, and
11.4% from disruptive disorders (de Vries, 2011).
Chart review studies of gender nonconforming youth presenting to
specialized gender identity clinics have shown similarly high or even higher rates of
psychiatric conditions: mood (12.4-64%), anxiety (16.3%-55%), and disruptive
disorders (9-11.4%) (Holt et al, 2016; Kaltiala-Heino et al, 2015; de Vries et al,
2015; Olson et al, 2015; Spack et al, 20102; Khatchadourian et al, 2014). The
range of prevalence across studies may be the result of cultural differences, varying
diagnostic criteria, and differing ages at assessment. These psychiatric conditions
appear to become more common in gender nonconforming individuals with

increasing age. Some studies have shown that older transgender youth suffer a
greater burden of co-occurring psychiatric conditions (McGuire et al, 2010),
and that gender nonconforming adults suffer a greater burden of co-occurring
psychiatric conditions compared to adolescents (de Vries et al, 2011b).
Self-harming Behavior and Suicidality
Click on the image to access
the 2017 endocrine society
Self-harming and suicide attempts are very prevalent among gender guidelines
nonconforming youth. Gender clinics report high rates of past suicide attempts
by patients presenting for care: Boston (9.3%, mean age 14.8; Spack et al, 2012),
London (10%, mean age 13.5; Holt et al, 2016), Los Angeles (30%, mean age
19.2; Olson et al, 2015). Rates of self-harm and suicidality also appear to increase
with age within this population (Aitken et al, 2016).
Autism Spectrum Disorder
A number of studies show that autism spectrum disorder (ASD) symptoms

are over-represented among transgender individuals. The rate of ASD among
the general population is estimated at around 1% (Lai et al, 2014). Clinical-
level rates of ASD symptomatology in transgender adults have been reported in
5-20% (Jones et al, 2012; Pasterski et al, 2014; Pohl et al, 2014). It is important
to note, however, that these studies measure autism symptomatology and did not
necessarily make a diagnosis of true ASD. These scales can be elevated in non-ASD
conditions including anxiety and depression. Social deficits among transgender
youth may be secondary to social ostracism and not due to an underlying ASD.
Two studies found increased gender variance (5.4%, 11.3%), defined by a positive
response to “wishes to be of the opposite sex” on the CBCL or YSR in referred
children, adolescents, and adults with ASD compared to non-referred controls
(Strang et al, 2014; van der Miesen et al, 2016a). However, the same was true
for an ADHD referred control group (Strang et al, 2018), raising the issue that a
higher probability of gender variance is characteristic of clinic referred samples in
general. It is also possible that youth with ASD may have rigid thinking that makes
them (or their parents) more likely to endorse the CBCL items of “sometimes
or often” wanting to be the opposite sex due to gender-atypical interests. This
does not necessarily suggest a core gender identity that diverges from their gender
assigned at birth (Turban & van Schalkwy, 2018).
Clinically, the co-occurrence of gender dysphoria and ASD may complicate
transgender care, as diagnosing gender dysphoria can be difficult (e.g., in the context
of the rigid thinking characteristic of ASD). Additionally, language difficulties can
make expression of gender dysphoria difficult for patients with ASD. Nonetheless,
a comprehensive narrative review of the literature has shown a role for transition
with pubertal blockade and cross-sex hormonal therapy in these patients following
an extended diagnostic process (van der Miesen et al, 2016b). Using a Delphi
method, a group of experts on ASD and gender dysphoria published initial clinical
guidelines for the assessment and treatment of patients with both conditions co-
occuring (Strang et al, 2018). Careful diagnosis of both conditions by specific
specialists, collaboration between clinicians from both fields, and risk assessment
and safety issues are part of the suggested management protocol.

THERAPEUTICS
Treatment of Prepubescent Children
The treatment for children with gender dysphoria has been the subject of
intense controversy recently (Drescher & Byne, 2012). As noted below, there are
three broad approaches that have been delineated in the literature:
• The oldest— characterized by Dreger (2009) as the “therapeutic model”
— consists of efforts, either directly (e.g., via specific suggestions that
parents can implement in the day-to-day environment) or indirectly
(e.g., via psychodynamically-informed approaches that treat the putative
underlying “causes” of the gender dysphoria) that actively attempt to
reduce cross-gender identification.
• An intermediate approach—described by some as “watchful waiting”

(Drescher & Byne, 2012)—in which no direct efforts are made to
“prohibit” a child’s gender-variant behavior, but that also advises parents
to keep options open about the child’s long-term gender identity and to
avoid early social transition.
• More recently, an approach—characterized by Ehrensaft (2012) as the

“affirmative model”— that considers all outcomes of gender identity to
be equally valid and desirable and allows children who express a desire
to socially transition to do so after careful counseling.
These approaches have been discussed in great detail in three reports

(American Psychological Association, 2015; Adelson, 2012; Byne et al, 2012), in
a special volume of the Journal of Homosexuality (Drescher & Byne, 2012), and
in various other essays and case reports, the references for which can be found in
these major reviews.
For the non-specialist, there are several key issues to keep in mind when
appraising this literature:
• Some of these approaches may be influenced by particular theoretical
formulations regarding the determinants of gender dysphoria and these
formulations guide or influence recommended treatment plans.
• There are no randomized controlled trials comparing the effects of these

treatments with regard to both short-term and long-term outcomes.
Indeed, Byne et al (2012) noted that, by and large, “the highest level of
evidence […] can best be characterized as expert opinion.”
• With some rare exceptions (Meyer-Bahlburg, 2002), there are no

manualized or even semi-manualized treatments that a clinician can
follow in developing a therapeutic plan.
Thus, clinicians need to educate themselves by reading about the therapeutic

model that they intend to follow and tailor it on a case-by-case basis. Below, we
provide brief summaries of these three treatment approaches.
Promoting Identification with the Gender Assigned at Birth
This approach aims to reduce through psychosocial interventions the

