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Gender Identity Disorders in Childhood and Adolescence Currently Debated Concepts and Treatment Strategies

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Gender identity disorders (GID) can appear even in early infancy with a variable degree of severity. Their prevalence in childhood and adolescence is below 1%. GID are often associated with emotional and behavioral problems as well as a high rate of psychiatric comorbidity. Their clinical course is highly variable. There is controversy at present over theoretical explanations of the causes of GID and over treatment approaches, particularly with respect to early hormonal intervention strategies. This review is based on a selective Medline literature search, existing national and international guidelines, and the results of a discussion among experts from multiple relevant disciplines. As there have been no large studies to date on the course of GID, and, in particular, no studies focusing on causal factors for GID, the evidence level for the various etiological models that have been proposed is generally low. Most models of these disorders assume that they result from a complex biopsychosocial interaction. Only 2.5% to 20% of all cases of GID in childhood and adolescence are the initial manifestation of irreversible transsexualism. The current state of research on this subject does not allow any valid diagnostic parameters to be identified with which one could reliably predict whether the manifestations of GID will persist, i.e., whether transsexualism will develop with certainty or, at least, a high degree of probability. The types of modulating influences that are known from the fields of developmental psychology and family dynamics have therapeutic implications for GID. As children with GID only rarely go on to have permanent transsexualism, irreversible physical interventions are clearly not indicated until after the individual's psychosexual development ist complete. The identity-creating experiences of this phase of development should not be restricted by the use of LHRH analogues that prevent puberty.
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834 Deutsches Ärzteblatt InternationalDtsch Arztebl Int 2008; 105(48): 834–41
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G
ender identity disorders can manifest themselves
in varying degrees of severity from early child-
hood onward (1, e1). The affected children express a
desire to belong to the opposite sex, or insist that they
actually do belong to it. They display characteristic
behaviors of the opposite sex, preferring playmates of
the opposite sex as well as the clothing and games (in-
cluding role-playing games) that typically pertain to it.
They reject anything regarded as belonging to their bio-
logical sex (2, e2); as a result, the outside world, with its
sociocultural gender stereotypes, perceives them as
discordant to the sex they were born with. Even young
children sometimes adamantly reject or deny their own
sex. They may also express a desire to have the genitalia
of the opposite sex, or even become convinced that they
already have them. The designation "gender identity di-
sorder in the strict sense of the term" is recommended
for such severely affected children.
The DSM-IV-TR criteria for gender identity disorders
(GID) in children and adolescents are reproduced in box 1
(e3). In the ICD-10, which is the classification system of
the World Health Organization, "gender identity disorder
of childhood" (F64.2) is included in Chapter F64, "gender
identity disorders"; this chapter also contains "trans-
sexualism" (F64.0), "dual-role transvestism" (F64.1),
and "other" and "unspecified GID" (F64.8 and F64.9,
respectively) (boxes 2 and 3). The diagnosis of gender
identity disorder of childhood requires that the symptoms
begin well before puberty: The ICD-10 emphasizes that
mere deviation from cultural gender stereotypes—
"tomboyish" behavior in girls, "girlish" behavior in
boys—is insufficient. "Transsexualism" (F64.0) may
only be diagnosed in adulthood (e4).
Gender identity disorders are thought to have a com-
plex biopsychosocial background (e5). A considerable
number of patients have been recruited by relatively few
clinics that have a specific research interest in this area
(Toronto, New York, London, Amsterdam; in Germany,
Frankfurt, Hamburg, and Berlin) (1, 3–5). The prevalence
of gender identity disorder in the strict sense is estimated
to be on an order of magnitude less than 1% (5, 6).
Bosinski et al., who reported representative data on the
frequency of GID in childhood and adolescence in the
German-speaking countries, found a prevalence figure
in this range for the German federal state of Schleswig-
REVIEW ARTICLE
Gender Identity Disorders
in Childhood and Adolescence
Currently Debated Concepts and Treatment Strategies
Alexander Korte, David Goecker, Heiko Krude, Ulrike Lehmkuhl,
Annette Grüters-Kieslich, Klaus Michael Beier
SUMMARY
Introduction: Gender identity disorders (GID) can appear
even in early infancy with a variable degree of severity.
Their prevalence in childhood and adolescence is below
1%. GID are often associated with emotional and behavioral
problems as well as a high rate of psychiatric comorbidity.
Their clinical course is highly variable. There is controversy
at present over theoretical explanations of the causes of
GID and over treatment approaches, particularly with
respect to early hormonal intervention strategies.
Methods: This review is based on a selective Medline
literature search, existing national and international
guidelines, and the results of a discussion among experts
from multiple relevant disciplines.
Results: As there have been no large studies to date on the
course of GID, and,in particular, no studies focusing on
causal factors for GID, the evidence level for the various
etiological models that have been proposed is generally
low. Most models of these disorders assume that they
result from a complex biopsychosocial interaction. Only
2.5% to 20% of all cases of GID in childhood and adolescence
are the initial manifestation of irreversible transsexualism.
