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Gender incongruence of childhood in the ICD-11: Controversies, proposal, and rationale
Abstract
As part of the development of the eleventh revision of the International Classification of Diseases (ICD-11), WHO appointed a Working Group on Sexual Disorders and Sexual Health to recommend changes necessary in the classification of mental and behavioural disorders in ICD-10 that are related to sexuality and gender identity. This Personal View focuses on the Working Group’s proposals to include the diagnosis gender incongruence of childhood in ICD-11 and to move gender incongruence of childhood out of the mental and behavioural disorders chapter of ICD-11. We outline the history of ICD and DSM child gender diagnoses, expert consensus, knowledge gaps, and controversies related to the diagnosis and treatment of extremely gender-variant children. We argue that retaining the gender incongruence of childhood category is justified as a basis to structure clinical care and to ensure access to appropriate services for this vulnerable population, which provides opportunities for education and informed consent, the development of standards and pathways of care to help guide clinicians and family members, and a basis for future research efforts.
... È da notare che nel DSM IV-TR la diagnosi di DIG presuppone che la persona esperisca un "disagio clinicamente significativo e compromissione di importanti aree del funzionamento della persona" (DSM IV-TR), di conseguenza la diagnosi non è proponibile per coloro che sono a proprio agio nel percepirsi come membri di sesso opposto. La Tabella 1.1 (Drescher et al., 2016) mostra un riepilogo delle diagnosi nelle diverse edizioni. ...
... Per l'ulteriore aggiornamento della nuova edizione, l'OMS ha voluto richiamare un team di esperti che andasse a formare il Working Group on Classification of Sexual Disorders and Sexual Health (WGSDSH) che si occupasse di aggiornare le categorie diagnostiche e decidere se inserire, cambiare o eliminare le precedenti categorie anche nell'ICD-11. Il gruppo ha compiuto una revisione estesa della letteratura scientifica si è espresso a favore del mantenimento della diagnosi, con il nome di "Incongruenza di genere", rimuovendola però dal capitolo dei disturbi mentali e del comportamento (Drescher et al., 2012;Drescher, Cohen-Kettenis, & Reed, 2016). Tuttavia, il percorso per arrivare a questa scelta non è stato privo di controversie e accesi dibattiti. ...
... Il dibattito sulla necessità di una diagnosi risale all'inizio degli anni '90, a seguito delle prime voci critiche contro le diagnosi per l'identità di genere in generale, e nello specifico per l'infanzia (Drescher et al., 2016). ...
Gender transition of adolescents and young people
... 2 Classification systems related to transgender identity have been controversial. [3][4][5] This controversy must be understood in the context of serious health disparities, poor access to health services, and experiences of violence and systematic discrimination among transgender people around the world. 6,7 Brazil, unfortunately, is challenged by the same difficulties, despite advances in social acceptance and efforts from many social and political groups to change the way the transgender people are seen. ...
... [6][7][8] There are two main reasons for this: 1) If the transgender condition was considered a mental disorder, it must be treated by psychiatric specialists exclusively, justifying denial of coverage for other related medical services by governments and private healthcare insurance companies; and 2) If the transgender condition was considered a mental disorder, some governments may deny transgender individuals self-determination and decision-making capacity to change legal documents, child custody, and reproduction. 3,4,[6][7][8] Therefore, the WHO Working Group on Sexual Disorders and Sexual Health, comprising experts from all WHO regions, recommended not just renaming (as gender incongruence) and re-conceptualizing these categories in a less stigmatizing manner, but also moving them out of the chapter on Mental and Behavioral Disorders to a new chapter on Sexual Disorders and Conditions Related to Sexual Health in the ICD-11. ...
... The WHO's recent report on Sexual Health, Human Rights, and the Law 20 described how poor access to accurate information and appropriate health services can provoke serious behavioral and mental health consequences for transgender people, including increased HIV contamination, anxiety, depression, substance abuse, and suicide. 3,4,21,22 It seems clear that Brazilian society ought to improve its tolerance and acceptance of gender and sexual diversity. 23 It is hoped that part of this change, as far as policies are concerned, will include reformulating the diagnostic guidelines that naturalize the transgender condition, without diminishing the rights that have already been acquired regarding access to clinical procedures. ...
Objective:
To describe self-reported experiences of gender incongruence related to discomfort and body changes to be more congruent to the desired gender, and to examine whether experiences of psychological distress related to gender identity were more strongly related to the experience of gender incongruence per se or to experiences of social rejection.
Methods:
This field study used a structured interview design in a purposive sample of transgender adults (aged >18 years or older) receiving health-care services in two main reference centers in Brazil.
Results:
A high proportion of participants (90.3%, n=93) reported experiencing psychological distress related to their gender identity and report having experienced social rejection related to their gender identity during the interview index period and that rejection by friends was the only significant predictor for psychological distress.
Conclusions:
Gender incongruence variables were not significant predictors of distress. This result supports the recent changes proposed by the Word Health Organization in ICD-11 to move transgender conditions from the Mental and Behavioral Disorders chapter to a new chapter on Sexual Disorders and Conditions Related to Sexual Health.
... Wobec powyższego ICD-11 jest w tym aspekcie bardziej użyteczne klinicznie, bo obejmuje oba warianty. O ile zmiany w ICD odnoszące się do młodzieży i osób dorosłych nie budzą wielu kontrowersji, o tyle utrzymanie i brzmienie diagnozy niezgodności płciowej w dzieciństwie nie spotkało się z pozytywnym odbiorem (Drescher, Cohen-Kettenis, Reed, 2016;Winter i in., 2017). Przeciwnicy takiego rozwiązania wyrażają obawę o patologizowanie nienormatywnej ekspresji u dzieci w wieku przedpokwitaniowym oraz o wprowadzanie pacjentów i rodziców w błąd: skoro istnieje diagnoza, istnieje także leczenie -np. ...
... Głosy przeciw koncentrują się wokół niepotrzebnej medykalizacji różnorodności płciowej w wieku, w którym i tak nie stosuje się żadnych interwencji medycznych mogących wymagać refundacji, zatem diagnoza nie warunkuje dostępu do leczenia profesjonalnego. Zasadność utrzymania rozpoznania motywowana jest koniecznością zapewnienia profesjonalnego wsparcia i edukacji dla rodziców oraz potrzebą wydzielenia tej subpopulacji dzieci nienormatywnych płciowo, dla których nie będzie to przemijający wariant rozwojowy i które doświadczają lub będą doświadczały z tego powodu dyskomfortu lub cierpienia (Drescher, Cohen-Kettenis, Reed, 2016). ...
Cel Celem artykułu jest omówienie ICD-11 pod kątem zmian, jakie zaszły w klasyfikacji wokół diagnoz związanych z tożsamością płciową. Metoda W tekście zwięźle przeanalizowano i omówiono zmiany dotyczące tożsamości płciowej w nowej klasyfikacji chorób pod kątem treści i języka oraz implikacji praktycznych i wymiaru społecznego. Wyniki Decyzja Światowej Organizacji Zdrowia o usunięciu transseksualizmu i utworzeniu nowej kategorii pod nazwą niezgodność płciowa w sekcji odrębnej niż choroby i zaburzenia psychiczne, była długo wyczekiwana przede wszystkim przez osoby specjalizujące się w zdrowiu psychicznym i seksualnym, ale także osoby pacjenckie przeżywające swoją płeć inaczej niż wynikałoby z przypisania przy urodzeniu.
... São avanços significativos, que contribuem para a diminuição do estigma enfrentado pelas pessoas transgêneros. O tema, contudo, ainda é permeado por muitos debates, principalmente por envolver aspectos que muitas vezes são percebidos desde a infância ou adolescência, e pela necessidade de políticas públicas para estruturar o atendimento e garantir acesso adequado dessa população aos cuidados da rede de atenção à saúde 5,6 . ...
... Apesar de esta perícia ter sido solicitada em um processo que foi iniciado antes da mudança ocorrida na lei brasileira 9 , muitas dúvidas e controvérsias ainda envolvem o tema. Questões relativas a direitos e deveres, como inscrição em concurso público, alistamento militar, participação em competições, previdência social, entre outras, ainda estão indefinidas, apesar das evoluções seguindo as tendências mundiais 5 . ...
O diagnóstico de disforia de gênero somente é feito após longo período, o qual é caracterizado por muito sofrimento psíquico e prejuízo funcional do indivíduo em diversos níveis. A saúde das pessoas transgênero não depende apenas de acompanhamento clínico adequado, mas também de um ambiente social e político que garanta a tolerância social, a igualdade de direitos e a cidadania plena. O objetivo deste relato é atualizar os termos em relação ao diagnóstico de disforia de gênero e incongruência de gênero, além de permitir uma reflexão sobre as dificuldades de abordar tais indivíduos, compreender o nível de sofrimento psíquico e a necessidade de perícia psiquiátrica, a qual poderá auxiliar o juiz na confirmação do diagnóstico de disforia de gênero e na exclusão de algum diagnóstico que poderia interferir na capacidade de decisão do paciente.