child’s cross-gender identification and gender dysphoria. These treatments

(described in the literature since the 1960s) have been quite varied. They include
classical behavior therapy, psychodynamic therapy (including psychoanalysis and
dynamically-informed play psychotherapy), parental counseling, and parent-
guided interventions in the naturalistic environment (e.g., encouragement of peer
relations of the same natal sex) (Meyer-Bahlburg, 2002). None of these treatments
have been found to be effective and are not recommended.
The underlying assumption of all these approaches rests on the view that
gender identity is not yet fixed in childhood and may be malleable through Click on the image to view
psychosocial treatment. There is also an implicit assumption or value judgment a clip about the treatment
issues facing transgender
that might be inferred from this approach, namely, that all things considered, a adolescents in Australia.
child’s long-term adaptation might be easier if he or she could come to feel content
with a gender identity that matches their natal sex.
Critics of this approach have argued that there is nothing inherently “wrong”
with a cross-gender identity and have challenged the view that trying to change
such an identity is warranted. Indeed, there are now several US states and one
province in Canada that have legislated that it is inappropriate to try and change
a minor’s gender identity when the minor is unable to consent to the treatment.
Exempt from this directive is “identity exploration,” which is different in that it
does not consider cis-gender identification to be a preferable outcome (Green,
2017). Critics have also noted that some of the earliest proponents of this treatment
held the belief that it might reduce the odds of the child later development a same-
sex sexual orientation (Pleak, 1999), although others rejected this as unethical
(Zucker, 1990). Another concern has been that these treatments might cause a
child to feel shame or other negative and maladaptive feelings (Adelson, 2012).
Watchful Waiting
The second approach takes an intermediate therapeutic position. On the

one hand, it does not recommend an early gender social transition on the grounds
that the extant follow-up studies have suggested that the majority of children with
gender dysphoria may desist for one reason or another (see above for the limitations
on these studies). On the other hand, it does not explicitly recommend any type
of limit-setting on the child’s gender variant behavior, with the exception that
in certain environments it might be risky or dangerous to display such behavior,
which Hill and Menvielle (2009) described as the “only at home” rule.
This approach also does not favor one type of long-term outcome over
another, noting that it is difficult to predict outcome for an individual child and that
the more important focus should be on the child’s general psychosocial adjustment
and wellbeing. This approach does, however, include recommendations to parents
to encourage in their child a variety of gender-related interests and social affiliation
with children of both genders. In some respects, the “watchful waiting” label
is a bit of a misnomer because clinical protocols appear to include information
provided to the parents that is more than “wait-and-see.” As noted by de Vries and
Cohen-Kettenis (2012), appropriate limit-setting with good explanation of why
the limits are set may be helpful, so that the child will learn “that not all desires
will be met,” which is important because “someone’s deepest desire or fantasy to
have been born in the body of the other gender will never be completely fulfilled.”
Although social transition according to this approach is not recommended at a
very young age, an increasing number of children have already socially transitioned

when they come to gender identity clinics (Steensma & Cohen-Kettenis, 2011).
Some of these children may have no clear memories of a time when they were
socially living in the birth assigned gender and have stopped talking about being
born different from their experienced gender. In these cases, it is encouraged that
parents create an open situation where the child has the possibility of returning to
the birth assigned gender. It is discussed with the child that, when gender identity
feelings change, it is nothing to be ashamed of, that nobody will be angry, that the
child may speak out, and that it is good to have tried. A form of psychotherapy
that helps the child to verbalize his or her feelings may be advised so that, by the
time the child may come back for the administration of gonadotropin releasing
hormone analogs, the child is able to talk about his or her feelings and can give
informed consent.
Affirmative Approach
The affirmative approach theorizes that clinician and parental attempts to

push children with gender incongruence to conform with their gender assigned at
birth might produce shame and stigma that can ultimately lead to psychopathology
(Ehrensaft, 2012). It considers all outcomes of gender identity to be equally
desirable and affirms any gender identity the child expresses.
Though similar to the watchful waiting model, an important difference is in
its attitude regarding early social transition. In the affirmative model, prepubertal
children who express a desire to socially transition and live full time in their
experienced gender (i.e., using cross-gender pronouns, a cross-gender name, cross-
gender clothing, etc.) are allowed to do so. The approach to social transition must
be carefully individualized with a nuanced understanding of the child’s gender
identification and the level of support within the child’s community; there must
also be an open discussion with the child highlighting that, despite the social
transition, the patient is free to transition back at any time (Edwards-Leeper et al,
2016).
This transition back to living as one’s birth gender can be difficult (Steensma
& Cohen-Kettenis, 2011), though this must be weighed against the potential
negative consequences of refusing to affirm a child’s identity and desire to transition
socially. The affirmative model hypothesizes that lack of affirmation might lead
to shame and consequent psychopathology. The therapeutic relationship in these
cases could also be negatively affected if the clinician strongly discourages an early
transition for a patient who persists in cross-gender identification.
Critics of social transition in prepubertal children have questioned whether
early social transition increases the rate of persistence of gender incongruence from
childhood into adolescence. Indeed, a multivariate regression analysis revealed that
early social transition was associated with persistence (Steensma et al, 2013b).
However, the direction of this association cannot be determined in this study.
While some believe that prepubertal social transition makes children more
likely to persist, the alternative interpretation is that those likely to persist are
also more likely to undergo early social transition, due to currently unidentified
factors. Additionally, this raises the ethical question of whether persistence should
be considered an undesirable outcome. The affirmative model suggests that all
outcomes of gender identity are equally desirable.