The current state of research on this subject does not allow
any valid diagnostic parameters to be identified with which
one could reliably predict whether the manifestations of
GID will persist, i.e.,whether transsexualism will develop
with certainty or, at least, a high degree of probability.
Conclusions: The types of modulating influences that are
known from the fields of developmental psychology and
family dynamics have therapeutic implications for GID.
As children with GID only rarely go on to have permanent
transsexualism, irreversible physical interventions are
clearly not indicated until after the individual’s psychosexual
development ist complete. The identity-creating experiences
of this phase of development should not be restricted by
the use of LHRH analogues that prevent puberty.
Dtsch Arztebl Int 2008; 105(48): 834–41
DOI: 10.3238/arztebl.2008.0834
Key words: gender identity disorder, transsexuality,
sex change, hormone treatment, child health
Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und
Jugendalters: Dr.med. Korte, Prof. Dr. med. Dipl.-Psych. Lehmkuhl
Institut für Sexualwissenschaft und Sexualmedizin: Dr.med. Goecker, Prof. Dr.
Dr.med. Dr. phil.Beier
Institut für Experimentelle Pädiatrische Endokrinologie: Prof. Dr. med. Krude,
Prof. Dr.med. Grüters-Kieslich
Charité-Universitätsmedizin Berlin
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Holstein (7); no newer data are available. There are
more boys than girls among the affected children, -
although this apparent asymmetry may well be due, in
part, to the greater social acceptance of gender-atypical
behavior in girls (e6). Though prospective studies are
lacking, a consensus of opinion holds that gender identity
disorders in children and adolescents are often associated
with serious emotional and behavioral problems and
with a high psychiatric comorbidity (1, 8) and also
manifest a highly variable and plastic course because
these patients' psychosexual development is not yet
complete (e2). The figure shows the possible courses of
gender identity disorder, as well as its main differential
diagnoses.
In view of the continuing diversity of scientific opinion
on the subject, with mutually exclusive positions held
by different parties, our goal in this article is to present
the main manifestations of, and diagnostic criteria for,
gender identity disorders and then to provide an over-
view of present hypotheses regarding its etiology, which
remains unknown. We will then discuss the current,
often heavily controversial debate on the "correct" ther-
apeutic approach, and, in particular, the question of early
hormonal treatment. Our discussion will necessarily
include a fundamental consideration of the ethical and
moral principles underlying medical treatment, with
particular attention to developmental psychology. This
article is based on a selective review of the literature,
including an analysis of the current international guide-
lines, as well as on the authors' own clinical experience
and insights gained in a critical and constructive debate
among experts from many countries in the framework of
an international, interdisciplinary research association.
Etiology and pathogenesis: neurobiological
and (developmental) psychological aspects
The development and maintenance of gender identity
disorders is held to be a multifactorial pathological pro-
cess, in which individual psychological factors exert
their effects in concert with biological, familial, and
sociocultural ones (e2). From the point of view of devel-
opmental psychology, it would be wrong to imagine that
patients with GID constitute a homogeneous group with
a uniform pathogenesis. Different theoretical conceptions
imply different—complementary, not necessarily con-
tradictory—notions of the possible causes of GID (e7).
In view of the still unsatisfactory state of the data, any
generalizations should be made with caution.
Neurobiological genetic research has not yet con-
vincingly shown any predominant role for genetic or
hormonal factors in the etiology of GID (1). Some study
findings were originally thought to suggest a possible
effect of sex steroids in utero and an inadequate mascu-
linization or defeminization of hypothalamic nuclei
("gender role centers") because of pathologically altered
maternal hormone levels (e8, e9); these findings are
now viewed more critically (9). On the other hand, studies
of gender identity in patients with various types of
intersex syndrome (e.g., complete versus partial androgen
receptor defects) have led to the formulation of a biological
BOX 1
DSM-IV-TR: Gender Identity Disorder in Children (302.6) and Gender Identity Disorder in
Adolescents or Adults (302.85)
AA..A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).
In cchhiillddrreenn, the disturbance is manifested by four (or more) of the following:
– Repeatedly stated desire to be, or insistence that he or she is, the other sex
– In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
– Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
– Intense desire to participate in the stereotypical games and pastimes of the other sex
– Strong preference for playmates of the other sex.
In aaddoolleesscceennttss aanndd aadduullttss, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other
sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
BB..Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
In cchhiillddrreenn, the disturbance is manifested by any of the following:
In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion
toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities
In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis,or assertion that she does not want to grow
breasts or menstruate, or marked aversion toward normative feminine clothing.
In aaddoolleesscceennttss aanndd aadduullttss, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex
characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or
belief that he or she was born the wrong sex.
CC..The disturbance is not concurrent with a physical intersex condition.
DD..The disturbance causes clinically significant distress or impairment in social, occupational,or other important areas of functioning.
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BOX 2
ICD-10 F64.2: Gender Identity Disorder of Childhood
FFoorr ggiirrllss::
AA..Persistent and intense distress about being a girl, and a stated desire to be a boy (not merely a desire for any perceived cultural advantages to
being a boy), or insistence that she is a boy.