... 10 I later went on to write about the controversies surrounding the diagnosis and treatment of transgender children and adolescents. [10][11][12] A modest correction: the sky is not falling Evans begins with a warning that the numbers of people being referred or seeking treatment at gender clinics has risen dramatically in recent years. This is true; and why there has been such an increase in numbers is a question of scientific and clinical curiosity. ...
... The latter is a mental disorder in both DSM and ICD. In WHO's ICD-11, the diagnosis of gender incongruence is no longer a mental disorder 4,12,16 and historically, the literature on the treatment of the latter has absolutely nothing to do with the treatment of the former. ...
This opinion piece responds to Marcus Evans's ‘Freedom to Think’ regarding treating adolescents diagnosed with gender dysphoria (DSM)/gender incongruence (ICD). Evans notes not everything is known about GD/GI, particularly its ‘causes’. Although correct, he presents this fact as a rationale for delaying treatment for all children presenting with GD/GI symptoms. However, Marcus does not specify how long such prolonged evaluations should last nor does he have much of an evidence base to support his recommendation. This author believes delaying treatment for GD/GI adolescents who need it for the benefit of children who ‘aren’t really’ transgender is an ethically troubling issue.
... Il percorso di questa diagnosi non è stato privo di controversie. Il dibattito sulla necessità di una diagnosi risale all'inizio degli anni '90, quando si sono iniziate a sollevare le prime voci critiche, nello specifico per l'infanzia (Drescher, 2010;Drescher, Cohen-Kettenis, & Reed, 2016). In seguito all'inclusione nel DSm-III della diagnosi del disturbo dell'identità di genere per l'infanzia, ad esempio, la teorica queer/femminista Eve Kosofsky Sedgwick (1993) affermò che in quel modo si forniva una scappatoia per restaurare la diagnosi dell'omosessualità, rimossa dalla stessa edizione del DSm. ...
... La dicitura incongruenza è meno patologizzante di disforia, perché non implica automaticamente una sofferenza. Il motivo di questa scelta risiede nella necessità della presa in carico (Drescher et al., 2016). L'eliminazione della diagnosi, soprattutto per l'infanzia, esporrebbe le persone trans* a molti rischi per la salute: il suo mantenimento implica lo sviluppo di centri specialistici che aiutino le famiglie a comprendere meglio il fenomeno e promuove la necessità di un training specialistico per i professionisti della salute -spesso completamente all'oscuro di tali problematiche (es. ...
SommARIo.-Il lavoro ripercorre la storia dell'identità di genere, costrutto nato alla fine degli anni Sessanta, dalla creazione fino ad oggi. In particolare, il lavoro si occupa di quelle situa-zioni in cui una persona-appartenente a quello che comunemente viene definito il mondo trans*-vive una mancanza di corrispondenza tra il genere assegnato alla nascita e il genere esperito. Nello scritto si ripercorrono le strade che la diagnosi legata alla varianza di genere-in infanzia, adolescenza ed età adulta-ha conosciuto nel tempo e nelle diverse classifica-zioni diagnostiche, fino ad arrivare alla trattazione del tema in ambito psicoanalitico. Si mette in luce quanto accanto ad istanze più patologizzanti, sia l'ambiente psichiatrico, sia quello psicoanalitico si siano arricchiti di un pensiero teorico-clinico che valorizza e ricono-sce la profondità dell'esperienza soggettiva delle persone trans*, non fermandosi quindi, alla riduttiva indicazione della sola diagnosi. Parole chiave: Identità di genere; diagnosi; trans*; sesso; genere; psicoanalisi. Introduzione La storia delle persone transgender 1 è molto più antica e complessa di quella della sua diagnosi, ne troviamo tracce in molte culture e società del passato con alterne vicende. Solo nell'ultimo secolo però, con lo sviluppo della psichiatria, la cultura occidentale ha deciso di occuparsene portandone *Psicologo, psicoterapeuta, dottore di ricerca, socio SIPsIA, candidato SPI. Lavora presso l'
... In addition, the global analysis provided evidence that including distress in the diagnostic model would make it less effective [15]. Although pathologization is considered a form of discrimination [16], the WHO has decided to maintain it to protect services access [17]. This has been widely criticized by TGD associations demanding complete depathologization, especially for children [18]. ...
Transgender and gender diverse (TGD) individuals’ depsychopathologization in the
eleventh revision of the International Classification of Diseases (ICD-11) faces systemic discrim-
inations built-in epistemic pipelines. Based on an analysis of unexploited data from ICD-11 and the
French translation process, this article addresses power issues in participatory research and systemic
discrimination within a socio-cultural context. We used a peer-driven participatory approach to
conduct qualitative analyses of the French version of the ICD based on contributions from 72 TGD
participants in the French study for ICD-11. The results highlight a major incongruence between
participants’ propositions and the final official translation. Alternative terms were proposed and
discussed by participants in regard to usage and concepts, but also encompassed participation and
perceived futility of maintaining pathologization. We found discrepancies in the French publication
and translation processes, respectively on gender categorization and back translation. These results
question the relevance and implementation of ICD-11 for TGD communities and highlight failures at
all three stages of the official French translation. Power issues have an impact on knowledge produc-
tion and, while mechanisms vary, all relate to epistemic injustice. Involving TGD communities in all
stages of medical knowledge production processes would reduce transphobic biases. Individuals
with personal stakes involved in politicized research areas appear all the more necessary today.
... We also organized and co-chaired a scientific symposium at the 2014 meeting of the American Psychiatric Association (Drescher & Byne, 2014), inviting proponents of different treatment approaches for prepubescent children to share their views (de Vries & Cohen-Kettenis, 2012;Ehrensaft, 2012;Zucker, Wood, Singh, & Bradley, 2012). I have also written about controversies surrounding the treatment of children and adolescents diagnosed with GD/GI and/or other gender concerns as well as gender atypical children who did not grow up to be transgender, sometimes referred to as desisters (Drescher, 2013;Drescher & Pula, 2014;Drescher, Cohen-Kettenis, & Reed, 2016a). While I share concerns about the treatment of children and adolescents, I have not yet succumbed to the culture war's growing "transgender panic." ...
This responds to “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults” by Levine et al., part of a small but growing, critical response to contemporary treatments of gender dysphoric/incongruent (GD/GI) children and adolescents. This author, while disagreeing with Levine et al. and other critics, hopes that with dialogue, research and engagement with the wider world, needs of all children, adolescents and young adults—those who have GD/GI and those who may not—will be best served. Critics of gender affirming treatments cite growing numbers of cases, “low level of evidence” supporting treatment, irreversible side effects and expressing regrets as reasons to oppose gender affirmative treatments. Although sharing similar concerns, the author does not conclude treatments should not be offered when appropriate. The critics’ alternative reads as “just talk to the young people and find out what is really bothering them.” Lacking empirical evidence for that approach does not appear to trouble them.
Levine et al.’s caricature of informed consent, which this author parodies, would dissuade anyone from treatment. Their approach does not appear to be written for purposes of engaging frontline clinicians with the aim of improving treatment. Instead, they read as appeals to third parties unfamiliar with the clinical presentations of these children—parents, caretakers courts, legislatures, state health departments and national health care systems—to discourage treatments from proceeding. This impression is further buttressed by a declaration of financial support from The Society for Empirical-Based Gender Medicine, a small group of outliers from mainstream clinicians treating minors with GD/GI who present as “truth-speaking” experts regarding “facts” being ignored, elided over or perhaps even covered up by the mainstream.
The author concludes by noting that clinicians who advocate for delaying treatment to GD/GI minors who need and may benefit from it to “protect” those who “aren’t really” transgender is an ethically troubling issue. In other words, “first, do no harm” is a sword that cuts two ways.
... Vorhandene Daten zur Prävalenz unterscheiden sich je nach zugrunde gelegtem Definitionskriterium (Nieder et al. 2016 (Drescher et al. 2016). Da das evidenzbasierte Wissen über die Entwicklungsverläufe von jungen Menschen mit GI/GD beschränkt ist und Faktoren, die die Persistenz bzw. ...
... A possible explanation for this change could be that pediatricians and mental health professionals have received more medical training and are more aware of the importance of access to specialized care in improving patients' well-being that, regardless of the clinical approach, is often complex and requires interventions involving families and social environments. 27 In addition, the fact that the main increase in referrals coincided with the creation of the specifically for minors GIU in our hospital (in 2008) may suggest, as has been observed in other countries, 28 that providing specialized units with trained professionals for this process may help to ensure access to these services. ...
Introduction: An increasing number of transgender minors are seeking help during the development of their gender identity and transitioning. Understanding their characteristics and the impact of transitioning on their mental health would be of help in the development of protocols to offer a better assistance to this population. The aim of this study was to examine the socio-demographic characteristics and clinical data related to gender identity, transitioning and persistence of transgender minors who were seen at the Gender Identity Unit (GID) of Catalonia, Spain.
Material and methods: All underage applicants who requested clinical assistance at the specialized GID from 1999 until 2016 were retrospectively evaluated using the minors' medical records.