Some people call it “transgender regret.” When you change from one gender to another
and then feel, somehow, you’ve made a mistake. Others call it “detransitioning” or a “reversal”.
Zahra Cooper calls it, simply “going back”, as she told the New Zealand Herald. […] For four
years, she struggled between the genders, being bullied at school and online for being “weird”.
At 18, she asked her family to start calling her “Zane” and using male pronouns. She began
to think about formally transitioning — taking hormones to become more masculine. […] In
December 2015, Zahra began taking testosterone, at first swallowing pills three times a day,
and then via injection. After what seemed such a long wait for treatment, she expected to
feel elated. But the euphoria many trans people describe at that point never really set in. “I
started getting really angry from the testosterone, which is a side effect,” she says. “But then I
started getting depressed. I was like, why am I depressed? I should be happy.” As the physical
changes began, Zahra grew more and more anxious. She fought with family, often storming
out of the house. “I was getting a deeper voice, facial hair and many other changes but I just
wasn’t happy with them,” she says. “I didn’t feel like myself.” Then eight months in, things hit
crisis point. Zahra tried to kill herself. Twice. […]
Zahra had begun dating a transgender boy called Tyson Kay. Tyson is 17. He too was
assigned female at birth, and at the time of Zahra’s breakdown was in the middle of his own
transition to male. “I didn’t know how he would feel,” she says. Going off testosterone meant
more mood swings, and an unpredictable end result. She didn’t know whether he would want
to hang around, and worried over how to break the news. In the end, Zahra texted him saying:
“I’m going to transition back”.
Separate from the question of persistence is the question of mental health

outcome following social transition. There is a paucity of literature studying
the effect of prepubertal social transition. One study examined 73 American
prepubertal children who were transgender in a binary fashion and allowed to
transition socially. Parents of these children completed short rating scales for
anxiety and depression at an unspecified time following the transition (Olson,
2016a). Data from these scales revealed that these children had notably lower
rates of internalizing psychopathology than previously reported for children
who did not transition. Furthermore, socially transitioned children in this study
showed developmentally normal levels of depression and only minimally elevated
(subclinical) levels of anxiety. It is important to note that families in this study had a
relatively high income, raising the question of whether this cohort is representative
of a broader socio-demographic population (Olson, 2016a). Though this early
work suggests that socially transitioned children have better mental health metrics
than children who did not socially transition, future research is needed to fully
understand the dynamic and long-term effects of social transition in a broader
population (de Vries et al, 2014).
Treatment of Adolescents
Once children reach puberty, transgender identity persists in the majority

of cases and medical intervention is often considered. At present, the effectiveness
of an approach that includes puberty suppression followed by hormone
administration and surgery has been evaluated in two studies in the same cohort of
Dutch adolescents. The first study evaluated gender dysphoria and psychological
functioning at two times, first, when the 70 adolescents entered the clinic (mean
age, 13.65 years) and, second, just before they started hormone treatment
(mean age, 16.64 years). Of interest, while adolescents improved with regard to
psychological functioning on several domains, gender dysphoria did not improve
and all adolescents went on with the next step of gender affirming hormones (de

Table H.3.3. Summary of Treatment for Transgender Youth
TIMING INTERVENTION
Pre-pubertal No endocrine intervention recommended. Patient should have regular psychotherapy

to discuss gender identity and assess possible future need for hormonal intervention
Early signs of puberty Pubertal blockade with gonadotropin-releasing hormone analogs to prevent the
development of secondary sex characteristics and provide additional time for
psychotherapy and consideration regarding partially reversible interventions
Age 14+ or 16+ (depending Cross-sex hormonal therapy with estrogen or testosterone. Less frequently, with other
on the center and patient) endocrine-acting medications that have less favorable side effect profiles.
Age 18 (for most centers) Gender affirming surgeries may be considered. Note that some surgeries may be
performed earlier for select patients.
Vries et al, 2011a). The second study added a third assessment, around one year
after gender affirmative surgery, when the first 55 adolescents who had been in
this treatment protocol had reached young adulthood (mean age, 20.70 years).
This time, gender dysphoria had resolved and psychological functioning measures
had improved further, with scores comparable to normative samples. The same
accounted for quality of life, subjective happiness, and satisfaction with life (de
Vries et al, 2014). These results are promising and suggest that starting treatment
at a relatively young age is possible. However, the results come from only one clinic
and concern a highly selected cohort that received support from their parents—
and often from their school and social environment—that started treatment only
after extensive assessment, and that had mental health counselling during the years
of treatment. Whether the same positive results can be expected for the larger
number of adolescents who are currently being treated in clinics and who vary
considerably in their quality of care and approach has yet to be determined.
Assessing Eligibility
According to Endocrine Society Guidelines, hormonally-based medical

intervention may be initiated at the earliest signs of puberty (i.e., Tanner 2 or 3)
with pubertal blockade (Hembree et al, 2017). Other conditions for eligibility
include meeting criteria for gender dysphoria, experiencing dysphoria toward early
pubertal changes, having adequate psychological and social support for treatment,
understanding the risks and benefits of treatment, and not suffering from a
psychiatric comorbidity that would interfere with treatment (Wylie et al, 2009).
To assess eligibility, most clinics offer assessment by a mental health professional
that sees the adolescent and his or her family over a longer period of time before
decisions regarding medical interventions are made. This time is used to prepare
the adolescent for the long period of medical treatment and weigh the pros and
cons of treatment so that an informed decision can be made. Although many

adolescents come with a clear wish for medical treatment, some are not sure yet
and want to explore their gender dysphoric feelings more broadly. Sometimes co-
occurring psychiatric difficulties like ASD with rigid thinking, severe depression
with acute suicidality, or anxiety with worrisome avoidance and school refusal,
complicate the diagnostic work and make attending regular check-ups and taking
medication impossible. Treatment of these psychiatric disorders may then be
necessary before endocrine intervention. The importance of parental support for
the psychological well-being of these adolescents is widely acknowledged (Simons
et al, 2013). The time used for assessment may also be helpful to address parents’
concerns and improve adolescent-parent relationship. The time needed before
medical intervention is provided will vary for each individual, but tends to be
longer when other psychosocial conditions are present (Costa et al, 2015; de Vries
et al, 2011b).
Reversible Interventions (Pubertal Blockade)
The first intervention (implemented at Tanner stages 2 or 3) is pubertal
blockade with gonadotropin-releasing hormone analogs.
Partially-Reversible Interventions (Cross-Sex Hormonal Therapy)
According to Endocrine Society guidelines, around the age of 16, patients
may choose to move onto the next intervention: cross-sex hormonal therapy with
estrogen or testosterone. Some researchers have noted that cross-sex hormones can
be instituted earlier, as delaying puberty outside the developmentally appropriate
age may cause social problems for these youth (Rosenthal, 2014). The newly-
Gonadotropin Releasing Hormone Analogs (Puberty Blockers)