BB..Either (1) or (2) must be present:
(1) Persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing, e.g. boys' underwear
and other accessories
(2) Persistent repudiation of female anatomical structures, as evidenced by at least one of the following:
Assertion that she has, or will grow, a penis
Rejection of urinating in a sitting position
Assertion that she does not want to grow breasts or menstruate.
CC..The girl has not yet reached puberty.
DD..The disorder must have been present for at least six months.
FFoorr bbooyyss::
AA..Persistent and intense distress about being a boy and an intense desire to be a girl or,more rarely, insistence that he is a girl.
BB..Either (1) or (2) must be present:
(1) Preoccupation with female stereotypical activities, as shown by a preference for either cross-dressing or simulating female attire,
or by an intense desire to participate in the games and pastimes of girls and rejection of stereotypical male toys, games and activities
(2) Persistent repudiation of male anatomical structures, as indicated by at least one of the following repeated assertions:
That he will grow up to become a woman (not merely in role)
That his penis or testes are disgusting or will disappear
That it would be better not to have a penis or testes.
CC..The boy has not yet reached puberty.
DD..The disorder must have been present for at least six months.
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hypothesis for the etiology of gender identity disorders,
in which these are caused by hormone resistance restricted
to the brain (10, 11). In addition, neuroanatomical find-
ings in the dichotomous brain nuclei of transsexual pa-
tients provide further evidence for a biological component
in the complex etiology of GID (12). Contrary to earlier
assumptions, gender identity cannot be changed by
external influences alone, i.e., attempts at so-called
"re-education," even when these attempts are begun as
early as the first year of life (13); this implies an early,
somatic determination of gender identity. Moreover,
because bodily and genital sensations exert a major effect
on psychosexual and gender-identity development, one
must assume that the overall process involves an inter-
action of biological and psychosocial factors. Etiological
and pathological influences should thus be sought in
both areas (e10).
Multiple publications have concerned a possible trau-
matic etiology of gender identity disorders (14) and an
overlap of the psychopathological findings in GID with
those of borderline personality disorder (15, e11, e12,
e13), although there is some controversy on the latter
point (16). A profound disturbance of the mother-child
relationship can often be empirically demonstrated and
is postulated to be a causative factor (e14). The desire to
belong to the opposite sex is held to be a compensatory
pattern of response to trauma. In boys, it is said to represent
an attempt to repair the defective relationship with the
physically or emotionally absent primary attachment
figure through fantasy; the boy tries to imitate his missing
mother as the result of confusion between the two
concepts of having a mother and being one (e15). In girls,
the postulated motivation for gender (role) switching is
the child's need to protect herself and her mother from a
violent father by acquiring masculine strength for her-
self (e16).
Other authors, in line with psychoanalytic theory, do
not attribute the desire to belong to the opposite sex to
any prior trauma. Rather, they postulate the formation of
a classic neurotic compromise, in which the child sym-
bolically achieves a symbiotic fusion with the loved
parent by switching genders (15, e17, e18). Excessive
identification with the opposite sex is said to help affected
boys cope with fears of loss of maternal attention (17,
e19, e20), while affected girls are said to identify with
their fathers in order to compensate for a relationship
with their mothers that they perceive to be deficient
(18).
From the perspective of developmental psychology,
psychopathology, and psychiatry, such maladaptive
reactions can be seen as failed attempts to fulfill particular
developmental tasks: separation from parents, establish-
ment of an individual identity, and attainment of sexual
maturity. Some adolescents, meanwhile, seem to view a
gender switch as a universal problem-solving strategy
when confronted by other, totally different developmental
tasks, bearing no relation to the establishment of sexual
identity, that they perceive as insurmountable. It seems
clear that the manner of psychological processing of
conflicts and traumatic experiences can be expected to
vary greatly from one child or adolescent to another,
depending to a major extent on temperamental factors
and on the developmental stage that the individual's
cognitive, emotional, and social skills have reached (19).
Learning theory and concepts derived from it tend to
favor a causative model in which the primary attach-
ment figure(s) is (are) postulated to exert an exogenous-
reinforcing, active-manipulative effect on the develop-
ment of features typifying the opposite sex. This explan-
atory approach ascribes primary importance to a desire
on the parent's part for the child to be of the opposite sex
(3). A high rate of psychological abnormalities in the
parents of children with GID has been reported in more
than one study (20, 21). It is essential, therefore, to
explore thoroughly the psychopathology of the child's
attachment figures and their "sexual world view,"
including any sexually traumatizing experiences they
may have undergone, in order to discover any potential
"transsexualogenic influences." The same holds for
overarching sociocultural variables. Presentations cur-
rently appearing in the mass media of ever younger
patients describing their treatment in euphoric terms are
a cause for concern. Two further reasons for the rising
demand for sex changes among minors would appear to
be the "feasibility delusion"—the notion that modern
medicine can effect a sex change with no problem at
all—and a tendency to view the choice of one's own sex
as a type of fundamental right (e10).
Current scientific controversies:
different treatment strategies
A review of the scientific literature reveals two different
scientific positions leading to different approaches to
treatment.