Results: 124 out of 140 minors were confirmed as being transgender, 83.1% of them were adolescents. The assigned male/female ratio was 1:1.2. 97.6% persisted in their transgender identity after a median follow-up time of 2.6 years. Prior to the first meeting, 48.5% were living in their affirmed role and, by the end of the study, this percentage rose to 87.1%. Yearly, the number of referrals exponentially grew whereas the age at referral decreased (rs=-0.2689, p=0.0013). Child consultations rose to a significant percentage (23.5%) over the last 6 years.
Conclusions: Over the 18-year period, the number of referrals increased considerably, more assigned natal female minors and children were seen, and more minors made the decision to go through social transition at a younger age. In contrast with other epidemiological studies conducted in this field, a consistently high rate of persistence was observed.
... A maior parte dos artigos dessa categoria considera o diagnóstico como uma ferramenta importante para estruturar cuidados clínicos e garantir acesso aos serviços de saúde adequados para a população transexual, assim como oportunidade para educação e orientação à população e também aos profissionais da saúde (Levine & Solomon, 2009;Green, 2010;Lawrence, 2010;Drescher et al., 2016;Reed et al., 2016;Zucker et al., 2016). Westphal (2015, p. 23) discute a transexualidade como um quadro clínico que pode ser utilizado por sujeitos psicóticos para "harmonizar o corpo ao significante 'mulher' destinado a representar ou reabsorver a dissociação corporal e psíquica na relação com o Outro e no campo social", ou seja, como uma suplência para resolver sua dissociação corporal. ...
A transexualidade é um aspecto da sexualidade que instiga o avanço compreensivo da própria sexualidade para além da naturalização dos modelos binários para o sexo e gênero. Questão de saúde pública discutida desde sua origem por saberes como a medicina, psicologia e psicanálise. Dessa maneira, a partir de uma revisão sistemática da literatura internacional, o objetivo deste estudo foi apresentar o perfil dos artigos publicados nos últimos dez anos tendo o fenômeno da transexualidade investigado a partir da relação com a psicanálise e psicopatologia. Compreender a vivência transexual sem compará-la aos modelos normativos ao sexo e ao gênero é desafio contemporâneo e necessário para tornar menos rígidos os saberes da psicologia e psiquiatria, e principalmente da psicanálise, assim como demais áreas da saúde e educação cuja práxis emerge ao contato com aspectos da pluralidade afetiva e sexual humana. A psicanálise, no contexto contemporâneo, é intimada para auxiliar e potencializar a compreensão subjetiva, inclusiva e despatologizantes das transexualidades.
... Children have no legal ability to provide informed consent for medical treatment or to engage in decision-making about their condition. As such, children often rely on caregivers and health professionals to make treatment decisions on their behalf (Drescher et al., 2016). Parents may not always make the right decisions for their child and a bioethical argument exists as to whether parental authority should not encompass denying children with gender dysphoria access to medical treatments (Priest, 2019). ...
Objective: To appraise the methodological quality of studies on the prevalence of psychiatric comorbidities for children presenting with gender dysphoria, including diagnosis and management.
Study design: A systematic review of 15 articles on psychiatric comorbidities for children diagnosed with gender dysphoria between the ages of two – 12 years.
Data sources: A systematic literature search of Medline, PsychINFO, CINAHL, Scopus and Web of Science for English-only studies published from 1980 to 2019, supplemented by other sources. Of 736 studies, 721 were removed following title, abstract or full-text review.
Results: Ten studies were retrospectively-oriented clinical case series or observational studies. There were few randomised, controlled trials. Over 80% of the data came from gender clinics in the United States and the Netherlands. Funding or conflicts of interest were often not declared. Mood and anxiety disorders were the most common psychiatric conditions studied. There was little research on complex comorbidities. One quarter of studies made a diagnosis by a comprehensive psychological assessment. A wide range of psychological tests was used for screening or diagnostic purposes. Over half of the studies diagnosed gender dysphoria using evidence-based criteria. A quarter of the studies mentioned treating serious psychopathology prior to addressing gender dysphoria.
KEY POINTS
What is already known about this topic:
• Children with gender dysphoria are likely to experience profound psychological and physical difficulties.
• Gender clinics around the world have different ways of assessing and treating children with gender dysphoria.
• Children often rely on caregivers and health professionals to make treatment decisions on their behalf.
What this topic adds:
• Children with gender dysphoria often experience a range of psychiatric comorbidities, with a high prevalence of mood and anxiety disorders, trauma, eating disorders and autism spectrum conditions, suicidality and self-harm.
• It is vitally important to consider psychiatric comorbidities when prioritising and sequencing treatments for children with gender dysphoria.
• The development of international treatment guidelines would provide greater consistency across diagnosis, treatment and ongoing management.
... The current version of the International Classification of Diseases (ICD-10) includes a category for gender identity disorders that is applicable to people with gender dysphoria within the 'mental health and behavioural disorders' chapter (8), though with the publication of ICD-11 in 2018 it will be moved to a proposed new chapter of 'conditions related to sexual health' (9). Equality legislation in the UK protects trans people from discrimination based on their gender identity, and this legislation may be subject to further development (10). ...
ScotPHN has undertaken a national needs assessment of gender identity services in Scotland. The national healthcare needs assessment has been informed by discussions with third sector organisations and NHS Boards. The work has been guided by a small project group whose membership includes representation from The Scottish Trans Alliance, LGBT Youth, LGBT Health & Well-being and Stonewall Scotland. The working project brief is available here: https://www.scotphn.net/projects/gender-re-assignment/introduction/
... A maior parte dos artigos dessa categoria considera o diagnóstico como uma ferramenta importante para estruturar cuidados clínicos e garantir acesso aos serviços de saúde adequados para a população transexual, assim como oportunidade para educação e orientação à população e também aos profissionais da saúde (Levine & Solomon, 2009;Green, 2010;Lawrence, 2010;Drescher et al., 2016;Reed et al., 2016;Zucker et al., 2016). Westphal (2015, p. 23) discute a transexualidade como um quadro clínico que pode ser utilizado por sujeitos psicóticos para "harmonizar o corpo ao significante 'mulher' destinado a representar ou reabsorver a dissociação corporal e psíquica na relação com o Outro e no campo social", ou seja, como uma suplência para resolver sua dissociação corporal. ...
Transsexualism is an aspect of sexuality that encourages the advancement of understanding own sexuality beyond the naturalization of binary models for sex and gender. Public health issue discussed since its origin by knowledge such as medicine, psychology and psychoanalysis. Thus, from a systematic review of the literature, the aim of this study was to present the profile of the articles published in the past decade with the phenomenon of transsexuality investigated from the relationship with psychoanalysis and psychopathology. Understanding the transsexual experience without comparing it to the normative models to sex and gender is contemporary challenge and needed to make less rigid the knowledge of psychology and psychiatry, and especially psychoanalysis, as well as other areas of health and education whose praxis emerge contact with aspects of human sexual and affective plurality. Psychoanalysis, in the contemporary context, is intimated to aid and enhance the subjective, inclusive and despatologizing understanding of transsexualities.
... Therefore, it is very important for people to have access to health services and vulnerability prevention. The quality of interventions is associated with how early such service is established, preferably before adolescence (27,28). ...
Since 2014, the Gender Identity Program (PROTIG) of Hospital de Clínicas de Porto Alegre (HCPA) has been assisting transgender youth seeking gender-affirmative treatment offered at a public health-care service specializing in gender in southern Brazil. This article aims to analyze sociodemographic and clinical data regarding the diagnoses of gender dysphoria and gender incongruence, psychiatric comorbidities, and clinical aspects of a sample of transgender youths seeking health care in the gender identity program. The research protocol consisted of a survey of the data collected in the global psychological evaluation performed at the health-care service for youths diagnosed with gender incongruence and their caretakers. Participating in this research were 24 transgender youths between 8 and 16 years old with diagnostic overlap of gender dysphoria [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)] and gender incongruence [International Classification of Diseases, 11th Revision (ICD-11)] and 34 of their caregivers. Of the young people, 45.8% were positive for some psychiatric comorbidity throughout their lives, with almost half (45.4%) having two or more psychiatric comorbidities in addition to gender dysphoria. The mental health professionals comprising affirmation care teams face the challenge of adapting the care protocols to the uniqueness of each demand by developing individualized forms to promote healthy development. This can be done by focusing not only on medical and physical interventions for gender affirmation but also on the promotion of mental health and general emotional well-being. Thus, the gender affirmation model, which advocates for global assessment and personalized guidance, proved to be adequate. Nevertheless, access to multidisciplinary health services specializing in gender is essential for promoting the general well-being of the population of transgender youth.
... [8][9][10] Since its introduction into the classification systems, there have always been controversies around the gender identityrelated diagnoses. 11 Because medical gender affirmative interventions are not (yet) needed in prepubertal children, in particular the childhood diagnosis is considered unnecessary by some to allow for access to health care. [12][13][14] Yet, clinicians working in other contexts claim that a childhood diagnosis for gender incongruence is still necessary to provide appropriate care. ...