Gonadotropin-releasing hormone is produced by neurons in the hypothalamus. This
hormone is secreted at very low levels in prepubertal children. At the initiation of puberty,
release of gonadotropin-releasing hormone becomes cyclical. This cyclical release results
in production of follicle stimulating hormone (FSH) and luteinizing hormone (LH) by the
anterior pituitary. These hormones then enter the peripheral circulation where they trigger the
production of sex hormones (estrogen in natal women and testosterone in natal men). These
hormones then initiate the irreversible development of secondary sex characteristics.
Gonadotropin-releasing hormone analogs (either as implants, depot injections, or
regular injections) maintain high levels of gonadotropin-releasing hormone in circulation.
Without physiological cyclical fluctuations in gonadotropin-releasing hormone analogs, FSH
and LH are not released and all downstream signaling is prevented. This allows the patient to
remain in an early pubertal state.
Pubertal blockade prevents the development of irreversible secondary sex
characteristics (voice deepening, breast development, etc.) and provides additional time
for gender dysphoric children to decide if they wish to fully transition physically into the
body of the opposite sex. Therefore, it does not need to be considered actual gender
affirmative medical treatment, but rather may function as an extended diagnostic phase. If
the gonadotropin-releasing hormone analogs are discontinued, their effects are reversible.
The patient undergoes natal puberty if the gonadotropin-releasing hormone analogs
are discontinued. Follow-up studies into young adulthood on the first cohort of puberty-
suppressed adolescents are reassuring in regard to side effects. Although there was
some decrease in bone density, there were no further concerns regarding liver and kidney
functioning and lipid profile (Klink et al, 2015; Schagen et al, 2016). Some clinicians advise to
evaluate bone age every three months and regular blood monitoring to ensure that puberty is
sufficiently suppressed (Wylie et al, 2009).

released 2017 Endocrine Society Guidelines agree with this approach. Additional
criteria for cross-sex hormonal therapy are identical to those for gonadotropin-
releasing hormone analogs in the Endocrine Society Guidelines.
Cross-sex hormones will initiate the development of secondary sex
characteristics of the desired puberty. These interventions are mostly irreversible
and carry a more significant side effect profile. The most prominent side effect
of estrogen therapy is hypercoagulability, though clinicians prescribing these
medications should be aware of the full spectrum of side effects. Of note,
hypercoagulability can be particularly problematic for patients undergoing high-
risk surgery such as vaginoplasty. Patients on these medications should be regularly
monitored for serum hormone concentrations as well and maintained within
normal testosterone and estrogen serum concentrations for their desired gender.
Spironolactone has been used for its anti-androgenic properties in select cases but
is generally not considered a first line treatment given its unfavorable side-effect
profile as a diuretic (Wylie et al, 2009).
Irreversible Interventions (Gender Affirming Surgeries)
At the legal age of adulthood, patients may choose to undergo a variety
of surgical interventions, including vaginoplasty, phalloplasty, scrotoplasty,
breast augmentation, facial reconstruction, hysterectomy, and reduction thyroid
chondroplasty, among others. Patients should be carefully counseled on the risks
and benefits of surgery. Specific surgical interventions are many and are out of the
scope of this chapter. Of note, some surgical interventions may be considered earlier
in the course of treatment. In the World Professional Association for Transgender
Health (WPATH) Standards of Care, mastectomies are being considered earlier
than age 18 (Coleman et al, 2011).
Fertility Considerations
There is a paucity of research on the effects of pubertal blockade and cross-
sex hormonal therapy on future fertility. Interested patients should be counseled
on fertility preservation options early in treatment and before starting hormonal
treatment.
CULTURAL ASPECTS
In providing care for transgender and gender nonconforming people, one will
need to consider the local legal situation, family dynamics, and patients’ and their
families’ attitudes, and adjust the services accordingly. When treating immigrant
families and ethnic minorities in Western countries, it is important to understand
the family’s culture and how they have been influenced by the host culture in
regards to sexuality and gender. One may not assume that immigration necessarily
altered background cultural concepts about sexuality and gender including stigma
— in many cases they become more rigid. Legal issues remain very important in
providing care as, even in the United States, there have been several recent setbacks
in the legal protection of transgender and gender nonconforming individuals.
SUMMARY
Gender nonconforming and gender dysphoric youth represent a vulnerable
demographic with high rates of co-occurring psychiatric conditions and suicidal
behavior, likely secondary to minority stress and dysphoria related to living in a