BOX 3
ICD-10 F64: Gender Identity Disorders
(except F64.2 ©see box 2)
FF6644..00 TTrraannsssseexxuuaalliissmm
AA..Desire to live and be accepted as a member of the opposite sex,
usually accompanied by the wish to make one's body as congruent as
possible with one's preferred sex through surgery and hormone treat-
ment.
BB..Presence of the transsexual identity for at least two years persistently.
CC..The disorder is not a symptom of another mental disorder, such as
schizophrenia, or associated with chromosomal abnormality.
FF6644..11 DDuuaall--rroollee ttrraannssvveessttiissmm
AA..Wearing clothes of the opposite sex in order to experience temporary
membership of the opposite sex.
BB..Absence of any sexual motivation for the cross-dressing.
CC..Absence of any desire for a permanent change to the opposite sex.
FF6644..88 OOtthheerr ggeennddeerr iiddeennt
tiittyy ddiissoorrddeerrss
FF6644..99 GGeennddeerr iiddeennttiittyy ddiissoorrddeerr,, uunnssppeecciiffiieedd
No specific criteria are defined for these diagnoses.
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>Multiple longitudinal studies provide evidence that
gender-atypical behavior in childhood often leads
to a homosexual orientation in adulthood, but only
in 2.5% to 20% of cases to a persistent gender iden-
tity disorder (3, 6, 22). Even among children who
manifest a major degree of discomfort with their
own sex, including an aversion to their own genitalia
(GID in the strict sense), only a minority go on to an
irreversible development of transsexualism (6).
Irreversibility of the manifestations, however, is
considered to be an indispensable requirement
before the diagnosis of transsexualism can be ma-
de, or any body-altering treatments initiated. In
England and Canada, in accordance with this view,
hormonal treatment or surgery is not recommended
until the patient's somatic and psychosexual devel-
opment is complete.
>In other countries, however, the opinion prevails
that it is appropriate to use LHRH (luteinizing hor-
mone-releasing hormone) analogues, which block
gonadotropin secretion and secondarily inhibit the
sex steroids, for diagnosis and treatment (23).
Using LHRH analogues is held to give the patient
time to assess whether GID will persist, and to
prevent the irreversible somatic changes
corresponding to the sex of birth (particularly voice
breaking and beard growth). This is supposed to
bring relief and prevent psychiatric comorbidity
(24). According to the standards of the Harry Ben-
jamin International Gender Dysphoria Association
(2001), "completely reversible" gonadotropin
blockade is to be followed in a second and a third
phase by "partially reversible" (estrogen/testosterone
therapy) and irreversible surgical interventions
(e2). The elevated risk of misdiagnosis if treatment
is begun early is considered to be acceptable in
view of the putatively better results of treatment for
correct indications (e21). In the Netherlands, the
minimal age for hormone therapy has been set at 12
years (e22).
The guidelines of the British Royal College of Psy-
chiatrists (1998) (e5) and, analogously, those of the Ger-
man Society for Child and Adolescent Psychiatry and
Psychotherapy (2007) generally recommend against treat-
ment with hormones of the opposite sex before the patient's
16th birthday, yet they support the administration of
(reversible) sex-steroid inhibitors at much earlier ages
in rare, individual cases (25).
A relevant criticism of this approach is that the appro-
priate criterion for judgments of this type is the patient's
biological, rather than chronological, age. Physical and
psychosexual development are already complete in some
individuals by age 16, but most adolescents at this age
are still in the process of establishing their sexual identity,
and the diagnostic and therapeutic approach should
accompany this process rather than overwhelm it. The
authors have currently based their own approach on these
considerations, working in a special interdisciplinary
clinic for GID that was established in 2007 at the Charité
Hospital in Berlin and that involves experts in adolescent
psychiatry, sexual medicine, and pediatric endocrinology.
All of the 21 patients who received a new diagnosis of
GID in our clinic up to mid-2008 (aged 5 to 17; 12 boys,
9 girls) had psychopathological abnormalities that, in
many cases, led to the diagnosis of additional psychiatric
disorders. As a rule, there were also major psychopatho-
logical abnormalities in their parents. The "motive for
switching" among the 15 adolescents in the group was
mainly a rejected (egodystonic) homosexual orientation
(see figure), the development of which would have been
arrested by puberty-blocking treatments.
The pros and cons of early hormonal therapy
Among the arguments in favor of early hormonal therapy
are some that are beyond dispute and others of which the
authors take a critical view. It is said that:
>Suppression of further somatosexual development
rapidly alleviates the patient's suffering.
>If puberty-blocking treatments and opposite-sex
hormones are given early, then a sex-change opera-
tion performed later on in life will have a better cos-
metic result.
Possible courses of GID of childhood (F64.2) and differential diagnoses in adolescence. Except
for the intersex syndromes and faulty recognition of gender identity in the setting of a psychotic
illness (i.e., a schizophrenic, schizotypic,or delusional disorder), many of the differential diag-
noses can only be confirmed or excluded in the course of the diagnostic and therapeutic process,
once the patient's sexual preference structure has been elucidated.