Purpose:
The World Health Organization general assembly approved the 11th revision of the International Classification of Diseases (ICD) in 2019 which will be implemented in 2022. Gender identity-related diagnoses were substantially reconceptualized and removed from the mental health chapter so that the distress criterion is no longer a prerequisite. The present study examined reliability and clinical utility of gender identity-related diagnoses of the ICD-11 in comparison with the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, ICD-10, and DSM-IV.
Methods:
Sixty-four health care providers assessed six videos of two children, two adolescents, and two adults referred for gender incongruence. Each provider rated one pair of videos with three of the four classification systems (ICD-11, DSM-5, ICD-10, and DSM-IV-TR). This resulted in 72 ratings for the adolescent and adult diagnoses and 59 ratings for the children's diagnoses.
Results:
Interrater agreement rates for each instrument ranged from 65% to 79% for the adolescence/adulthood diagnoses and from 67% to 94% for the childhood diagnoses and were comparable regardless of the system used. Only agreement rates for ICD-11 were significantly better than those for DSM-5 for both age categories. Clinicians evaluated all four systems as convenient and easy to use.
Conclusion:
In conclusion, both classification systems (DSM and ICD) and both editions (DSM-IV and DSM-5 and ICD-10 and ICD-11) of gender identity-related diagnoses seem reliable and convenient for clinical use.
... One of these is gender identity disorder, a term that was used in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4, 1994(DSM-4, , revision 2000, but was replaced in the fifth edition (2013) with gender dysphoria (dysphoria meaning profound distress) to remove the connotation that transgender people are disordered. 3 The International Classification of Diseases (ICD-11) published by the World Health Organization in 2019 employs gender incongruence rather than gender dysphoria, recognizing that not all transgender individuals who search for healthcare interventions suffer from the distress that is regarded as a criterion for gender dysphoria (Drescher, Cohen-Kettenis, & Reed, 2016;Turban & Ehrensaft, 2018). ...
Intersex/DSD and transgender healthcare for children and adolescents has increasingly become a topic for public and academic debate. Key contestations concern early healthcare interventions in intersex/DSD care and ‘cautious gatekeeping’ in transgender care. With this article, which is based on an integrative literature review and expert interviews, we offer more insight into these debates, by mapping and comparing the arguments used by different stakeholders in both fields. Our analytical comparison of the debates reveals that contradictory perceptions of gender, the malleability of bodies and the autonomy of children/adolescents guide the arguments. While medical and psychological research may provide valuable input to further the debates, they remain inherently ethical and interwoven with gendered norms and expectations. This necessitates critical inter- and multidisciplinary conversations both in healthcare and in academic research.
... Indeed, one of the main differences between ICD-11 and DSM-5 diagnostic formulations is DSM-5´s requirement of distress or dysfunction related to GI/GD 9 , which in DSM has traditionally been a requirement for virtually all mental disorders [10][11] . In ICD-11, the essential diagnostic features refer only to aspects of Gender Incongruence (GI) or GD itself (i.e., the experience of incompatibility between an individual's experienced identity and the assigned sex) 12 . ...
... Ziel der Studie ist es, die Jugendlichen zu charakterisieren, die unsere Spezialsprechstunde aufsuchen sowie die Auswirkungen der Behandlung auf die psychische Gesundheit sowie die Behandlungsqualität zu überprüfen. Die DSM-5 Diagnostik mit der Kategorie "Genderdysphorie" wird anstelle der veralteten ICD-10 Diagnostik mit den Kategorien "Störung der Geschlechtsidentität des Kindesalters" und "Transsexualität" verwendet, da letztere nicht mehr den aktuellen Standards entsprechen und die Diagnostik im ICD-11 mit der Kategorie "Geschlechtsinkongruenz" weitgehend umgestaltet werden wird (Drescher, Cohen-Kettenis, Reed, 2016). Die Diagnostik fand mittels klinischen Interviews von Mitarbeiter/innen des Genderteams unter Supervision der Leiterin der Spezialsprechstunde (DP) statt. ...
The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results The specialist clinic for children and adolescents with gender dysphoria (GD) of the Psychiatric University Hospital of Zurich shows an increasing number of referrals since its foundation in 2009. Since 2014 we started an observational study including adolescents aged 13 years and older. At the time of the first appointment (T0) N = 77 participants completed a battery of questionnaires assessing demographic factors, general psychopathology, quality of life as well as gender identity, social transitioning and GD treatment modalities. Few of the adolescents were socially transitioned and had hormone therapy but 77.9 % wished to get hormone therapy. Follow up assessment T1 was performed after at least one year of treatment in our specialist clinic. 51 adolescents completed an online follow-up examination including the same questionnaires and baseline parameters as well as a scale measuring treatment satisfaction. At T0, 77.3 % of the adolescents scored in the clinical range of the Youth Self Report (YSR) total score, which did not decrease significantly until T1 in our preliminary follow up sample. Puberty blocking before T0 correlated negatively with the YSR score, indicating less psychopathology in treated patients. Preliminary longitudinal analysis suggests that social transitioning influences quality of life (Kidscreen subscale autonomy and parental relationship). At T1, 52 % of the adolescents were socially transitioned in all contexts and 70 % received gender affirming hormonal treatment. Gender identity changed between T0 and T1 in about 18 % of the cases. Treatment satisfaction in most cases was high.
... The overall transgender health care approach in childhood and adolescence aims to improve psychological functioning and quality of life outcomes in the long term [9,10]. However, medical interference in a physically healthy body is the subject of controversy and ethical debates (e.g., [4,9,10,[12][13][14]), mainly because evidence to inform best clinical practices for both puberty suppression [9] and gender-affirming (GA) interventions [10] is scarce. Furthermore, there is still a lack of knowledge on adolescent gender identity development [15] and factors associated with adolescent desistence or persistence of childhood GD [16]. ...
Empirical evidence concerning the psychosocial health outcomes after puberty suppression and gender-affirming (GA) medical interventions of adolescents with gender dysphoria (GD) is scarce. The aim of the present study was to describe how dimensions of psychosocial health were distributed among different intervention groups of adolescents with a GD diagnosis from the Hamburg Gender Identity Service before and after treatment. Participants included n = 75 adolescents and young adults from a clinical cohort sample, measured at their initial intake and on average 2 years later (M treatment duration = 21.4 months). All cases were divided into four different intervention groups, three of which received medical interventions. At baseline, both psychological functioning and quality of life scores were significantly below the norm mean for all intervention groups. At follow-up, adolescents in the gender-affirming hormone (GAH) and surgery (GAS) group reported emotional and behavioral problems and physical quality of life scores similar to the German norm mean. However, some of the psychosocial health outcome scores were still significantly different from the norm. Because this study did not test for statistically significant differences between the four intervention groups or before and after treatment, the findings cannot be generalized to other samples of transgender adolescents. However, GA interventions may help to improve psychosocial health outcomes in this sample of German adolescents. Long-term treatment decisions during adolescence warrant careful evaluation and informed, participatory decision-making by a multidisciplinary team and should include both medical interventions and psychosocial support. The present study highlights the urgent need for further ongoing longitudinal research.
... The moving of the adult and adolescent diagnosis was very well received and there wasn't much resistance within WHO to making that change. Where controversy emerged was that some people were angry about the retention of a 'gender incongruence of childhood' diagnosis (see Drescher et al., 2016a;Drescher et al., 2016b;Winter et al., 2016). They argued that we'd gone from psycho-pathologising children to pathologising children with a medical condition. ...
Jack Drescher, MD, is an American psychiatrist and psychoanalyst known for his work on the history of theorising about, diagnosing, treating and mistreating sexual minorities. Dr Drescher was a member of the American Psychiatric Association’s DSM-5 expert working group on Sexual and Gender Identity Disorders, which revised the DSM- IV-TR diagnosis of gender identity disorder to the DSM-5 diagnosis of ‘gender dysphoria’. He was also a member of the World Health Organization expert working group that recommended replacing ICD-10’s gender identity disorder with ‘gender incongruence’, as well as moving the diagnosis out of the mental disorders section of the latest International Classification of Diseases (ICD-11). Dr Drescher is also an expert on sexual orientation change efforts (SOCE) and served on the American Psychological Association’s Task Force on Appropriate Therapeutic Responses to Sexual Orientation. He has published a number of books in the field including Psychoanalytic Therapy and the Gay Man (Drescher, 1998a) and Sexual Conversion Therapy: Ethical, clinical and research perspectives (Shidlo et al., 2001). In February 2020, I interviewed him about his role in the recent ICD-11 revisions and his views on tackling the practice of conversion therapy. What follows is an edited version of our conversation. (Adam Jowett, Chair of the Psychology of Sexualities Section)
... Gender diverse children and adolescents are a heterogeneous group presenting, in most cases, an incongruence between the young person's perceived gender identity and gender assigned at birth (Almirall & Chronis-Tuscano, 2016;Drescher et al., 2016;Spivey & Edwards-Leeper, 2019). The diagnosis of gender dysphoria (GD) was introduced by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) for cases in which this incongruence causes significant discomfort, distress, and the necessity of clinical attention. ...