body that does not match one’s experienced gender. Prepubescent children with
gender variant behavior or identification are best supported with psychotherapy
and socio-familial interventions. For those children who continue to have strong
cross-sex identification in adolescence, pubertal blockade and cross-sex hormone
therapy to align patients’ bodies with their experienced identities have been shown
to improve mental health outcomes.
REFERENCES
Achenbach TM, Rescorla LA. Manual for the ASEBA School- Byne W, Bradley SJ, Coleman E et al. Report of the American
Age Forms & Profiles: An Integrated System of Multi- Psychiatric Association Task Force on Treatment of
Informant Assesment. Burlington, VT, University of Gender Identity Disorder. Archives of Sexual Behavior
Vermont, Research Center for Children, Youth, & 41:759-796, 2012.
Families, 2001. Chayet S. Moi, Nikki, 13 ans, née Niko. Le Monde,
Adelson SL. Practice parameter on gay, lesbian, or bisexual 2014(December 10). Retrieved from http://www.
sexual orientation, gender nonconformity, and gender lemonde.fr/m-actu/article/2014/12/10/moi-nikki-13-
discordance in children and adolescents. Journal of the ans-nee-niko_4534297_4497186.html
American Academy of Child and Adolescent Psychiatry Chen M, Fuqua J, Eugster EA. Characteristics of referrals for
51:957-974, 2012. gender dysphoria over a 13-year period. Journal of
Aitken M, Steensma TD, Blanchard R et al. Evidence for an Adolescent Health 58:369-371, 2016.
altered sex ratio in clinic-referred adolescents with Clark TC, Lucassen MFG, Bullen P et al. The health and well-
gender dysphoria. Journal of Sexual Medicine 12:756- being of transgender high school students: results from
763, 2015. the New Zealand adolescent health survey (Youth’12).
Aitken M, VanderLaan DP, Wasserman L et al. Self-harm and Journal of Adolescent Health 55:93–99, 2014.
suicidality in children referred for gender dysphoria. Cohen-Kettenis PT, Pfäfflin F. Transgenderism and Intersexuality
Journal of the American Academy of Child and in Childhood and Adolescence: Making Choices.
Adolescent Psychiatry 55:513-520, 2016. London, Sage, 2003.
American Psychiatric Association. Diagnostic and Statistical Cohen-Kettenis PT, van Goozen SH. Pubertal delay as an aid in
Manual of Mental Disorders, Third ed. Washington, diagnosis and treatment of a transsexual adolescent.
DC, Author, 1980. European Child & Adolescent Psychiatry 7:246-248,
American Psychiatric Association. Diagnostic and Statistical 1998.
Manual of Mental Disorders, Third ed., rev. Colapinto J. As Nature Made Him: The Boy Who Was Raised as a
Washington, DC, Author, 1987. Girl. New York, Harper Collins Publishers, 2000.
American Psychiatric Association. Diagnostic and Statistical Coleman E, Bockting W, Botzer M et al. Standards of care for
Manual of Mental Disorders, 4th ed. Washington, DC, the health of transsexual, transgender and gender non-
Author, 1994. conforming people, version 7. International Journal of
American Psychiatric Association. Diagnostic and Statistical Transgenderism 13:165-232, 2011.
Manual of Mental Disorders, Fifth ed. Arlington, VA, Conron KJ, Scott G, Stowell GS et al. Transgender health in
American Psychiatric Press, 2013. Massachusetts: Results from a household probability
American Psychological Association. Guidelines for psychological sample of adults. American Journal of Public Health
practice with transgender and gender nonconforming 102:118-122, 2012.
people. American Psychologist 70:832-864, 2015. Coolidge FL, Thede LL, Young SE. The heritability of gender
Andres R, Flores JLH, Gates GJ et al. How Many Adults Identify identity disorder in a child and adolescent twin
as Transgender in the United States? Los Angeles, The sample. Behavior Genetics 32:251-257, 2002.
Wiliams Institute, 2016. Costa R, Dunsford M, Skagerberg E et al. Psychological support,
Arcelus J, Bouman WP, Van Den Noortgate W et al. Systematic puberty suppression, and psychosocial functioning in
review and meta-analysis of prevalence studies in adolescents with gender dysphoria. Journal of Sexual
transsexualism. European Psychiatry 30:807-815, 2015. Medicine 12:2206-2214, 2015.
Berglund H, Lindstrom P, Dhejne-Helmy C et al. Male-to- Dessens AB, Slijper FM, Drop SL. Gender dysphoria and gender
female transsexuals show sex-atypical hypothalamus change in chromosomal females with congenital
activation when smelling odorous steroids. Cerebral adrenal hyperplasia. Archives of Sexual Behavior
Cortex 18:1900-1908, 2008 34:389-397, 2005.