FIGURE
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>The patient's psychosocial and sexual functioning
will improve, and psychiatric comorbidity will be
prevented.
In addition to these arguments, most advocates of early
hormonal intervention assert that the effects of puberty-
blocking treatment are totally reversible. This is true,
however, only with respect to its physical effects, not
with respect to the irreversible damage it does to the pro-
cess of psychosexual development.
The counterargument to the claimed advantages of
puberty-blocking treatment consists of the following
disadvantages:
>A treatment of this kind changes the individual's
sexual experience both in fantasy and in behavior.
It restricts sexual appetite and functionality and
thereby prevents the individual from having age-
appropriate (socio-)sexual experiences that he or
she can then evaluate in the framework of the diag-
nostic-therapeutic process. As a result, it becomes
nearly impossible to discover the sexual preference
structure and ultimate gender identity developing
under the influence of the native sex hormones
(e10).
>Experience has shown that, in not a few cases, a
strongly and resolutely asserted desire to change to
the opposite sex becomes markedly neutralized
over the course of time, and the individual later
undergoes a homosexual "coming-out" (1, 3). In
view of this fact, it must be understood that early
hormone therapy may interfere with the patient's
development as a homosexual. This may not be in
the interest of patients who, as a result of hormone
therapy, can no longer have the decisive experiences
that enable them to establish a homosexual identity.
>The parents' psychological abnormalities (20) and
their effect on the child can promote the consolida-
tion of GIS (21). All psychodynamically relevant
conflicts and "transsexualogenic" factors that may
be present should be thoroughly analyzed and worked
through in psychotherapy or family therapy;
indeed, when this is done, there is a real chance that
the patient will, in the end, no longer a desire a sex
change. If a purely biologistic approach is taken
and a "rapid solution" with hormone therapy is
initiated too early, these important aspects of the
diagnostic and therapeutic process are likely to fall
by the wayside.
>It is not known with any certainty at present how
hormone therapy before the end of puberty might
affect the further development of gender identity, or
to what extent it might even iatrogenically induce
persistence of GID. Thus, even in a case of treat-
ment retrospectively judged to have been success-
ful, one cannot necessarily assume that the patient's
transsexualism was a predetermined matter at the
outset.
>Children and adolescents generally lack the emo-
tional and cognitive maturity needed to consent to a
treatment that will have lifelong consequences. The
fact must be taken into account that children with
GID have an above average prevalence of deficient
social skills, behavioral abnormalities, and psy-
chiatric comorbidities (5, 8) and are therefore par-
ticularly susceptible to the temptation of a supposedly
rapid solution to all of their problems.
Conclusions
The diagnosis and treatment of gender identity disorders
in childhood and adolescence falls within the expertise
of child and adolescent psychiatrists, who should,
however, regularly call upon the expertise of colleagues
in sexual medicine and pediatric endocrinology. Patients
should not be forced into theoretical constructs; on the
contrary, rather, the currently debated pathogenetic con-
cepts and attributions of causality should be critically
evaluated in each individual case. It thus seems permis-
sible, or even necessary, to make use of multiple explan-
atory approaches at the same time and to incorporate
these into clinical therapeutic work. Family dynamic
factors, in particular, have implications for treatment.
In the authors' view, development inhibiting (LHRH
analogues) or body altering (estrogens/androgens) hor-
mone therapy should not be initiated before the patient's
psychosexual development is complete, in view of the
current lack of scientific data on these forms of treat-
ment and the potential danger of aggravating a gender
identity disorder. Somatosexual maturity is attained by
girls at the menarche and by boys at the time of the first
ejaculation; in either sex, the age at which this occurs is
highly variable, ranging from 11 to 16 years. Conse-
quently, there is also a great deal of variation with respect
to the time at which psychosexual development can be
said to be complete, and this is the relevant time for
decision-making about hormone therapy.
The critical question of the determination of maturity
and the linked question of establishing the indication for
hormonal interventions are therefore not merely a matter
of biological age. Rather, they must be answered on an
individual basis for each patient, and in a process that is
fundamentally interdisciplinary. There are no simple
criteria, however, by which the completion of psycho-
sexual development can be defined. The available
empirical data on partner-oriented sociosexual develop-
mental steps are not suitable for this purpose; they do
make clear, though, that by age 17 (for example) one-
third of adolescents have not yet had any experience of
genital petting or coital intimacy (e23).
A uniform interdisciplinary approach to the care of
children and adolescents with GID all across Germany
is an important objective for the future. Once this has
been accomplished, a multicenter study can be performed
to put the care of these patients on a broader empirical
basis. The primary objective must be to obtain a scientif-
ically grounded answer, based on observations on the
further developmental course of young patients who
have established their sexual identities under the accom-
paniment of psychotherapy, to the question whether the
early initiation of puberty-blocking or opposite-sex hor-
monal treatments might be appropriate—if not for all
patients, then at least for a well-defined subgroup.
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Conflict of interest statement
The authors declare that no conflict of interest exists as defined by the guide-
lines of the International Committee of Medical Journal Editors.
