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Geschlechtsidentitätsstörungen (Geschlechtsdysphorie) und deren Behandlung im Kindes- und Jugendalter
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Kinder und Jugendliche mit einer Geschlechtsdysphorie, die an spezialisierten Ambulanzen vorstellig werden und eine medizinische Behandlung ersuchen, stellen eine heterogene klinische Population dar. Manche der Betroffenen weisen neben der Geschlechtsdysphorie zusätzlich komorbide psychiatrische Störungsbilder unterschiedlichen Schweregrads auf. Der vorliegende Artikel widmet sich in diesem Zusammenhang den komplexen behandlungstechnischen Herausforderungen, die sich bei Jugendlichen mit Geschlechtsdysphorie und Persönlichkeitspathologien ergeben. Wir stellen die Kasuistik eines 18-jährigen Jugendlichen vor, um davon ausgehend die differenzialdiagnostische Komplexität und die Problemstellung im Hinblick auf Behandlungsentscheidungen zu veranschaulichen. Von zentraler Bedeutung in unserer anschließenden Diskussion ist die Rolle der Psychotherapie in der Behandlung dieser jungen Menschen. Wir argumentieren für eine ergebnisoffene Psychotherapie als wesentlicher Bestandteil der Behandlung und diskutieren die ethischen Abwägungen in diesem Zusammenhang.
Gender identity disorder (GID), gender dysphoria (GD) respectively, is considered a multifactorial disease whose etiology is subject to complex bio-psycho-social conditions, each with different weighting. As a result, therapists, who treat children and adolescents with GID/GD, have to deal with a very heterogeneous group with individually varying causes, differing psychopathology and varying disease progression. In addition to general psychiatric aspects of development, particularly psychiatric comorbidity, but also the different individual psychodynamics – i. e. the specific constellation of conflicts and possible ego deficits and structural deficits in the learning history of the person are of differential importance. In regard to the indication for gender reassignment measures this sometimes is relevant for the decision. The difficulties arising for decision making and the usefulness of a systematic evaluation of case reports as a basis for further optimization of the treatment recommendations are illustrated by two case reports. In the course of this, also the disadvantages and potential dangers of too early diagnostic definition and introduction of gender somato-medical and legal measures are shown exemplarily.
Almost 50 years of clinical observation and research on children with gender identity disorder have provided useful information on phenomenology, diagnostic and assessment procedures, associated psychopathology, tests of etiological hypotheses, and natural history. In contrast, best practice guidelines and evidence-based therapeutics have lagged sorely behind these other domains. Accordingly, the therapist must rely on the “clinical wisdom” that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions. Because of this state of affairs, dogmatic assertions about best practice should be avoided.
Objective:
To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
Method:
The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
Results:
We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
Conclusion:
Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
The study by Wallien and Cohen-Kettenis 7 needs to be contextualized in this specialty area’s small history. In the 1960s, when the phenomenon of transsexualism (a term that preceded the use of the GID acronym) in adults started to attract clinical attention, a number of medical centers in the United States and elsewhere established specialty clinics for these patients to provide recommendations and guidelines for the advisability of hormonal and surgical sex reassignment. At the time, an important part of the patients’ narrative history was that the origins of their gender dysphoria (the felt sense of incongruity between one’s gender identity and birth sex) was said to have begun in early childhood. In the 1960s, a team
Sexuelle Identität ins Grundgesetz? Recht &
- F Pfäfflin
Pfäfflin F. Sexuelle Identität ins Grundgesetz? Recht & Psychiatrie 2010; 28: 123 – 131