de Vries ALC, Cohen-Kettenis PT. Clinical management of Green R. Banning therapy to change sexual orientation or gender
gender dysphoria in children and adolescents: The identity in patients under 18. Journal of the American
Dutch approach. Journal of Homosexuality 59:301- Academy of Psychiatry and the Law 45:7-11, 2017.
320, 2012. Guillamon A, Junque C, Gomez-Gil E. A review of the status
de Vries ALC, Doreleijers TA, Steensma TD et al. Psychiatric of brain structure research in transsexualism. Archives
comorbidity in gender dysphoric adolescents. Journal of Sexual Behavior 2016, doi:10.1007/s10508-016-
of Child Psychology and Psychiatry 52:1195-1202, 0768-5.
2011a. Hembree WC, Cohen-Kettenis PT, Gooren L et al. Endocrine
de Vries ALC, Kreukels BPC, Steensma TD et al. Comparing treatment of gender-dysphoric/gender-incongruent
adult and adolescent transsexuals: An MMPI-2 and persons: an Endocrine Society clinical practice
MMPI-A study. Psychiatry Research 186:414-418, guideline. The Journal of Clinical Endocrinology &
2011b. Metabolism, 102(11):3869-3903, 2017.
de Vries ALC, McGuire JK, Steensma TD, et al. Young adult Hill DB, Menvielle E. “You have to give them a place where
psychological outcome after puberty suppression and they feel protected and safe and loved”: The views
gender reassignment. Pediatrics 134:696-704, 2014. of parents who have gender-variant children and
de Vries ALC, Steensma TD, Cohen-Kettenis PT et al. Poor peer adolescents. Journal of LGBT Youth 6:243-271, 2009.
relations predict parent- and self-reported behavioral Hines M. Gonadal hormones and sexual differentiation of
and emotional problems of adolescents with gender human brain and behavior. In: Pfaff DW, Arnold AP,
dysphoria: A cross-national, cross-clinic comparative Etgen AM et al (eds) Hormones, Brain and Behavior,
analysis. European Child & Adolescent Psychiatry 2nd ed. San Diego, Academic Press, 2009, pp. 1869-
25:579-588, 2016. 1910.
Diamond M, Sigmundson HK. Sex reassignment at birth: Hines M. Gender development and the human brain. Annual
Long-term review and clinical implications. Archives of Review of Neuroscience 34:69-88, 2011.
Pediatrics & Adolescent Medicine 151:298-304, 1997. Holt V, Skagerberg E, Dunsford M. Young people with features
Dreger A. Gender identity disorder in childhood: Inconclusive of gender dysphoria: Demographics and associated
advice to parents. Hastings Center Report 39:26-29, difficulties. Clinical Child Psychology and Psychiatry
2009. 21:108-118, 2016.
Drescher J, Byne W. Introduction to the special issue on “The Hsieh S, Leininger J. Resource list: Clinical care programs for
Treatment of Gender Dysphoric/Gender Variant gender-nonconforming children and adolescents.
Children and Adolescents.” Journal of Homosexuality Pediatric Annals 43:238-244, 2014.
59:295-300, 2012 Hughes IA, Houk C, Ahmed SF et al. Consensus statement on
Drescher J, Cohen-Kettenis PT, Reed GM. Gender incongruence management of intersex disorders. Archives of Disease
of childhood in the ICD-11: Controversies, proposal, in Childhood 91:554-563, 2006.
and rationale. Lancet Psychiatry 3:297-304, 2016. Jones RM, Wheelwright S, Farrell K et al. Female-to-male
Drummond KD, Bradley SJ, Peterson-Badali M et al. A follow- transsexual people and autistic traits. Journal of Autism
up study of girls with gender identity disorder. and Developmental Disorders 42:301-306, 2012.
Developmental Psychology 44:34-45, 2008 Kaltiala-Heino R, Sumia M, Tyolajarvi M et al. Two years of
Edwards-Leeper L, Leibowitz S, Sangganjanavanich VF. gender identity service for minors: Overrepresentation
Affirmative practice with transgender and gender of natal girls with severe problems in adolescent
nonconforming youth: Expanding the model. development. Child and Adolescent Psychiatry and
Psychology of Sexual Orientation and Gender Diversity Mental Health 9:9, 2015, doi:10.1186/s13034-015-
3:165-172, 2016. 0042-y.
Ehrensaft D. From gender identity disorder to gender identity Khatchadourian K, Amed S, Metzger DL. Clinical management
creativity: True gender self child therapy. Journal of of youth with gender dysphoria in Vancouver. Journal
Homosexuality 59:337-356, 2012. of Pediatrics 164:906-911, 2014.
Fridell SR, Zucker KJ, Bradley SJ et al. Physical attractiveness of Klink D, Caris M, Heijboer A et al. Bone mass in young
girls with gender identity disorder. Archives of Sexual adulthood following gonadotropin-releasing hormone
Behavior 25:17-31, 1996. analog treatment and cross-sex hormone treatment in
Giedd JN, Raznahan A, Mills KL, et al. Magnetic resonance adolescents with gender dysphoria. Journal of Clinical
imaging of male/female differences in human Endocrinology & Metabolism 100:E270-E275, 2015,
adolescent brain anatomy. Biology of Sex Differences doi: 10.1210/jc.2014-2439.
3(1):19, 2012, doi: 10.1186/2042-6410-3-19. Kreukels BPC, Guillamon A. Neuroimaging studies in people
Green R. Sexual Identity Conflict in Children and Adults. New with gender incongruence. International Review of
York, Basic Books, 1974. Psychiatry 28:120-128, 2016.
Green R. The “Sissy Boy Syndrome” and the Development of Kruijver FP, Zhou JN, Pool CW et al. Male-to-female
Homosexuality. New Haven, CT, Yale University Press, transsexuals have female neuron numbers in a
1987. limbic nucleus. Journal of Clinical Endocrinology &
Metabolism 85:2034-2041, 2000.

Kuyper L, Wijsen C. Gender identities and gender dysphoria in Olson KR, Durwood L, DeMeules M et al. Author response
the Netherlands. Archives of Sexual Behavior 43:377- to McKean, Vande Voort, and Croarkin (2016).
385, 2014. Pediatrics 138(1): doi:10.1542/peds.2016-1203B,
Lai MC, Lombardo MV, Baron-Cohen S. Autism. Lancet 2016b.
383:896-910, 2014. Padawer R. Boygirl. The New York Times Magazine pp. 18-23,
Lawrence AA. Sexual orientation versus age of onset as bases 36, 46, 2012 (August 12).
for typologies (subtypes) for gender identity disorder Pasterski V, Gilligan L, Curtis R. Traits of autism spectrum
in adolescents and adults. Archives of Sexual Behavior disorders in adults with gender dysphoria. Archives of
39:514-545, 2010. Sexual Behavior 43:387-393, 2014.
Marantz S, Coates S. Mothers of boys with gender identity Pasterski V, Zucker KJ, Hindmarsh PC et al. Increased cross-
disorder:A comparison of matched controls. Journal gender identification independent of gender role
of the American Academy of Child and Adolescent behavior in girls with congenital adrenal hyperplasia:
Psychiatry 30:310-315, 1991. Results from a standardized assessment of 4- to
Mazur T. Gender dysphoria and gender change in androgen 11-year-old children. Archives of Sexual Behavior
insensitivity or micropenis. Archives of Sexual Behavior 44:1363-1375, 2015.
34:411-421, 2005. Pleak R. Ethical issues in diagnosing and treating gender-
McDermid SA, Zucker KJ, Bradley SJ et al. Effects of physical dysphoric children and adolescents. In: Rottnek
appearance on masculine trait ratings of boys and M (ed). Sissies & Tomboys: Gender Nonconformity
girls with gender identity disorder. Archives of Sexual & Homosexual Childhood. New York, New York
Behavior 27:253-267, 1998. University Press, 1999, pp. 44-51.
McGuire JK, Anderson CR, Toomey RB et al. School climate for Pohl A, Cassidy S, Auyeung B, et al. Uncovering steroidopathy
transgender youth: A mixed method investigation of in women with autism: A latent class analysis.
student experiences and school responses. Journal of Molecular Autism 5:27, 2014.
Youth and Adolescence 39:1175-1188, 2010. Reardon S. Largest ever study of transgender teenagers set to kick
Merke DP, Bornstein SR. Congenital adrenal hyperplasia. Lancet off. Nature 531:560, 2016.
365:2125-2136, 2005. Richter-Appelt H, Discher C, Gedrose B. Gender identity and
Meyer-Bahlburg HFL. Gender identity disorder in young boys: recalled gender related childhood play-behaviour in
A parent-and peer-based treatment protocol. Clinical adult individuals with different forms of intersexuality.
Child Psychology and Psychiatry 7:360-376, 2002. Anthropologischer Anzeiger 63:241-256, 2005.
Meyer-Bahlburg HFL. Gender identity outcome in female-raised Rider GN, McMorris BJ, Gower AL et al. Health and care
46, XY persons with penile agenesis, cloacal exstrophy utilization of transgender and gender nonconforming
of the bladder, or penile ablation. Archives of Sexual youth: a population-based study. Pediatrics, 2018
Behavior 34: 423-438, 2005. p.e20171683.
Meyer-Bahlburg HFL, Baratz Dalke K, Berenbaum SA et al. Ristori J, Steensma TD. Gender dysphoria in childhood.
Gender assignment, reassignment and outcome in International Review of Psychiatry 28:13-20, 2016.
disorders of sex development: Update of the 2005 Rosenthal SM. Approach to the patient: Transgender youth:
consensus conference. Hormone Research in Paediatrics Endocrine considerations. Journal of Clinical
85:112-118, 2016. Endocrinology & Metabolism 99:4379-4389, 2014.
Money J, Hampson JG, Hampson JL. Imprinting and the Rosin H. A boy’s life. The Atlantic 302(4):56-59, 62, 64, 66-
establishment of gender role. Archives of Neurology and 68, 70-71, 2008.
Psychiatry 77:333-336, 1957. Ruigrok AN, Salimi-Khorshidi G, Lai MC, et al. A meta-
Morrison EG. Transgender as ingroup or outgroup? Lesbian, analysis of sex differences in human brain structure.
gay, and bisexual viewers respond to a transgender Neuroscience & Biobehavioral Reviews 39:34-50,
character in daytime television. Journal of 2014.
Homosexuality 57:650-665, 2010. Schagen SE, Cohen-Kettenis PT, Delemarre-van de Waal HA
Olson KR. Prepubescent transgender children: et al. Efficacy and safety of gonadotropin-releasing
hormone agonist treatment to suppress puberty in
What we do and do not know. Journal
gender dysphoric adolescents. Journal of Sexual
of the American Academy of Child and Medicine 13:1125-1132, 2016.
Adolescent Psychiatry 55:155-156, 2016. Schoning S, Engelien A, Bauer C et al. Neuroimaging
differences in spatial cognition between men and
Olson J, Schrager SM, Belzer M et al. Baseline physiologic and
male-to-female transsexuals before and during
psychosocial characteristics of transgender youth
hormone therapy. Journal of Sexual Medicine
seeking care for gender dysphoria. Journal of Adolescent
7:1858-1867, 2010.
Health 57:374-380, 2015.
Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms—
Olson KR, Durwood L, DeMeules M et al. Mental health of
meeting the health needs of transgender people. New
transgender children who are supported in their
England Journal of Medicine 375:101-103, 2016.
identities. Pediatrics 137(3): doi:10.1542/peds.2015-
3223, 2016a.

