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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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... includes a revised definition of gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) and a substantial shift in presentations, that includes an increase in adolescent (Dèttore et al., 2015;Edwards-Leeper & Spack, 2012;Telfer et al., 2017;De Vries & Cohen-Kettenis, 2012) and gender queer or non-binary individuals (Butler et al., 2018;Richards et al., 2016). These changes have resulted in the development of a number of patientreported outcome measures (PROMs) that focus on psychological distress and functioning in individuals with gender dysphoria. ...
... Bowman et al. (2021) conducted an assessment of the usability and quality of the GPSQ and other measures of gender dysphoria using the Consensusbased Standards for the Selection of Health Measurement Instruments (COSMIN; Mokkink et al., 2018;Prinsen et al., 2018;Terwee et al., 2018). In this review, the authors found that one of the major limitations of the GPSQ was that it was designed to only assess gender dysphoria in populations over the age of 18 years, which is problematic given the well-documented increase in adolescents presenting for treatment (Dèttore et al., 2015;Edwards-Leeper & Spack, 2012;Telfer et al., 2017;De Vries & Cohen-Kettenis, 2012). While this limitation does not impact the quality of the measurement, it does prevent it from being used reliably in populations under the age of 18 and to do so would likely result in numerous concerns regarding the content validity of the measure (De Vet et al., 2011). ...
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The Gender Preoccupation and Stability Questionnaire (GPSQ) is a 14-item measure used to assess the effectiveness of medical, surgical, social, and psychological interventions in trans and gender diverse adults who experience gender dysphoria. One major limitation of the GPSQ is that it was not developed for use with adolescents. This study aims to validate a revised version of the GPSQ, the Gender Preoccupation and Stability Questionnaire—2nd Edition (GPSQ-2) with the aim of adapting the measure to be applicable to individuals aged 13 and above. This research was conducted in three stages: 1) development of the GPSQ-2 to address previously identified issues with validity and comprehensibility of the GPSQ and to increase the applicability of the measure to adolescents; 2) pilot testing, using a purposive sample and semi-structured interviews, to assess the relevance, comprehensibility, and comprehensiveness of the GPSQ-2; and 3) validation using a community sample to assess the psychometric properties of the GPSQ-2. The pilot study was conducted with seven participants (Mage = 28.43, SD = 15.50; age range: 13–59). The GPSQ-2 was found to be easy to understand, relevant to individuals who experienced gender dysphoria, and that it did not have any identifiable omissions. The validation study was conducted with 141 participants (Mage = 36.44; SD = 14.76; age range 14–73). The GPSQ-2 was found to be a reliable and valid 14-item scale with two factors: preoccupation and stability. The GPSQ-2 is a structurally sound measure of gender dysphoria that can be used in populations aged 13 and above.
... Within the present scope of research on TNB individuals, the diagnosis of Gender Dysphoria and the symptom experiences of gender dysphoria are often used interchangeably, which can lead to confusion among researchers and practitioners as to how gender dysphoria is experienced (Byne et al., 2018;Davy & Toze, 2018). The symptom experience of gender dysphoria is understood as a continuous construct that reflects the varying degrees of distress that can be experienced both within and across individuals (de Vries & Cohen-Kettenis, 2012;Jones, Bouman, Haycraft, & Arcelus, 2019;Pulice-Farrow, Cusack, & Galupo, 2020). ...
Article
Despite recent trans-affirming research centering experiences of gender dysphoria and its relation to psychological outcomes, there is a dearth of research studying the components of experiences of gender dysphoria. This has limited the ability of clinicians to intervene and reduce the distress caused by gender dysphoria. The current study utilized an online qualitative approach based on cognitive-behavioral therapy thought trackers to ask 108 transgender and nonbinary participants four prompts: a) antecedents of gender dysphoria, b) associated thoughts, c) emotions, and e) ways of coping. Analyses of these prompts revealed that gender dysphoria is frequently triggered by body, social, and intrapersonal experiences and is associated with a range of thoughts (e.g. body, gender presentation, medical transition, and self-harm focused) and emotions (e.g. anger, sadness, fear, and suppression) related to experiences of gender dysphoria. Participants noted engaging in both facilitative coping strategies (e.g. mindfulness, gender affirmation, medical transition, social interactions, and cognitive reframes) as well as avoidant strategies (e.g. distraction; suppression; avoid viewing body/self, social interactions, and voice; and identity concealment) to deal with gender dysphoria. Considering the lack of published therapeutic interventions targeting gender dysphoria, the discussion focuses on the ways the current findings can inform clinical practice with TNB individuals.