Manuscript submitted on 19 March 2008; revised version accepted on
15 October 2008.
Translated from the original German by Ethan Taub, M.D.
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Key messages
Gender identity disorders
in childhood and adolescence
>Gender identity disorders of childhood (ICD-10 F64.2,
DSM-IV 302.6) are only rarely the initial manifestation
of a transsexual development (in 2.5% to 20% of
cases). Nonetheless, because of the severe social
isolation that they cause, they are often associated with
a considerable degree of emotional stress for the
affected children (and their parents), as well as with
a high psychiatric comorbidity, especially disturbances
of affective and social behavior that require treatment.
The presence of intersexual anomalies must be ruled
out on clinical, genetic, and endocrinological grounds.
>The course of GID is highly variable and plastic. Gender
identity disorders are often the forerunner of a homosexual
orientation. In adolescence, the main differential
diagnoses are sexual maturation disorder (ICD-10
F66.0) and a rejected (repressed or denied) egodystonic
homosexual orientation (ICD-10 F66.1), as well as
fetishistic transvestism (ICD-10 F65.1), severe personality
disorders, and—less commonly—psychotic disorders.
>The guiding principle for the treatment of children with
gender identity disorder is strengthening the patient's
feeling of belonging to the gender of birth without
placing a negative value on his or her atypical gender-
role behavior.The child's parents, and usually also the
school or kindergarten, must be involved in the
treatment, and any comorbid psychiatric disorders must
be dealt with appropriately as well.
>Adolescents should be treated in a diagnostic and
therapeutic process that is open to multiple outcomes,
utilizing the concepts of adolescent psychiatry and
sexual medicine. This will enable the affected adolescents
to resolve their own identity conflicts. The treating
physician should assess the degree of persistence of
the patient's desire for a gender transformation while
paying special attention to other unresolved developmental
tasks and/or conflicts aside from the specific problem of
GID.
>The diagnosis of a transsexual, i.e., irreversible,GID is
permissible only when the individual's psychosexual
development is complete and after his or her sexual
preference structure has been elucidated. A further
prerequisite is that the sexual preference structure must
have become established without any influence from
extraneous hormones. It follows that the use of puberty-
inhibiting LHRH analogues or sex steroids of the opposite
sex during adolescence, at any chronological age,
would seem to be appropriate only in rare cases for
strict indications, when it is certain that nascent
transsexualism is the correct diagnosis.
841 Deutsches Ärzteblatt InternationalDtsch Arztebl Int 2008; 105(48): 834–41
MEDICINE
21. Cohen-Kettenis PT, Gooren LJ:Transsexualism: a review of etiology,
diagnosis and treatment. J Psychosom Res 1999; 46: 315–33.
22. Drummond KD, Bradley SJ,Peterson-Badali M, Zucker KJ:A follow-
up study of girls with gender identity disorder. Developmental
Psychology 2008; 44: 34–45.
23. Cohen-Kettenis PT, van Goozen SH: Pubertal delay as an aid in
diagnosis and treatment of a transsexual adolescent. Eur Child
Adolesc Psychiatry 1998; 7: 246–8.
24. Cohen-Kettenis PT, van Goozen SH: Sex reassignment of adoles-
cent transsexuals: a follow-up study.J Am Acad Child Adolesc
Psychiatry 1997; 36: 263–71.
25. Meyenburg B: Störungen der Geschlechtsidentität (F64) sowie der
sexuellen Entwicklung und Orientierung (F66). Leitlinien der Deut-
schen Gesellschaft für Kinder- und Jugendpsychiatrie und -psycho-
therapie 2007; 167–78.
Corresponding author
Dr.med. Alexander Korte
Klinik für Psychiatrie, Psychosomatik und Psychotherapie
des Kindes- und Jugendalters
Charité-Universitätsmedizin (CVK)
Augustenburger Platz 1
13353 Berlin, Germany
alexander.korte@charite.de
For e-references please see:
www.aerzteblatt-international.de/ref4808
@
Deutsches Ärzteblatt InternationalDtsch Arztebl Int 2008; 105(48):Korte et al.:e-references I
MEDICINE
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REVIEW ARTICLE
Gender Identity Disorders
in Childhood and Adolescence
Currently Debated Concepts and Treatment Strategies
Alexander Korte, David Goecker, Heiko Krude, Ulrike Lehmkuhl,
Annette Grüters-Kieslich, Klaus Michael Beier
... Arguments against the use of GnRHa that have been raised include possible long-term adverse effects on health, psychological, and sexual functioning (Laidlaw, Cretella, & Donovan, 2019;Richards, Maxwell, & McCune, 2019;Vrouenraets et al., 2015). Some state that adolescents may be unable to make far-reaching decisions at a young age, especially in the presence of comorbid psychiatric conditions, which are common among youth with gender dysphoria (Korte et al., 2008;Laidlaw et al., 2019;Vrouenraets et al., 2015). Furthermore, gender identity develops and may change during adolescence. ...