Shields JP, Cohen R, Glassman JR et al. Estimating population T’Sjoen G, De Cuypere G, Monstrey S et al. Male gender
size and demographic characteristics of lesbian, gay, identity in complete androgen insensitivity
bisexual, and transgender youth in middle school. syndrome. Archives of Sexual Behavior 40:635-638,
Journal of Adolescent Health 52:248–250, 2013. 2011.
Simons L, Schrager SM, Clark LF et al. Parental support Turban JL, van Schalkwyk GI, 2018. “Gender dysphoria” and
and mental health among transgender adolescents. autism spectrum disorder: is the link real? Journal
Journal of Adolescent Health 53:791-793, 2013. of the American Academy of Child & Adolescent
Singh D. A Follow-up Study of Boys with Gender Identity Psychiatry 57(1); 8-9, 2018.
Disorder. Unpublished doctoral dissertation, van Caenegem E, Wierckx K, Elaut E et al. Prevalence
University of Toronto, 2012. of gender nonconformity in Flanders, Belgium.
Skagerberg E, Carmichael P. Internalizing and externalizing Archives of Sexual Behavior 44:1281-1287, 2015.
behaviors in a group of young people with gender van der Miesen AI, Hurley H, Bal A et al. Gender variance and
dysphoria. International Journal of Transgenderism autism spectrum disorder. Manuscript submitted for
14:105-112, 2013. publication, 2016a.
Soleman RS, Schagen SE, Veltman DJ et al. Sex differences van der Miesen AI, Hurley H, de Vries ALC. Gender
in verbal fluency during adolescence: A functional dysphoria and autism spectrum disorder: A narrative
magnetic resonance imaging study in gender review. International Review of Psychiatry 28:70-
dysphoric and control boys and girls. Journal of 80, 2016b.
Sexual Medicine 10:1969-1977, 2013. Vance SR, Cohen-Kettenis PT, Drescher J et al. Opinions
Spack NP, Edwards-Leeper L, Feldman HA et al. Children and about the DSM gender identity disorder diagnosis:
adolescents with gender identity disorder referred to Results from an international survey administered
a pediatric medical center. Pediatrics 129:418-425, to organizations concerned with the welfare of
2012. transgender people. International Journal of
Steensma TD, Cohen-Kettenis PT. Gender transitioning before Transgenderism 12:1-14, 2010.
puberty? [Letter to the Editor]. Archives of Sexual Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of
Behavior 40:649-650, 2011. gender-dysphoric children. Journal of the American
Steensma TD, Kreukels BPC, de Vries ALC et al. Gender Academy of Child and Adolescent Psychiatry
identity development in adolescence. Hormones and 47:1413-1423, 2008.
Behavior 64:288-297, 2013a. Wallien MS, Swaab H, Cohen-Kettenis PT. Psychiatric
Steensma TD, McGuire JK, Kreukels BPC et al. Factors comorbidity among children with gender identity
associated with desistence and persistence of disorder. Journal of the American Academy of Child
childhood gender dysphoria: A quantitative follow- and Adolescent Psychiatry 46:1307-1314, 2007.
up study. Journal of the American Academy of Child Wood H, Sasaki S, Bradley SJ et al. Patterns of referral to a
and Adolescent Psychiatry 52:582-590, 2013b. gender identity service for children and adolescents
Steensma TD, van der Ende J, Verhulst FC et al. Gender (1976-2011): Age, sex ratio, and sexual orientation.
variance in childhood and sexual orientation in Journal of Sex & Marital Therapy 39:1-6, 2013.
adulthood: A prospective study. Journal of Sexual Wylie CH, Cohen-Kettenis PT, Delemarre-van de Waal H
Medicine 10:2723-2733, 2013c. et al. Endocrine treatment of transsexual persons:
Steensma TD, Zucker KJ, Kreukels BPC et al. Behavioral and An Endocrine Society Clinical Practice Guideline.
emotional problems on the Teacher’s Report Form: Journal of Clinical Endocrinology & Metabolism
A cross-national, cross-clinic comparative analysis 94:3132-3154, 2009.
of gender dysphoric children and adolescents. Zhou JN, Hofman MA, Gooren LJ et al. A sex difference in
Journal of Abnormal Child Psychology 42:635-647, the human brain and its relation to transsexuality.
2014. Nature 378:68-70, 1995.
Strang JF, Kenworthy L, Dominska A et al. Increased gender Zucker KJ. Gender identity disorder. In: Martin A, Volkmar
variance in autism spectrum disorders and attention FR (eds). Lewis’s Child and Adolescent Psychiatry: A
deficit hyperactivity disorder. Archives of Sexual Comprehensive Textbook, 4th ed. Baltimore, MD,
Behavior 43:1525-1533, 2014 Lippincott Williams & Wilkins, 2007, pp. 669-680.
Strang, JF, Meagher H, Kenworthy L et al. Initial clinical Zucker KJ. Treatment of gender identity disorders in children.
guidelines for co-occurring autism spectrum In: Blanchard R, Steiner BW (eds). Clinical
disorder and gender dysphoria in adolescents. Management of Gender Identity Disorders in Children
Journal of Clinical Child & Adolescent Psychology and Adults. Washington, DC, American Psychiatric
47:105-115, 2018. Press, 1990, pp. 25-45.
Swaab DF, Garcia-Falgueras A. Sexual differentiation of the Zucker KJ, Bradley SJ. Gender Identity Disorder and Psychosexual
human brain in relation to gender identity and sexual Problems in Children and Adolescents. New York,
orientation. Functional Neurology 24:17-28, 2009. Guilford Press, 1995.
The Associated Press. David Reimer, 38, subject of the John/ Zucker KJ, Wild J, Bradley SJ et al. Physical attractiveness of
Joan case. 2004 (May 12). boys with gender identity disorder. Archives of Sexual
Behavior 22:23-36, 1993.