... GD is a dimensional phenomenon that may exist to a greater or lesser degree, and it can manifest itself in various ways. Children with strong gender dysphoric feelings may be very sensitive to their environment and verbalize these feelings only at certain times and under certain circumstances, whereas other children may express their dysphoria more openly (18). Cultural differences across countries might influence behavioral expressions of different gender identities (9). ...
Article
Objective: In this study, we aim to describe the demographic and clinical characteristics and psychological functioning of children with gender dysphoria (GD) symptoms aged between 3-12 years. Material and Methods: The study group included 20 children (17 males, 3 females; mean age 6.63±2.43 years) with GD symptoms. A sociodemographic data form was used to collect data with regards to demographic and clinical characteristics, and pre- peri-and postnatal features. The Child Behavior Checklist (CBCL) is used to assess behavioral and emotional problems in the child. Results: The boy/girl ratio in the study group was 5.66. The mean age at onset of gender-nonconforming behaviors was 2.85±1.17 years and the mean age of admission to our clinic was 5.82±2.27 years. 20% of the mothers reported a preference for an opposite-sex child prior to conception; 20 % of the mothers reported prenatal stress, 20% of the mothers had prenatal and 25% had postnatal depressive symptoms. There was a risk of miscarriage in 10% of children and 25% were born prematurely. 55% of our study sample exceeded the clinical threshold for internalizing problems and 40% exceeded the clinical threshold for externalizing problems in CBCL ratings. Conclusion: There were more prepubertal boys than girls referred for GD symptoms and the age at referral was younger compared to western countries. In addition, findings of this study indicate that children with GD have poorer psychological functioning possibly due to social intolerance for cross-gender behaviors and/or interests alongside the GD per se.
... It is different from the legal right to provide informed consent, which depends on age and differs across countries depending on their regulations [4]. In the care for transgender and gender diverse adolescents specifically, the assessment of decision-making competence is delicate and a special concern, because it concerns one's gender identity, which inherently is self-determined while still in development at this stage, and involves decisions with potentially far reaching lifelong consequences, often made at a young age [5,6]. Treatment decisions involve starting puberty suppression to pause the biological hormonal development, gender affirming hormonal treatment and (when reaching adulthood) gender affirming surgery [7]. ...
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Background Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care. Methods The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care. Results Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions. Discussion Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.
Article
In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.
Chapter
Until the past decade, clinicians and researchers assumed that the medical evaluation and treatment of both women and men were the same. This archaic and dangerous notion persisted in spite of the clear anatomic and physiologic differences between the genders. Today, we fully understand that this paradigm is false. In all specialties of medicine, practitioners and researchers are beginning to consider the influence of sex and gender and how it should inform the care of their patients. This book focuses on the issue of sex and gender in the evaluation and treatment of patients specifically in the delivery of acute medical care. It serves as a guide both to clinicians interested in the impact of sex and gender on their practice and to researchers interested in the current state of the art in the field and critical future research directions.
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It has been a quarter of a century since Dutch clinicians proposed puberty suppression as an intervention for “juvenile transsexuals,” which became the international standard for treating gender dysphoria. This paper reviews the history of this intervention and scrutinizes the evidence adduced to support it. The intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible. The main evidence for the Dutch protocol came from a longitudinal study of 70 adolescents who had been subjected to puberty suppression followed by cross-sex hormones and surgery. Their outcomes shortly after surgery appeared positive, except for the one patient who died, but these findings rested on a small number of observations and incommensurable measures of gender dysphoria. A replication study conducted in Britain found no improvement. While some effects of puberty suppression have been carefully studied, such as on bone density, others have been ignored, like on sexual functioning.
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Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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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
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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.
Article
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.
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• 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.