Introduction
In today’s Italy, gender diversity has assumed a remarkable resonance and visibility in both scientific and popular literature, which has facilitated the development of studies regarding treatments and support for children and adolescents with gender-related issues.
Aim
the aim of this study was to conduct a preliminary evaluation of how Italian clinicians (psychologists and pediatricians) perceive gender variant children and adolescents, evaluating their approach to clinical practice.
Methods
An online questionnaire directed to clinicians regarding their experience with, and perceptions of, gender variant children and adolescents was used for the first part of the research. In the second part of this study, Consensual Qualitative Research (CQR) methodology was applied to semi-structured interviews aimed at investigating clinicians’ approach to clinical practice.
Results
Professionals reported 374 cases, including 200 children (aged 2–11 years) and 174 adolescents (aged 12–19 years); a total of 10 interviews were conducted with professionals.
Conclusion
This study highlights the increase of gender variant children and adolescents seen by professionals, but also the poor awareness of Italian professionals about gender diversity and their care, as well as an absence of a network model of intervention.
... L'é volution des connaissances scientifiques et humanistes, les cadres lé gislatifs qui diffè rent en fonction des pays, conditionnent dans une large mesure l'é laboration des recommandations de projets d'accompagnement de la jeunesse trans et la possibilité de leur mise en oeuvre. De ce point de vue, l'article de Drescher et al. propose un é clairage synthé tique entre consensus cliniques et thé rapeutiques et thé matiques de recherche sur les variances majeures de l'identité de genre chez l'enfant [11]. La connaissance des trajectoires dé veloppementales des enfants et adolescents pré sentant des variances de genre demeure fondamentale [15]. ...
Résumé
Depuis quelques années, en France, des consultations dédiées aux transidentités de l’enfant et de l’adolescent s’organisent. Dans un contexte d’évolution récente du concept de genre, l’expérience des équipes étrangères des Gender Clinics et les standards de soins internationaux guide l’organisation de l’accès aux soins et de l’offre d’accompagnement de cette population.
... C'est pourtant une prise en charge de l'incongruence de genre qui a été médicalement déclenchée. Cette prise en charge a « entrainé » la patiente dans un circuit pédiatrique, avec évaluation des stades pubertaires et examen endocrinien, évaluation chirurgicale, soutien social, ou proposition de rencontre de pairs (Drescher, 2016). Ce fut sans doute un égarement médical. ...
Chez l'adolescent, le diagnostic de dysphorie de genre est délicat, car il se trouve dans une période de bouleversement hormonal, de changements physiques et d'inconfort psychique. La prise en charge pédiatrique, endocrinologique, voire chirurgicale va dépendre de ce discernement diagnostique. La confirmation diagnostique de l'incongruence de genre est d'autant plus impor-tante qu'elle va pouvoir conduire à un suivi individualisé et personnalisé. Nous avons ainsi tenté de déceler comment comprendre cette intrication de cadres nosologiques dans la période de l'adolescence. La prudence s'impose lorsque l'incongruence de genre se révèle être associée à une personnalité ou un trouble psychiatrique, dont l'instabilité peut induire une confusion chez les soignants. La relation de cooccurrence entre trouble psychiatrique et dysphorie de genre, d'un point de vue clinique (et non statistique), semble être particulièrement délicate à démêler. Une réflexion prudente peut cependant permettre d'apporter une information adéquate, un diagnostic précis et un suivi personnalisé. Mots-clés : Dysphorie de genre, incongruence de genre, adolescence. Cet article se veut purement descriptif. Il ne saurait tenter d'imposer une vision engagée d'une thématique hautement polémique. Son but-au-delà de l'explicitation des concepts tels qu'ils sont enseignés aux praticiens du soin (en psychopathologie)-est de montrer que même si les termes employés par les différents corps de métier, les associations, les groupements d'individus ou les institutions politisées diffèrent, sur la forme, ils doivent inspirer une grande prudence quant à leur utilisation.
... Among the main arguments in favor of removing the diagnostic code, trans authors and allies highlight the lack of clinical utility, the Western character of a conceptualization of gender diversity in childhood as a problem that requires health care, the potential stigmatizing effect, and a contradiction between a removal of diagnostic codes related to sexual orientation and the maintenance of the Gender Incongruence of Childhood code [1,2,20,21,28,30,33,[54][55][56][57][58][59][60][61][62]. Furthermore, the critical discourses counter reasons contributed by the defenders of the diagnosis [126,127], arguing that a specific diagnosis for gender diverse children is not necessary for covering psychological support, justifying access to puberty blockers, or promoting research and training [1,2,20,21,28,30,33,[54][55][56][57][58][59][60][61][62]. ...
Abstract Trans people are exposed to multiple human right violations in clinical practice and research. From 1975 on, gender transition processes have been classified as a mental disorder in diagnostic classification manuals, a classification that was removed recently from ICD, International Classification of Diseases, and continues in DSM, Diagnostic and Statistical Manual of Mental Disorders. Trans people in different world regions are forced to accept psychiatric diagnoses and assessment in order to get access to trans health care, subject to reparative therapies and exposed to transphobic institutional and social discrimination and violence. In many countries, gender identity laws include medical requirements, such as psychiatric diagnosis, hormone treatment, genital surgery, or sterilization. In the scientific literature, a frequent pathologization of trans experiences can be identified, by means of pathologizing conceptualizations, terminologies, visual representations, and practices, as well as ethnocentric biases. Trans activism and scholarship have questioned widely the pathologization of trans people in clinical practice and research. Over the last decade, an international trans depathologization movement emerged, demanding, among other claims, the removal of the diagnostic classification of transexuality as a mental disorder, as well as changes in the health care and legal context. International and regional bodies built up a human rights framework related to sexual, gender and bodily diversity that constitute a relevant reference point for trans depathologization activism. The Yogyakarta Principles, published in 2007 and extended in 2017 by means of the Yogyakarta Principles plus 10, establish an application of international human rights law in relation to sexual orientation, gender expression, gender identity, and sex characteristics. International and regional human rights bodies included demands related to depathologization in their agenda. More recently, advancements towards trans depathologization can be observed in the diagnostic classifications, as well as in the health care and legal context. At the same time, trans people continue being exposed to pathologization and transphobic violence. The Human Rights in Patient Care (HRPC) framework offers a human right-based approach on health care practices. The paper aims at analyzing the shared human rights focus and potential alliances between the trans depathologization perspective and the HRPC framework.
... Pojawiają się także głosy, że postrzeganie nienormatywności płciowej u dzieci jako czegoś problematycznego, może w konsekwencji przyczynić się do ponownego patologizowania homoseksualności, szczególnie męskiej, która często rozwojowo przejawia się właśnie w taki sposób. Zwolennicy utrzymania diagnozy mówią z kolei o konieczności zapewnienia profesjonalnego wsparcia i edukacji dla rodziców oraz o potrzebie wydzielenia tej subpopulacji dzieci nienormatywnych płciowo, dla których nie będzie to przemijający wariant rozwojowy i które doświadczają lub będą doświadczały z tego tytułu dyskomfortu lub cierpienia [19]. ...
Psychiatrists, psychotherapists and sexologists specialising in therapy and support of teenage patients have noticed a significant rise in reports of lack of acceptance of the gender assigned at birth, questioning it, rejecting it, and various ways of experiencing it. Although the history of work with transgender adults goes back to the 1920s, gender dysphoria in adolescents remains a complex phenomenon, and any attempts at standardisation of approaches and protocols have so far been unsuccessful. The controversies associated with the issue often result in hasty conclusions and the false – according to the authors of the present paper – assumption that the population of adolescents who experience gender dysphoria or gender incongruence is homogenous. The present article reviews the changes in the diagnoses associated with gender identity made in the DSM and ICD classifications in recent decades, psychological health and neurodiversity of patients reporting gender dysphoria, most common models of treatment, including their advantages and disadvantages, as well as the challenges for diagnosis and treatment in work with this population.
... There has been great concern that pre-pubertal children who only show gender-variant behaviour but have no gender identity-related problems would erroneously receive a diagnosis and be treated by clinicians and parents as future transgender adults [133]. By introducing an anatomic dysphoria requirement and lengthening the required duration of the gender incongruence, the ICD-11 diagnosis for children has been narrowed considerably. ...
An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO’s focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.
... Most individuals with gender dysphoria have a strong desire to be treated as the opposite gender (or some alternative gender) and/or to be rid of their natal sexual characteristics and a strong conviction of having feelings and reactions typical of the other gender (or some alternative gender). ICD-10 and ICD-11 respectively refer to the discrepancy between biological sex and experienced gender by transsexualism and gender incongruence [2][3][4]. The term 'transgender' refers to a variety of gender identities incongruent with one's biological sex [5,6], whereas cisgender refers to individuals whose gender identity is congruent with their birth sex [7]. ...
Purpose: To explore whether the increase observed in referrals to child and adolescent gender identity services (GIDSs) has been similar in four Nordic countries and in the UK.
