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Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach
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The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth's functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.
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... Gender diversity may emerge at any age and often persists [7]. In addition, some of these children, but not all, suffer from gender dysphoria, which is the distress resulting from the incongruence between their perceived gender identity and their sex assigned at birth [8,9]. ...
... These data clearly demonstrate the magnitude of the phenomenon and the increasing need to provide informed and specialized care to this population [10][11][12]. Indeed, all TGD youth have special health needs and should benefit from specialized care delivered by clinicians who are informed in matters of gender diversity [8,9]. ...
Introduction: The aim of this study was to evaluate (i) the knowledge about different dimensions of sexual identity in a group of family pediatricians and (ii) the efficacy of a training program to improve knowledge and reduce genderism and heteronormativity. Methods: A pre-post-follow-up study was conducted with 96 Italian pediatricians (48 men and 48 women) who participated in a 6-h training program and divided into 2 sections. The first section was theoretical and focused on the conceptual foundations of sexual identity, the depathologizing approach to gender diversity, and the role of pediatricians as the first contacts of children's or adolescents' family. The second part was experiential and included the presentation of a clinical case and the activation of a group reflection on the management of gender-diverse youth. Knowledge about sexual identity, genderism, and heteronormativity was measured. Results: Pre-training questionnaires revealed that the mean score of knowledge about sexual identity was 7.13 ± 3.21. One-way within-subject ANOVA revealed significant effects from pre-to post-training and from pre-to follow-up assessment but not from post-training to follow-up assessment, suggesting that significant changes in the knowledge about sexual identity (F = 39.75, p < 0.001), in personal biases related to genderism (F = 7.46, p < 0.01), and in heteronormative attitudes (F = 44.99, p < 0.001) and behaviors (F = 79.29, p < 0.001) were achieved through the training and maintained at follow-up. Conclusion: These findings indicate the importance of training pediatricians to work with gender-diverse youth and provide them with the best clinical interventions.
... 8 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions. 9 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses. [8][9] 13d Describe any methods used to synthesize results and provide a rationale for the choice(s). ...
... 9 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses. [8][9] 13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If metaanalysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used. ...
It is unclear whether the literature on adolescent gender dysphoria (GD) provides evidence to inform clinical decision making adequately. In the final of a series of three papers, we sought to review published evidence systematically regarding the types of treatment being implemented among adolescents with GD, the age when different treatment types are instigated, and any outcomes measured within adolescence. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none at that time), we searched Ovid Medline 1946 -October week 4 2020, Embase 1947-present (updated daily), CINAHL 1983-2020, and PsycInfo 1914-2020. The final search was carried out on 2nd November 2020 using a core strategy including search terms for 'adolescence' and 'gender dysphoria' which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 19 papers from 6 countries representing between 835 and 1354 participants were included in our final sample. All studies were observational cohort studies, usually using retrospective record review (14); all were published in the previous 11 years (median 2018). There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 71% to 95%, with a mean of 82%. Puberty suppression (PS) was generally induced with Gonadotropin Releasing Hormone analogues (GnRHa), and at a pooled mean age of 14.5 (±1.0) years. Cross Sex Hormone (CSH) therapy was initiated at a pooled mean of 16.2 (±1.0) years. Twenty-five participants from 2 samples were reported to have received surgical intervention (24 mastectomy, one vaginoplasty). Most changes to health parameters were inconclusive, except an observed decrease in bone density z-scores with puberty suppression, which then increased with hormone treatment. There may also be a risk for increased obesity. Some improvements were observed in global functioning and depressive symptoms once treatment was started. The most common side effects observed were acne, fatigue, changes in appetite, headaches, and mood swings. Adolescents presenting for GD intervention were usually offered puberty suppression or cross-sex hormones, but rarely surgical intervention. Reporting centres broadly followed established international guidance regarding age of treatment and treatments used. The evidence base for the outcomes of gender dysphoria treatment in adolescents is lacking. It is impossible from the included data to draw definitive conclusions regarding the safety of treatment. There remain areas of concern, particularly changes to bone density caused by puberty suppression, which may not be fully resolved with hormone treatment.
... So it simply has psychological connotations: one's subjective state.". Now as Gender dysphoria, It is defined as a six-month gap between one's experienced or expressed sex and designated sex, as shown by the inconsistency between stated sex and primary and/or secondary sexual traits, extreme desire to get rid of one's primary and/or secondary sexual characteristics, a strong desire for primary and/or secondary sexual characteristics of the other sex (de Vries & Cohen-Kettenis, 2012;de Vries et al., 2006;Devor, 1996;Eftekhar et al., 2015). ...