... Furthermore, gender identity develops and may change during adolescence. Concerns have been raised that the use of GnRHa may influence this process and might increase the likelihood of persistence of gender dysphoria (Korte et al., 2008;Laidlaw et al., 2019;Richards et al., 2019;Stein, 2012;Vrouenraets et al., 2015). It is unknown if the use of GnRHa prevents resolution of gender dysphoria (Korte et al., 2008). ...
... Concerns have been raised that the use of GnRHa may influence this process and might increase the likelihood of persistence of gender dysphoria (Korte et al., 2008;Laidlaw et al., 2019;Richards et al., 2019;Stein, 2012;Vrouenraets et al., 2015). It is unknown if the use of GnRHa prevents resolution of gender dysphoria (Korte et al., 2008). Many prepubertal children with gender dysphoria no longer experience gender dysphoria in adolescence, and the experience of romantic and sexual attraction is thought to play an important role in this process (Steensma, Biemond, de Boer, & Cohen-Kettenis, 2011). ...
Article
Full-text available
Gonadotropin-releasing hormone analogues (GnRHa) are recommended as initial treatment for adolescents diagnosed with gender dysphoria, providing time to follow gender identity development and consider further treatment wishes without distress caused by unwanted pubertal changes. This has been described as an extended diagnostic phase. However, there are also concerns about the physical, neurocognitive, and psychosocial effects of this treatment. In this retrospective study, we document trajectories after the initiation of GnRHa and explore reasons for extended use and discontinuation of GnRHa. Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys; median age, 15.0 years [range, 11.1–18.6] and 16.1 years [range, 10.1–17.9]). After a median duration of 0.8 years (0.3–3.8) on GnRHa, 125 (87%) started gender-affirming hormones (GAH). Nine (6%) discontinued GnRHa, five of whom no longer wished gender-affirming treatment. Thirteen had used GnRHa for longer than required by protocol for reasons other than logistics and regularly met with a mental health professional during this time, supporting the use of GnRHa treatment as an extended diagnostic phase. In conclusion, the vast majority who started GnRHa proceeded to GAH, possibly due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment. Due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome. Few individuals discontinued GnRHa, and only 3.5% no longer wished gender-affirming treatment.
... At the same time, it is striking that these medical media hardly represent the topic of trans* among children and adolescents. In the "Deutsches Ärzteblatt", there was precisely one article on the topic (Korte et al., 2008) as well as two letters to the editor (Jacobeit and Wüsthof, 2009) and a reply to the latter by the primary author (Korte, 2009). This one article vehemently represents the conservative position. ...
Chapter
In this chapter, we analyse the discourse on the medical treatment of transgender adolescents in the German print media. Using the example of the controversy about puberty blockers, we show how conservative positions portray deviations from the cis-normative gender order as a "fashion" and "zeitgeist phenomenon" and thus attempt to delegitimise accepting treatment that is oriented towards the needs of adolescents and represents the current state of medical research.
... The rate of regret, detransition, and desistance from transgender identification is largely unknown (Butler & Hutchinson, 2020). The majority of patients with classical, childhoodonset gender dysphoria (61%-98%) desist from transgender identification some time in adolescence or young adulthood (Korte et al., 2008;Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013;Zucker, 2018). The minority who persist with their transgender identification into adulthood and undergo "gender-affirmative" surgeries have been reported to have low rates of regret (van de Grift, Elaut, Cerwenka, Cohen-Kettenis, & Kreukels, 2018) and detransition (Dhejne, Öberg, Arver, & Landén, 2014). ...
... While there is a growing acceptance of treating adults who present for transition, the meaning and approach to gender variance in children and adolescents is more controversial. It is beyond the scope of this paper to review those issues (see Bartlett, Vasey, & Bukowski, 2000;Cohen-Kettenis & Pfäfflin, 2009;Corbett 1996Corbett , 1998Ehrbar, Witty, Ehrbar, & Bockting, 2008;Hill et al., 2007;Isay, 1997;Kennedy, 2008;Korte et al., 2008;Menvielle, Tuerk, & Perrin, 2005;Möller, Schreier, Li, & Romer, 2009;Richardson, 1996Richardson, , 1999Wallien & Cohen-Kettenis, 2008;Zucker, 2008aZucker, , 2008bZucker, , 2009 but it is worth highlighting some of them. ...
... Staphorsius et al. [52] investigated the effects of puberty blockers on executive functioning (EF), studying the performance of adolescents treated with GnRH analogs at the Tower of London task (ToL) and found no significant differences compared to nontreated adolescents. Nonetheless, many professionals working with gender-variant youth remain critical about the use of puberty suppression because of the lack of studies on the long-term physical and psychological outcomes [53,54], and concerns have been raised about the risk of making incorrect treatment decisions, as gender identity often fluctuates during adolescence. Moreover, adolescents might have poor decision-making abilities, especially regarding future developmental effects of puberty suppression such as the hindering of fertility preservation [ [51,55]; see also [46] ]. ...