Materials and methods: Numbers of referrals per year in 2011–2017 were obtained from all GIDS in Denmark, Finland, Norway, Sweden and the UK and related to population aged <18.
Results: A similar pattern of increase in referral rates was observed across countries, resulting in comparable population adjusted rates in 2017. In children, male:female birth sex ratio was even; in adolescents, a preponderance of females (birth sex) was observed, particularly in Finland.
Conclusions: The demand for GIDSs has evolved similarly across Nordic countries and the UK. The reasons for the increase are not known but increased awareness of gender identity issues, service availability, destigmatization as well as social and media influences may play a role.
... Such reclassification could be important to reduce stigma. 6 It is currently extremely difficult for transgender people to access hormone treatment or gender-affirming surgery and there is limited availability of transgender health care. 7 In addition, contrary to growing international standards, 8 in China transgender people require at least a year of some form of psychotherapy before obtaining approval for gender-affirming surgery. ...
... Diverse gender identities are now being seen as subjective human experience variations rather than mental disorders, with the main diagnostics manuals having removed such stigmas and changed the embedded pathologies from previous diagnoses of "gender identity disorder" to "gender dysphoria" (GD) in the diagnostic and statistical manual of mental disorders (DSM-5; [4]) and to "gender incongruence" in the latest editions of the International Classification of Diseases (ICD-11; [5,6]) and of the psychodynamic diagnostic manual (PDM-2; [7]). The scientific community now embraces a complex view of gender variance, considered as a multi-determined construct whose development is based on the interactions of biological [8][9][10], psychological, and social factors [11]. ...
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.
... In this regard, it should be noted that not all children with gender variability grow to be transgender adults and that a transgender adult does not always grow from a childhood diagnosis [18]. In the WPATH' Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [13], one of the roles of mental health professionals working with children and adolescents with gender dysphoria is to help families to have an accepting and nurturing response to the concerns of their children. ...
... This is usually accompanied by a sense of discomfort with or of the inappropriateness of ones anatomical sex and a wish to undergo surgery and hormonal treatment to make the body congruent with the preferred sex. Gender incongruence refers to an incongruence between one's natal sex and present experienced gender, and is also the term to be introduced instead of Transsexualism in the forthcoming ICD-11 [3]. "Transgender" is used as an umbrella term to refer to a variety of gender identities incongruent with one's natal sex [4]. ...
Background:
Increasing numbers of adolescents are seeking treatment from gender identity services, particularly natal girls. It is known from survey studies some adolescents exaggerate their belonging to minorities, thereby distorting prevalence estimates and findings on related problems. The aim of the present study was to explore the susceptibility of gender identity to mischievous responding, and prevalences of cis-gender, opposite-sex and other/ non-binary gender identities as corrected for likely mischievous responding among Finnish adolescents.
Method:
The School Health Promotion Survey 2017 data was used, comprising data on 135,760 adolescents under 21 years (mean 15.73, ds 1.3 years), 50.6% females and 49.4% males. Sex and perceived gender were elicited and gender identities classified based thereon. Likely mischievous responding was analysed using inappropriate responses to biodata and handicaps.
Results:
Of the participants, 3.5% had most likely given facetious responses, boys more commonly than girls, and younger adolescents more commonly than older. This particularly concerned reporting of non-binary gender identity. Corrected prevalence of opposite-sex identification was 0.6% and that of non-binary identification was 3.3%. In boys, displaying non-binary gender identity increased from early to late adolescence, while among girls, opposite-sex and non-binary identifications decreased in prevalence from younger to older age groups.
Conclusion:
Prevalence of gender identities contrary to one's natal sex was more common than expected.
... There is substantial debate about the classification of gender identity diagnoses, [11][12][13][14] including those of childhood, in the upcoming revision of the International Classification of Diseases (ICD)-11 and in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; terminology defined in the appendix). 15 The Working Group on Sexual Disorders and Sexual Health was convened by WHO in 2012 to recommend necessary changes to the ICD-10 regarding diagnoses related to sexuality and gender. ...
... It has been proposed to change Transsexualism to Gender Incongruence in the upcoming ICD 11th Revision (ICD-11) [5]. Moreover, there is significant debate concerning the need for a specific diagnosis of Gender Incongruence in Childhood [6,7]. In the Diagnostic and Statistical Manual of Mental Disorders (DSM), Transsexualism was first replaced with Gender Identity Disorder in the fourth edition and then with Gender Dysphoria in the more recent fifth edition. ...
Lesbian, gay, bisexual, transgender, and intersex (LGBTI) individuals face specific mental health challenges, as will be described in this chapter. Many studies reported elevated mental health problems for LGB individuals compared with their heterosexual counterparts. Fewer studies are available for trans(-gender) and inter(-sex) individuals, but the majority reported increased levels of mental health problems compared with their cisgendered or non-inter counterparts. Current explanatory models centre on the pathogenic effect of homonegativity, transnegativity, and internegativity, as well as the underlying rigid gender roles, resulting in minority stressors that LGBTI individuals and those who are perceived as LGBTI are faced with. Such experienced or internalized minority stress can explain mental health disparities well. This contrasts with the long-standing medical view that LGBTI conditions are inherently pathological. Evidence-based LGBTI-specific prevention and intervention programmes are emerging.
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.
This chapter addresses phenomena seen in children that represent departure from a gender essentialist viewpoint. This is the idea that normal people can be categorized as male or female, and that social behavior should ordinarily follow from biological sex. Gender essentialism is integral to most traditional religious and philosophical systems, but is now almost excluded from many academic and professional forums. This chapter discusses gender incongruity, and disorders of sexual differentiation, as examples of challenges to the gender essentialist viewpoint.
The term conversion therapy refers to any practices intended to alter a person's sexual orientation, gender expression, gender identity, or any combination thereof. The present-day scientific consensus is that such practices are not only ineffective, but highly harmful and fundamentally unethical. However, historical connections exist between applied behavior analysis and the design and dissemination of conversion therapy practices. The purpose of this paper is to highlight these connections and to call for further attention and action from contemporary behavior analysts on this matter. Specifically, we call for continued discussion and review of previously published conversion therapy papers according to present-day guidelines for ethical research, position statements from professional organizations, additional ethics guidelines for behavior-analytic practice, and future behavior-analytic research and practice efforts that support LGBTQ+ people.
This chapter begins by addressing questions about the nature of truth from the perspectives of both philosophy and psychiatry. The section on philosophy outlines different views of progress in science, considers the question of progress in philosophy, and discusses the relationship between science and philosophy. The section on psychiatry outlines different views of progress in this field, and proposes a position that goes beyond scientism (i.e. it is key to recognize important gaps in psychiatry) and skepticism (i.e. it is key to recognize those advances that psychiatry has made), and that values epistemic virtues such as transparency and fallibility. Work in cognitive-affective neuroscience is then used to shed light on these philosophical and psychiatric debates. Finally, work on a range of relevant issues is discussed: the nature of human nature, progress in psychiatric classification, progress in biological psychiatry, progress in psychotherapy, and the pseudoscience versus science demarcation, so exemplifying and expanding the positions put forward here.
Gender identities in transition Abstract. In recent years, the healthcare system has been confronted with an increasing number of children and adolescents with gender nonconformity, gender incongruence, and gender dysphoria. Medical professionals are still debating how to interpret this phenomenon and how best to meet the healthcare needs of this diverse group of young people. Meanwhile, the transgender and gender nonconforming youths themselves face enormous challenges in finding appropriate support and treatment in the mental healthcare system. This article reviews the available epidemiological data, the paradigm shift in the social, legal, and medical systems, the developments in diagnostic classifications (DSM-5, ICD-11) as well as important aspects of the AWMF S3 guideline for adults with gender incongruence and gender dysphoria. In addition, it describes the complexity of working with transgender, gender nonconforming, and gender-questioning youth in the context of the current discourse and the underlying ethical dilemmas. In conclusion, this article outlines the challenges facing child and adolescent psychiatry and psychotherapy in this complex environment.
Studies suggest that the majority of gender diverse children (up to 84%) revert to the gender congruent with the sex assigned at birth when they reach puberty. These children are now known in the literature as ‘desisters’. Those who continue in the path of gender transition are known as ‘persisters’. Based on the high desistence rates, some advise being cautious in allowing young children to present in their affirmed gender. The worry is that social transition may make it difficult for children to de-transition and thus increase the odds of later unnecessary medical transition. If this is true, allowing social transition may result in an outright violation of one of the most fundamental moral imperatives that doctors have: first do no harm. This paper suggests that this is not the case. Studies on desistence should inform clinical decisions but not in the way summarised here. There is no evidence that social transition per se leads to unnecessary medical transition; so should a child persist, those who have enabled social transition should not be held responsible for unnecessary bodily harm. Social transition should be viewed as a tool to find out what is the right trajectory for the particular child. Desistence is one possible outcome. A clinician or parent who has supported social transition for a child who later desists will have not violated, but acted in respect of the moral principle of non-maleficence, if the choice made appeared likely to minimise the child’s overall suffering and to maximise overall the child’s welfare at the time it was made.