Despite the traditional trends in gender classification, people are suffering from a condition known as Gender Dysphoria (GD) in Asian countries generally and in Pakistan particularly. The study was intended to explore how young individuals with gender dysphoria define and interpret their gender identity. Through the purposive sampling technique, eleven young individuals (19–30 years) with GD were recruited from three cities in Pakistan; Gujrat, Jhelum, and Lahore. Semi-structured interviews were undertaken, and theme analysis was used to examine the data. The study findings revealed that participants utilized the internet as an information source to explore and learn about their gender. They had the chance to investigate, discover, validate, and embrace their genders through talking with others both inside and outside the transgender community. The influence of gender confusion and bodily pain on their emotional well-being may be worsened or lessened depending on how others respond and support them. Participants believed that the stigma and prejudice towards persons with GD were fueled by a lack of knowledge, awareness, and education. As a result, there was a desire to protest and initiate social action to decrease the stigma and improve the quality of life of individuals with gender dysphoria.
... The GIDS was recommended to close in 2022 in the wake of the interim report on its functioning commissioned by NHS England. Prior to that closure, internal dissent about its service philosophy, predicated on the affirmative model of care adopted from the Center of Expertise on Gender Dysphoria, in Amsterdam in the 1990s, eventually triggered departures from disaffected staff, with disciplinary action taken against some of those who stayed but protesting (Biggs, 2023;de Vries & Cohen-Kettenis, 2012;Gilligan, 2019). Between 2016 and 2019, 35 psychologists resigned and some began to express their concerns about an emerging iatrogenic medico-legal challenge of those wishing to de-transition, who resented their treatment when younger (Butler & Hutchinson, 2020). ...
... What is known is that the proportional overoccurrence of intersecting autism and gender diversity exists in multiple nations and societies and across a broad age range (including in adulthood). 8 Findings from the 2 existing clinical and linked research programs specializing in intersecting autism and gender diversity (co-first author J.F.S., Director of the Gender and Autism Program in Washington, DC, USA, and co-first author A.I.R.v.d.M., Clinician Researcher with the Center of Expertise on Gender Dysphoria in Amsterdam, the Netherlands) suggest that time can help young people in general to best discern their needs regarding gender, whether they be social, medical, and/or legal, 27,29 and this is true also for autistic youth, specifically. 27,30 One of these studies identified that a substantial proportion of youth (w30%), autistic and nonautistic, showed shifts in their gender-related medical requests over time; this study was conducted in the US clinic, which followed the Dutch care model of more extended evaluation spread out over time to determine needs. ...
... This type of assessment is often used as a first step to developing therapeutic or psycho-educational recommendations for a child, parents/guardians, and/or family, if any, which can be discussed collaboratively with a child and other significant family members. [20][21][22] Comprehensive assessments with transgender and gender diverse children should access and integrate information from multiple sources, domains, and methods as part of the assessment Sources of Information: Almost all assessments of TGD youth will involve parents/ guardians, unless they are unavailable, such as when a TGD child is residing in a therapeutic residential facility and parents or legal caregivers are inaccessible or otherwise inappropriate to include (maltreating, non-custodial parents, for example) We recommend the consideration of including cisgender siblings in an assessment process if they have a significant impact on the TGD child, as is suggested by some research, 23,24 or if they may have unexplored needs related to their relationship with their TGD sibling. Other extended family members can also participate in a child assessment, at the discretion of the child, parents/guardians, and the provider performing the assessment. ...
... Por otro lado, se está implantando un nuevo modelo de tratamiento, conocido como modelo afirmativo del género (gende affirmative model) 27 , que se basa únicamente en el principio del consentimiento informado 28 y elimina el requerimiento de evaluación y acompañamiento psicológico 29 . Así, este modelo se distancia del modelo biopsicosocial tradicional, que enfatiza la importancia de realizar evaluaciones psicosociales exhaustivas antes de recomendar cualquier tipo de intervención social o médica 30,31 . En España, los nuevos protocolos de tratamiento existentes en algunas comunidades, como Andalucía, surgidos tras la aprobación de leyes autonómicas, eliminan la recomendación de evaluación psicológica y ofrecen servicios aislados de atención en proximidad, generalmente de carácter endocrinológico y sin la participación de equipos multidisciplinares 1,3 . ...
Introducción. La destransición de género es el acto de detener o revertir los cambios sociales, médicos y/o administrativos con- seguidos durante un proceso de transición de género. Se trata de un fenómeno emergente de gran interés a nivel clínico y social.
Método. Se condujo una búsqueda sistemática en siete bases de datos entre 2010 y 2022, se rastrearon manualmente las referencias de los artículos y se consultaron libros especializados. Se realizó un análisis cuantitativo y de contenido.
Resultados. Se incluyeron 138 registros, 37% correspondientes a estudios empíricos y 38,4% publicados en 2021. Se identifican al menos ocho términos para hacer referencia a la destransición, con diferencias en sus definiciones. La prevalencia difiere en función del criterio utilizado, siendo menor para la destransición/arrepentimiento (0-13,1%) que para la descontinuación de la asistencia/tratamiento médico (1,9%-29,8%), y menor para la destransición/arrepentimiento tras cirugía (0-2,4%) que para la destransición/arrepentimiento tras tratamiento hormonal (0-9,8%). Se describen más de 50 factores psicológicos, médicos y socioculturales que influyen en la decisión de destransicionar, así como 16 factores predictores/asociados a la destransición. No se encuentran guías de abordaje sanitario ni legislativo. Los debates actuales se centran en los interrogantes sobre la naturaleza de la disforia de género y el desarrollo de la identidad, el papel de los profesionales con respecto al acceso a los tratamientos médicos y el impacto de las destransiciones sobre la futura accesibilidad a dichos tratamientos.
