National Association of Practising Psychiatrists

Managing Gender Dysphoria/Incongruence in Young People: A Guide for Health Practitioners

Gender dysphoria/incongruence in young people is a contested area of medical practice.  This approach avoids political, social, religious and ideological positions.

This approach to developing a guide for managing gender dysphoria [1] or gender incongruence [2] in children and adolescents aims to protect and safeguard the health, safety and welfare of the child.  This guide prioritises the best interests of the child in accordance with human rights obligations under the International Convention of the Rights of the Child [3]. 

Specifically,

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

It acknowledges that childhood and adolescence is a time of rapid physical and psycho-social growth and profound personal development, during which young people may question their identity, sexual orientation and gender.  As the child matures and progresses through puberty this questioning usually resolves, and in the majority of cases the young person who has gender incongruence issues accepts his/her biological sex and adult body [4, 5].  

It is based upon an understanding that gender dysphoria/incongruence can be both a symptom and a syndrome.  For a young person to have the syndrome of gender dysphoria/incongruence there must be a significant, established and prolonged pattern [2] of desire and behaviour that indicates the person insists they are a gender different to their natal (birth assigned) gender.

It recognises that gender dysphoria/incongruence can often be a manifestation of complex pre-existing family, social, psychological or psychiatric conditions [6].  A holistic approach to assessment includes a comprehensive exploration for these potential conditions in order to more fully understand a child presenting with gender dysphoria/incongruence [7,8].  Where these conditions are presenting as gender dysphoria/incongruence, the treatment of the underlying condition is a priority.

Individualised psychosocial interventions (e.g., psychoeducation, individual therapy, school-home liaison, family therapy) should be first-line treatments for young people with gender dysphoria/incongruence.  Exploratory psychotherapy should be offered to all gender questioning young people to identify the many potential sources of distress in their lives in addition to their gender concerns.  Clinicians can provide a range of ethical psychological interventions (e.g., supportive psychotherapy, CBT, and dynamic psychotherapy) to assist the young person to clarify and resolve these contributory factors.  Such approaches are consistent with established principles of comprehensive, systemic youth health care [7].  They should be undertaken before experimental puberty-blocking drugs [9] and other medical interventions (e.g., cross-sex hormones, sex reassignment surgery) are considered.

Medical interventions to block puberty and cross-hormone treatment to achieve feminisation and masculinisation according to the young person’s perceived gender are not fully reversible and can cause significant adverse effects on physical, cognitive, reproductive and psychosexual development [9,10,11,12,13,14,15,16,17,18]. 

Currently, while some individuals report a successful transition, we are not aware of published long-term prospective outcome studies that have followed up adults who have undergone childhood or adolescent transition that show substantial benefit. As a consequence, there is no consensus that medical treatments such as the use of puberty-blocking drugs, cross-sex hormones or sexual reassignment surgery lead to better future psychosocial adjustment [17,18,19,20,21,22].

Increasing numbers of individuals who have undergone hormonal treatment and surgical interventions subsequently report experiencing regret and a wish to de-transition. They describe significant psychological and physical suffering, including loss of fertility and sexual function as a consequence of decisions made when younger [23,24,25,26,27,28,29].  

Medico-legal considerations must be fully appreciated in this area of clinical practice.  Health professionals are exposed to significant legal risk:

If a child or adolescent is found not to have been competent to give an informed consent,

If gender affirming treatment is not preceded by a comprehensive psycho-social assessment, that considers and excludes alternate diagnoses, or

If the patient was not informed of all the risks of puberty blockers and cross-hormone treatment including their experimental nature [9]. 

Clinicians should therefore reflect carefully before recommending treatments for gender dysphoria/incongruence. 

The still unproven risks and benefits of gender reassignment interventions make it imperative that parents and children under 18 years and young people over 18 years are made aware of the current evidence of potential harm regarding gender transition and provide fully informed consent before potentially damaging and irreversible treatment is commenced.

This cautious approach is also mirrored in general clinical guidance by national advisory bodies in Finland [30] and the Karolinska Hospital in Sweden [31] that recommend treatment methods for gender dysphoria in minors.

In preparing this guide, advice was obtained from a number of senior medical specialists in child and adolescent psychiatry, adult psychiatry, forensic psychiatry, and clinical psychology and from physicians and other clinicians who have cared for young people experiencing gender dysphoria/incongruence, and legal practitioners who have experience in this field.  Contributors to this guide include Dr Philip Morris, Dr Roberto D’Angelo, Dr George Halasz, Dr Cary Breakey, Prof Dianna Kenny, Dr Carlos D’Abrera, Dr Vivienne Elton, and Dr Ron Spielman.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

2. World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en

3. UN Commission on Human Rights, Convention on the Rights of the Child., 7 March 1990, E/CN.4/RES/1990/74, available at: https://www.refworld.org/docid/3b00f03d30.html [accessed 3 November 2020]

4. Entwistle K. Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child Adolesc Ment Health. 2020. doi:10.1111/camh.12380

5.  Ristori J, Steensma T. Gender dysphoria in childhood. International Review of Psychiatry. 2016;28(1):13-20.  doi:10.3109/09540261.2015.1115754

6. Kozlowska K, et al.  Attachment patterns in children and adolescents with gender dyshoria.  Frontiers in Psychology, 12 January 2021.