The main purpose of this work is to explain in detail the social, psychological, psychiatric and health perspective of LGBT women. We will do so by starting to explain the Instrument of Sex Orienteering, necessary to understand the main differences, the most significant ones, in the diverse group of LGBT women. LGBT means Lesbian, Gay, Bisexual, Transgender, Transexual, Questioning etc. We will continue with an examination of the various aspects, following the track of the other chapters of the book and focusing on the health aspects. Sex orienteering has been coined to describe LGBT sub-minorities in all their main nuances (Table 17.1). This is a useful instrument especially for adolescents who may be questioning about their own sexual orientation. They may be still confused about their own differences, especially between gender identity and sexual orientation. There may be another gap between self-well-being and illness, especially in a familiar or social perspective. Eventually the sex orienteering psychoeducational tool is somewhat helping for them to understand themselves better.
The acronym LGBT is used to indicate a very wide range of individuals – lesbian, gay, bisexual, transgender – who, despite intuitive differences related to diverse sexual orientations and gender identities, may be considered a homogeneous group due to the specific needs and peculiarities of development pathways, often marked by experiences of stigmatization and discrimination. In recent years, the request for psychological help from people belonging to this population has significantly increased, and this makes the definition of objectives and intervention strategies necessary. This paper aims at highlighting specific aspects, critical issues, and operational contexts related to clinical intervention with LGBT people, with particular reference to psychological counseling. After a brief historical and cultural overview on the relationship between the psychological sciences and the phenomena related to groups belonging to sexual and gender minorities, two of the most prevalent theoretical perspectives in the scientific and professional system on LGBT issues are described: the minority stress theory (a perspective used in scientific research as a key to understanding the high levels of stress usually encountered in such a population) and the affirmative paradigm (a perspective currently privileged in clinical practice with LGBT clients). Thus, the contribution is focused on the development of the LGBT dimensions within the counseling context, retracing various historical stages that led the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) to propose a set of guidelines which are briefly discussed, as they represent a fundamental tool for professionals involved in helping relationships. In conclusion, the current research perspectives highlighting an unsatisfactory scenario regarding the empirical evidence on the effectiveness of counseling interventions addressed to LGBT clients are discussed.
Gender dysphoria is defined in the Fifth Edition of Diagnostic and Statistical Manual of American Psychiatric Association (DSM-5) as a marked incongruence between one's experienced/expressed gender and the assigned gender, of at least 6 months' duration. The 11th Revision of the International Classification of Diseases (ICD-11) defines gender incongruence as a marked and persistent incongruence between an individual's experienced gender and the assigned sex, while the experienced gender incongruence must have been continuously present for at least several months. Compared to gender identity disorders and transsexualism, the two most recent classification systems bring terminological and conceptual changes that can be positively evaluated. However, the approach chosen by ICD-11 is closer to clinical reality and can generally be considered more useful, meaningful and helpful to individuals with transgender identities.
Along with the progression and the changes of culture and society, the taxonomy of sexual disorders seems to be in continuous evolution. The recent release of DMS-5 operated many advances with the aim to correct and clarify previous debates in the field of sexual disorders. A minimum duration time and frequency of disorders, particular gender differences, distinctions between paraphilias and mental disorders, and elimination of labeling terms such as gender identity disorder were only some of the innovations that were made. Nonetheless, the revised classification has yielded many controversies that mainly arose from the paucity of empirical supporting data. In particular, it was pointed out that the DSM-5 was not conceived to identify prevalence rates, standardize diagnostic features, bring in appropriate treatments, which were the original objectives of the first release of DSM. The aim of this chapter was to summarize and critically revise major changes and debates among this new edition of DSM.
The World Health Organization (WHO)'s priorities for the development of the classification of mental and behavioural disorders in the ICD-11 include increasing its clinical utility in global mental health settings (1) and improving the identification and diagnosis of mental disorders among children and adolescents (2).
An issue that has been hotly debated in the area of childhood psychopathology is the assessment, diagnosis and treatment of children with severe irritability and anger (3,4). Although virtually all children display irritable and angry behaviours at times, some children exhibit them more frequently and more intensely, to the extent that they become an impairing form of emotional dysregulation. Recent findings indicate that these children with chronic and severe irritability/anger have not been adequately identified through existing classification systems, are at an increased risk for particular negative outcomes, and have not received appropriate treatment. To the extent that ICD-11 can help clarify the clinical picture of irritability/anger, children and families will benefit from more accurate diagnoses, more useful prognoses, and more effective interventions.
This paper provides a brief overview of the issue, followed by several possible options and the current proposal for the classification of childhood irritability/anger in ICD-11. This proposal represents a markedly different – but we believe more scientifically justifiable – solution to the problems in this area than that selected for DSM-5 (5).
The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.
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.
Objectives:
We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada.
Methods:
We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries.
Results:
An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy).
Conclusions:
Past negative experiences with providers, along with limited financial resources and a lack of access to transition-related services, may contribute to nonprescribed hormone use and self-performed surgeries. Promoting training initiatives for health care providers and jurisdictional support for more accessible services may help to address trans people's specific needs.
Abstract The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.
Children and adolescents who are growing up gay, lesbian, bisexual, gender nonconforming, or gender discordant experience unique developmental challenges. They are at risk for certain mental health problems, many of which are significantly correlated with stigma and prejudice. Mental health professionals have an important role to play in fostering healthy development in this population. Influences on sexual orientation, gender nonconformity, and gender discordance, and their developmental relationships to each other, are reviewed. Practice principles and related issues of cultural competence, research needs, and ethics are discussed.
Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.
The optimal approach to treating minors with gender dysphoria/gender variance (GD/GV) is much more controversial than treating these phenomena in adults. This is because children have limited capacity to participate in decision making regarding their own treatment, and even adolescents have no legal ability to provide informed consent. Minors must, therefore, depend on parents or other caregivers to make treatment decisions on their behalf, including those that will influence the course of their lives in the long term. Presently, the highest level of evidence available for selecting among the various approaches to treatment is best characterized as "expert opinion." Yet, opinions vary widely among experts and are influenced by theoretical orientation and assumptions and beliefs regarding the origins of gender identity, as well as its perceived malleability at particular stages of development. This article outlines some of the more salient points raised by the clinicians who treat GD/GV and their discussants. This article summarizes what the editors believe is known and what has yet to be learned about minors with GD/GV, their families, their treatment, and their surrounding cultures.
This article provides a summary of the therapeutic model and approach used in the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto. The authors describe their assessment protocol, describe their current multifactorial case formulation model, including a strong emphasis on developmental factors, and provide clinical examples of how the model is used in the treatment.
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.
Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones.
A cohort study with a median follow-up of 18.5 years at a university gender clinic. Methods Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses.
In the MtF group, total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-specific mortality were not significantly different from those of the general population.
The increased mortality in hormone-treated MtF transsexuals was mainly due to non-hormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death. In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.
The aim of this qualitative study was to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. Twenty five adolescents (M age 15.88, range 14-18), diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood, participated in this study. Data were collected by means of biographical interviews. Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification. Although, both persisters and desisters reported a desire to be the other gender during childhood years, the underlying motives of their desire seemed to be different.
In this article, I review the diagnostic criteria for Gender Identity Disorder (GID) in children as they were formulated in the DSM-III, DSM-III-R, and DSM-IV. The article focuses on the cumulative evidence for diagnostic reliability and validity. It does not address the broader conceptual discussion regarding GID as "disorder," as this issue is addressed in a companion article by Meyer-Bahlburg (2009). This article addresses criticisms of the GID criteria for children which, in my view, can be addressed by extant empirical data. Based in part on reanalysis of data, I conclude that the persistent desire to be of the other gender should, in contrast to DSM-IV, be a necessary symptom for the diagnosis. If anything, this would result in a tightening of the diagnostic criteria and may result in a better separation of children with GID from children who display marked gender variance, but without the desire to be of the other gender.
The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental disorder and that perpetuating DSM-IV-TR's GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.
The aim was to formulate practice guidelines for endocrine treatment of transsexual persons.
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.
Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines.
Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.
To establish the psychosexual outcome of gender-dysphoric children at 16 years or older and to examine childhood characteristics related to psychosexual outcome.
We studied 77 children who had been referred in childhood to our clinic because of gender dysphoria (59 boys, 18 girls; mean age 8.4 years, age range 5-12 years). In childhood, we measured the children's cross-gender identification and discomfort with their own sex and gender roles. At follow-up 10.4 +/- 3.4 years later, 54 children (mean age 18.9 years, age range 16-28 years) agreed to participate. In this group, we assessed gender dysphoria and sexual orientation.
At follow-up, 30% of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric. Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation.
Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality.