Article
Full-text available
Purpose In recent years, an increasing number of specialized gender clinics have been prescribing gonadotropin-releasing hormone (GnRH) analogs to adolescents diagnosed with gender dysphoria (GD) to suppress puberty. This paper presents qualitative research on the hormone therapy (HT) experiences of older trans-people and their views on puberty suppression. The main aim of this research was to explore the psychological aspects of hormonal treatments for gender non-conforming adults, including the controversial use of puberty suppression treatments. Methods Using a semi-structured interview format, ten adult trans-women were interviewed (mean age: 37.4) to explore their personal histories regarding GD onset and development, their HT experiences, and their views on the use of GnRH analogs to suppress puberty in trans-children and adolescents. Results: the interview transcripts were analyzed using the consensual qualitative research method from which several themes emerged: the onset of GD, childhood experiences, experiences with puberty and HT, views on the puberty suspension procedure, and the effects of this suspension on gender identity and sexuality. Conclusions The interviews showed that overall, the participants valued the new treatment protocol due to the opportunity to prevent the severe body dysphoria and social phobia trans-people experience with puberty. It seems that the risk of social isolation and psychological suffering is increased by the general lack of acceptance and stigma toward trans-identities in the Italian society. However, during gender transitions, they highlight the need to focus more on internal and psychological aspects, rather than over-emphasize physical appearance. This study gives a voice to an under-represented group regarding the use of GnRH analogs to suppress puberty in trans-individuals, and collected firsthand insights on this controversial treatment and its recommendations in professional international guidelines.
... The Dutch protocol is largely used, but it has its critics. [33][34][35] Controversy regarding the use of drugs for puberty touches on fundamental ethical concepts in pediatrics: the best interests of the minor, autonomy and the role of social context. Professionals recognize the distress of young people with GD and feel an urge to treat them. ...
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Riittakerttu Kaltiala-Heino,1–3 Hannah Bergman,4 Marja Työläjärvi,2 Louise Frisén4 1Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland; 2Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland; 3Vanha Vaasa Hospital, Vaasa, Finland; 4Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Abstract: Increasing numbers of adolescents are seeking treatment at gender identity services in Western countries. An increasingly accepted treatment model that includes puberty suppression with gonadotropin-releasing hormone analogs starting during the early stages of puberty, cross-sex hormonal treatment starting at ~16 years of age and possibly surgical treatments in legal adulthood, is often indicated for adolescents with childhood gender dysphoria (GD) that intensifies during puberty. However, virtually nothing is known regarding adolescent-onset GD, its progression and factors that influence the completion of the developmental tasks of adolescence among young people with GD and/or transgender identity. Consolidation of identity development is a central developmental goal of adolescence, but we still do not know enough about how gender identity and gender variance actually evolve. Treatment-seeking adolescents with GD present with considerable psychiatric comorbidity. There is little research on how GD and/or transgender identity are associated with completion of developmental tasks of adolescence. Keywords: gender dysphoria, gender identity, adolescence, developmental tasks
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A discussion of "The Transsexual Wish in a Psychotic Character" by Katherine MacVicar, M.D. Patients in increasing numbers are seeking sex-reassignment surgery. The topic receives coverage in both the lay and professional press; many advocate surgery as the only "cure". Clinical study reveals that these patients have borderline personality organization and are seeking to discard bad and aggressive features and to replace them with a new idealized perfection. Surgical procedures in these cases can usefully be conceptualized as a new type of psychosurgery.
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This paper touches on two issues that have been disputed by child analysts: the genesis of the transsexual symptom complex, and the question of transference neurosis in child analysis. My observation, as reported previously (Loeb and Shane, 1980) and shown in the present case, is that the transsexual symptom complex can develop out of intrapsychic conflict and can be resolved in a fully developed transference neurosis. In the analysis of a four-and-a-half-year-old boy with transsexual symptoms, I was abstinent--not benevolent or supportive--and both positive and negative transference feelings developed into a full-blown transference neurosis. Then, as I interpreted its elements, we worked through his conflicts, which manifested themselves as acting out of his identification with his aggressive, seductive, and castrating grandmother. As he came to understand his conflicts, the boy's transsexual symptoms vanished.
Article
A three-year, nine-month-old boy began analysis by wishing he was a girl and pretending he was a superheroine. Over the course of almost five years, the cross-gender defense against fear of loss of the object, anal loss, and castration by the object reorganized in all libidinal phases through early latency. Developmental arrests seemed to occur during the anal rapprochement and oedipal phases that led to observable cross-gender strivings by two and a half years of age. The role of early childhood illness, narcissistic vulnerability, mother's childhood wish for a sister, the mother's adult wish for a daughter, a shared fantasy between mother and child, identification with the perceived power and beauty of mother and grandmother, pathological sibling rivalry that influenced identification with his sister, were demonstrated in his play during sessions. Interwoven in the background was the impact of an emotionally absent father, a dying grandfather, and an accident-prone uncle. This paternal matrix seemed to discourage budding masculinity and encourage feminine identifications. The analyst's approach and the child's responses to interpretation of the transference manifestations, cross-gender behavior, fantasies, and play are presented. Finally, the gradual resolution of the conflicted wish to be a girl was supplanted by the emergence of appropriate gender identification. A two-year followup appeared to confirm his postanalytic gender stance and continuing consolidation of stable gender development.