Conclusiones. La destransición de género es una realidad compleja, heterogénea, poco estudiada y escasamente comprendida. Se requiere un abordaje y estudio sistemático que permita comprender su prevalencia real, implicaciones y manejo a nivel sanitario.
0 Ambulatério de Género e Sexualidades (AmbGen) do Hospital das Clinicas da Universidade Estadual de Campinas é um dos poucos dispositivos publicos que acolhem população da infancia e adolescência com variabilidade de género. A psiquiatria e psicologia investigam transtornos mentais, desencadeadores do sofrimento psfquico, disforias relacionados à incongruência de géneto e, no caso de criancas e adolescentes, acolhem as familias buscando compreensao da dinamica familiar, esclarecimento dedúvidas e estigmas. A intervenção hormonal na adolescéncia é possivel em dois momentos: no inicio da puberdade, através deterapia medicamentosa visando blogueio puberal, e hormonização cruzada. A adequação corporal & identidade de género da pessoa trans, através da hormonização, é desejada pela maior parte dos adultos atendidos. A arteterapia realiza atendimentos nos quais busca fornecer padrdes adequados à questdes relevantes, utilizando- se de modalidades expressivas e vivéncias de processoscriativos, uma maneira terapéutica diferenciada que propicia um ambiente acolhedor por um viés artistico. Caracteristicas de gênero e voz são muito abrangentes. Sendo assim, a terapia fonoaudiológica a pessoas trans nao se restringe apenas a produção vocal, mas também se relaciona a outros aspectos da comunicagdo e do discurso.
The roots of the recent controversy about how mental health professionals should respond to gender non-conforming children are traced. To make historical sense, this paper distinguishes between epistemological (discursive) and ontological (non-discursive) aspects and describes their features, since 1970. This helps to clarify some of the confusions at the centre of the still heated debate about sexuality and gender identity today. In the concluding discussion, the philosophical resource of critical realism is used to interpret the historical narrative provided. It cautions against the anachronistic tendency to amalgamate the short-lived, and now defunct, experiment of aversion therapy for homosexuality with more recent defences of exploratory psychotherapy. The latter have challenged a different form of experimentation: the bio-medicalisation of gender non-conforming children.
This paper presents findings of a detailed service audit of cases seen at a specialist service for children and adolescents with gender identity disorders. The audit looked at clinical features, associated features, demographic characteristics and complexity of the cases. Data were extracted from patient files of the first 124 cases seen by the service. Clinical features were assessed based on DSM-IV criteria (American Psychiatric Association, 1994) and associated features were based on the clinical features list of the Association of Child Psychology and Psychiatry (ACPP) data set (Berger et al., 1993). A range of results is presented documenting the occurrence and frequency of different clinical features at different ages. These include the finding that stereotypically gendered clothing (i.e. boys cross-dressing and girls refusing to wear skirts) is more significant in pre-pubertal children, whereas dislike of bodily sexual characteristics becomes more predominant in post-pubertal children. The most common associated features were relationship difficulty with parents/carers (57%), relationship difficulty with peers (52%) and depression/misery (42%). Gender identity problems have wide-reaching implications for children and their families and problems may become more entrenched with the onset of puberty. Although specialist support and co-ordination of services becomes essential particularly at this time, interventions in childhood may have the function of preventing difficulties becoming more severe during adolescence. http://web.archive.org/web/20070525044205/http://www.symposion.com/ijt/ijtvo06no01_01.htm
Empirical studies were evaluated to determine whether Gender Identity Disorder (GID) in children meets the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV, American Psychiatric Association, 1994) definitional criteria of mental disorder. Specifically, we examined whether GID in children is associated with (a) present distress; (b) present disability; (c) a significantly increased risk of suffering death, pain, disability, or an important loss of freedom; and if (d) GID represents dysfunction in the individual or is simply deviant behavior or a conflict between the individual and society. The evaluation indicates that children who experience a sense of inappropriateness in the culturally prescribed gender role of their sex but do not experience discomfort with their biological sex should not be considered to have GID. Because of flaws in the DSM-IV definition of mental disorder, and limitations of the current research base, there is insufficient evidence to make any conclusive statement regarding children who experience discomfort with their biological sex. The concluding recommendation is that, given current knowledge, the diagnostic category of GID in children in its current form should not appear in future editions of the DSM.
Background. We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome. Method. Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses. Results. After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes. Conclusions. The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.
• We evaluated the Children's Global Assessment Scale (CGAS), an adaptation of the Global Assessment Scale for adults. Our findings indicate that the CGAS can be a useful measure of overall severity of disturbance. It was found to be reliable between raters and across time. Moreover, it demonstrated both discriminant and concurrent validity. Given these favorable psychometric properties and its relative simplicity, the CGAS is recommended to both clinicians and researchers as a complement to syndrome-specific scales.