Zuger B. Early effeminate behavior in boys: Outcome and

significance for homosexuality. Journal of Nervous and
Mental Disease 172:90-97, 1984.

Transgender and Gender Non-Conforming Youth: Other Disorders

Uploaded by

Copyright:

Available Formats

Transgender and Gender Non-Conforming Youth: Other Disorders

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Transgender and Gender Non-Conforming Youth: Other Disorders

Uploaded by

Copyright:

Available Formats

IACAPAP Textbook of Child and Adolescent Mental Health

Jack L Turban, Annelou LC de Vries, Kenneth J Zucker &

Transgender and gender non-conforming youth H.3 1

TERMINOLOGY AND DEFINITIONS

Transgender and gender non-conforming youth H.3 2

experience gender identity issues different from those experienced by individuals

Transgender and gender non-conforming youth H.3 3

Figure H.3.1 The “Genderbread Person”

The “genderbread person” has been developed as an educational tool to

UNDERSTANDING GENDER IDENTITY AND

Transgender and gender non-conforming youth H.3 4

Table H.3.1 Terminology

Transgender and gender non-conforming youth H.3 5

Gender, being a core feature of identity, is influenced by the language spoken. In

HISTORY OF GENDER IDENTITY AND MEDICINE

Transgender and gender non-conforming youth H.3 6

development were innovative and of great influence, beginning in the 1950s.

Transgender and gender non-conforming youth H.3 7

DIAGNOSIS AND ASSESSMENT

Transgender and gender non-conforming youth H.3 8

Table H.3.2 Summary comparison of diagnostic criteria for gender dysphoria in

GENDER DYSPHORIA IN ADOLESCENTS AND

A marked incongruence between one’s

● In boys (assigned gender), a strong

Transgender and gender non-conforming youth H.3 9

DSM-5 renamed gender identity disorder as “gender dysphoria,” aiming to

Transgender and gender non-conforming youth H.3 10

Although formal epidemiological studies of gender dysphoria (previously

Of pre-pubertal children referred to gender identity clinics, the majority

BIOLOGICAL AND PSYCHOSOCIAL DETERMINANTS

Transgender and gender non-conforming youth H.3 11

Twin studies suggest a strong heritable component with additional

Transgender and gender non-conforming youth H.3 12

In the US, the Trump

majority of female-raised individuals with congenital adrenal hyperplasia (~95%),

Past literature has investigated the potential role of parental characteristics

Transgender and gender non-conforming youth H.3 13

Transgender and gender non-conforming youth H.3 14

predict the likelihood of cross-gender identification persistence from childhood

In contrast to the low rates of persistence from childhood into adolescence,

Childhood gender variant behavior has been found to be a strong predictor

COEXISTING PSYCHIATRIC CONDITIONS

Transgender and gender non-conforming youth H.3 15

A number of studies show that autism spectrum disorder (ASD) symptoms

Transgender and gender non-conforming youth H.3 16

• An intermediate approach—described by some as “watchful waiting”

• More recently, an approach—characterized by Ehrensaft (2012) as the

These approaches have been discussed in great detail in three reports

• There are no randomized controlled trials comparing the effects of these

• With some rare exceptions (Meyer-Bahlburg, 2002), there are no

Thus, clinicians need to educate themselves by reading about the therapeutic

This approach aims to reduce through psychosocial interventions the

Transgender and gender non-conforming youth H.3 17

The second approach takes an intermediate therapeutic position. On the

Transgender and gender non-conforming youth H.3 18

The affirmative approach theorizes that clinician and parental attempts to

Transgender and gender non-conforming youth H.3 19

Separate from the question of persistence is the question of mental health

Once children reach puberty, transgender identity persists in the majority