7. Kozlowska K, et al.  Australian Children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service.  Human Systems: Therapy, Culture and Attachments, 22 April 2021.

8. Kosky R. Gender‐disordered children: does inpatient treatment help? Medical Journal of Australia 1987;146:565-69 (June 1, 1987). doi: 10.5694/j.1326-5377.1987.tb120415.x

9. https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock-Judgment.pdf

10. Vlot MC, Klink DT, den Heijer M, Blankenstein MA, Rotteveel J, Heijboer AC. Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone. 2017;95:11-19. doi: S8756-3282(16)30333-7 [pii].

11. Vlot MC, Wiepjes CM, de Jongh RT, T’Sjoen G, Heijboer AC, den Heijer M. Gender-affirming hormone treatment decreases bone turnover in transwomen and older transmen. J Bone Miner Res. 2019;34(10):1862-1872.  doi: 10.1002/jbmr.3762 [doi].

12. Schneider M, Spritzer P, Soll B et al. Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case  under Pubertal Suppression. Front Hum Neurosci. 2017;11. doi:10.3389/fnhum.2017.00528

13. Auer MK, Ebert T, Pietzner M, et al. Effects of sex hormone treatment on the metabolic syndrome in transgender individuals: Focus on metabolic cytokines. J Clin Endocrinol Metab. 2018;103(2):790-802. doi: 10.1210/jc.2017- 01559 [doi].

14. Alzahrani T, Nguyen T, Ryan A, et al. Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circ Cardiovasc Qual Outcomes. 2019;12(4):e005597. doi: 10.1161/CIRCOUTCOMES.119.005597 [doi].

15. Nota NM, Wiepjes CM, de Blok, C. J. M., Gooren LJG, Kreukels BPC, den Heijer M. Occurrence of acute cardiovascular events in transgender individuals receiving hormone therapy. Circulation. 2019;139(11):1461-1462.  doi: 10.1161/CIRCULATIONAHA.118.038584 [doi].

16. Goodman M, Nash R. Examining health outcomes for people who are transgender. https://www.pcori.org/research-results/2013/examining-health-outcomes-people-who-are-transgender. Updated 2014. Accessed Nov 7, 2019.

17. https://www.evidence.nhs.uk/document?id=2334888&returnUrl=search%3ffrom%3d2020-01-01%26q%3dgender%2bdysphoria%26sp%3don%26to%3d2021-03-31

18. https://www.evidence.nhs.uk/search?q=Evidence+review%3A+Gender-affirming+hormones+for+children+and+adolescents+with+gender+dysphoria

19. 22 Dhejne C, Lichtenstein P, Boman M, Johansson AL, Langstrom N, Landen M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS One. 2011;6(2):e16885.  doi: 10.1371/journal.pone.0016885 [doi].

20. Bränström, R., & Pachankis, Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry. 2019;177(8), 727- 734. https://doi.org/10.1176/appi.ajp.2019.19010080

21. Correction to Bränström and Pachankis. American Journal Of Psychiatry. 2020;177(8), 734-734.  https://doi.org/10.1176/appi.ajp.2020.1778correction

22. Kalin, N. Reassessing Mental Health Treatment Utilization Reduction in Transgender Individuals After Gender Affirming Surgeries: A Comment by the Editor on the Process. American Journal Of Psychiatry. 2020;177(8), 764- 764. https://doi.org/10.1176/appi.ajp.2020.20060803

23. Lesbian Strength 2019 – Charlie Evans. YouTube. https://www.youtube.com/watch?v=-JazgA3AdUE. Published 2019. Accessed November 1, 2019.

24. Female detransition and reidentification: Survey results and interpretation. archive Web site.  https://guideonragingstars.tumblr.com/post/149877706175/female-detransition-and-reidentification-survey.  Accessed Nov 7, 2019.

25. Pique resilience project. PIQUE RESILIENCE PROJECT Web site. https://www.piqueresproject.com/. Accessed Nov 7, 2019.

26. Subreddit survey update! : detrans. Reddit.com. https://www.reddit.com/r/detrans/comments/azj8xd/subreddit_survey_update/. Published 2019. Accessed November 1, 2019.

27. Reddit.com. Has anyone been to gender therapy? What was your experience?: detrans. [online]:https://www.reddit.com/r/detrans/comments/aeo5zd/has_anyone_been_to_gender_therapy_what_was_your/ Published 2019. Accessed November 1, 2019.

28. Tumblr: Guide on raging stars. Female detransition and reidentification survey. Available:  https://tinyurl.com/female-detrans-survey. Published 2016. Accessed November 1, 2019.

29. Vandenbussche E.  Detransition-related needs and support: A cross-sectional online survey.  Journal of Homosexuality online, 30 April 2021.

30. Recommendation of the Council for Choices in Medical Treatment Methods for Dysphoria Related to Gender Variance In Minors.  Health Care in Finland (PALKO / COHERE Finland), 11 June 2020.

31. https://segm.org/sites/default/files/Karolinska%20Policy%20Change%20K2021-3343%20March%202021%20%28English%2C%20unofficial%20translation%29.pdf

Dr Philip Morris

President National Association of Practising Psychiatrists