Over the years, the DSM diagnosis of gender identity disorder (and its predecessors gender identity disorder of childhood [GIDC] and transsexualism) has attracted controversy as a mental disorder, for its diagnostic criteria, as a target of therapeutic intervention, and for its relationship to a homosexual sexual orientation. Another point of controversy is the claim that the diagnosis of GIDC was introduced into the DSM-III in 1980 as a kind of "backdoor maneuver" to replace homosexuality, which was deleted from the DSM-II in 1973. In this article, we challenge this historical interpretation and provide an alternative account of how the GIDC diagnosis (and transsexualism) became part of psychiatric nosology in the DSM-III. We argue that GIDC was included as a psychiatric diagnosis because it met the generally accepted criteria used by the framers of DSM-IIIfor inclusion (for example, clinical utility, acceptability to clinicians of various theoretical persuasions, and an empirical database to propose explicit diagnostic criteria that could be tested for reliability and validity). In this respect, the entry of GIDC into the psychiatric nomenclature was guided by the reliance on "expert consensus" (research clinicians)--the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published.
To describe the real life challenges and HIV-risk behaviors of male-to-female (MTF) transgender youth from communities of color.
A convenience sample (n = 51) of ethnic-minority MTF transgender youth aged 16-25 years completed an anonymous questionnaire including demographics, psychosocial measures, and participation in substance use and sexual risk behaviors. Descriptive analyses and analyses of association were used to interpret the data.
The median age of participants was 22 years, and 57% were African-American. Twenty-two percent reported being human immunodeficiency virus positive (HIV+). Prevalence of life stressors among the sample included history of incarceration (37%), homelessness (18%), sex in exchange for resources (59%), forced sexual activity (52%), difficulty finding a job (63%), and difficulty accessing health care (41%). Within the past year, 98% had sex with men, 49% had unprotected receptive anal intercourse, and 53% had sex under the influence of drugs or alcohol. Substance use within the past year was common, with marijuana (71%) and alcohol (65%) most frequently reported. Twenty-nine percent of participants had used injection liquid silicone in their lifetime. Other injection drug use and needle-sharing behaviors were rare. Compared with other racial/ethnic groups, HIV was found in higher rates among African-American youth (p < .05). HIV status was not associated with any other demographic characteristic, psychosocial measure, sexual or substance use behavior.
These findings suggest that MTF transgender youth of color have many unmet needs and are at extreme risk of acquiring HIV. Future research is needed to better understand this adolescent subgroup and to develop targeted broad-based interventions that reduce risky behaviors.
This study used three focus groups to explore factors that affect the experiences of youth (ages 15 to 21) who identify as transgender. The focus groups were designed to probe transgender youths' experiences of vulnerability in the areas of health and mental health. This involved their exposure to risks, discrimination, marginalization, and their access to supportive resources. Three themes emerged from an analysis of the groups' conversations. The themes centered on gender identity and gender presentation, sexuality and sexual orientation, and vulnerability and health issues. Most youth reported feeling they were transgender at puberty, and they experienced negative reactions to their gender atypical behaviors, as well as confusion between their gender identity and sexual orientation. Youth noted four problems related to their vulnerability in health-related areas: the lack of safe environments, poor access to physical health services, inadequate resources to address their mental health concerns, and a lack of continuity of caregiving by their families and communities.
The transgendered people have played an important role in ancient Indian culture over millennia. They were portrayed in famous Hindu religious scriptures such as Ramayana and Mahabharata. They were given imperative roles in the royal courtyards of Mughal emperors. Their downfall came only at the onset of British rule during the eighteenth century when they were blacklisted and treated as criminal elements in society. Only in 2014, India's Supreme Court has made a landmark ruling by declaring that the transgendered people must have access to equal opportunity in society. In spite of this legal recognition, transgenders at large have been forced to live on the fringes of the contemporary Indian society. This article explores their past glories, present struggles and future ambitions in the world's largest democracy.
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.
This article describes a clinical program designed to address broadly defined mental health needs of children who experience stress related to not fitting into normative gender types and argues for the need for integrated services that address the spectrum of gender variance. An array of services useful to children and their families is proposed. The article describes the clinical population served, common clinical and social problems, and a rationale for the interventions provided.
True gender self child therapy is based on the premise of gender as a web that weaves together nature, nurture, and culture and allows for a myriad of healthy gender outcomes. This article presents concepts of true gender self, false gender self, and gender creativity as they operationalize in clinical work with children who need therapeutic supports to establish an authentic gender self while developing strategies for negotiating an environment resistant to that self. Categories of gender nonconforming children are outlined and excerpts of a treatment of a young transgender child are presented to illustrate true gender self child therapy.
In 2007, an interdisciplinary clinic for children and adolescents with disorders of sex development (DSD) or gender identity disorder (GID) opened in a major pediatric center. Psychometric evaluation and endocrine treatment via pubertal suppressive therapy and administration of cross-sex steroid hormones was offered to carefully selected patients according to effective protocols used in Holland. Hembree et al.'s (2009) Guidelines for Endocrine Treatment of Transsexual Persons published by the Endocrine Society endorsed these methods. A description of the clinic's protocol and general patient demographics are provided, along with treatment philosophy and goals.
The conceptual issues are briefly noted with respect to the distinctions between classification and diagnosis; the question of whether mental disorders can be considered to be 'diseases'; and whether descriptive psychiatry is outmoded. The criteria for diagnosis are reviewed, with the conclusion that, at present, there are far too many diagnoses, and a ridiculously high rate of supposed comorbidity. It is concluded that a separate grouping of disorders with an onset specific to childhood should be deleted, the various specific disorders being placed in appropriate places, and the addition for all diagnoses of the ways in which manifestations vary by age. A new group should be formed of disorders that are known to occur but for which further testing for validity is needed. The overall number of diagnoses should be drastically reduced. Categorical and dimensional approaches to diagnosis should be combined. The requirement of impairment should be removed from all diagnoses. Research and clinical classifications should be kept separate. Finally, there is a need to develop a primary care classification for causes of referral to both medical and non-medical primary care.
With regard to transsexual developments, onset age (OA) appears to be the starting point of different psychosexual pathways.
To explore differences between transsexual adults with an early vs. late OA.
Data were collected within the European Network for the Investigation of Gender Incongruence using the Dutch Biographic Questionnaire on Transsexualism (Biografische Vragenlijst voor Transseksuelen) and a self-constructed score sheet according to the DSM-IV-TR (Diagnostic and Statistical Manual, Fourth Edition, Text Revision) criteria of Gender Identity Disorder (GID) and Gender Identity Disorder in Childhood (GIDC). One hundred seventy participants were included in the analyses.
Transsexual adults who, in addition to their GID diagnosis, also fulfilled criteria A and B of GIDC ("a strong cross-gender identification,"persistent discomfort about her or his assigned sex") retrospectively were considered as having an early onset (EO). Those who fulfilled neither criteria A nor B of GIDC were considered as having a late onset (LO). Participants who only fulfilled criterion A or B of GIDC were considered a residual (RES) group.
The majority of female to males (FtMs) appeared to have an early OA (EO = 60 [77.9%] compared to LO = 10 [13%] and to RES = 7 [9.1%]). Within male to females (MtFs), percentages of EO and LO developments were more similar (EO = 36 [38.7%], LO = 45 [48.4%], RES = 12 [12.9%]). FtMs presented to gender clinics at an earlier age than MtFs (28.04 to 36.75). The number of EO vs. LO transsexual adults differed from country to country (Belgium, Germany, the Netherlands, Norway).
OA has a discriminative value for transsexual developments and it would appear that retrospective diagnosis of GIDC criteria is a valid method of assessment. Differences in OA and sex ratio exist between European countries.
The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.
The psychiatric impact of interpersonal abuse associated with an atypical presentation of gender was examined across the life course of 571 male-to-female (MTF) transgender persons from the New York City Metropolitan Area. Gender-related abuse (psychological and physical), suicidality, and Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) major depression were retrospectively measured across five stages of the life course using the Life Chart Interview. Among younger respondents (current age of 19-39), the impact of both types of abuse on major depression was extremely strong during adolescence and then markedly declined during later stages of life. Among older respondents (current age of 40-59), the impact of both types of abuse on major depression was strong during adolescence and then marginally declined during later stages of life. The effects of both types of abuse on suicidality were weaker but more consistently observed across the life course among both the younger and older respondents. Gender-related abuse is a major mental health problem among MTF transgender persons, particularly during adolescence. As these individuals mature, however, the consequences of this abuse appear less severe, which may represent the development of moderately effective mechanisms for coping with this abuse.
We investigated health care utilization, barriers to care, and hormone use among male-to-female transgender persons residing in New York City to determine whether current care is in accord with the World Professional Association for Transgender Health and the goals of Healthy People 2010.
We conducted interviews with 101 male-to-female transgender persons from 3 community health centers in 2007.
Most participants reported having health insurance (77%; n = 78) and seeing a general practitioner in the past year (81%; n = 82). Over 25% of participants perceived the cost of medical care, access to specialists, and a paucity of transgender-friendly and transgender-knowledgeable providers as barriers to care. Being under a physician's care was associated with high-risk behavior reduction, including smoking cessation (P = .004) and obtaining needles from a licensed physician (P = .002). Male-to-female transgender persons under a physician's care were more likely to obtain hormone therapies from a licensed physician (P < .001).
Utilization of health care providers by male-to-female transgender persons is associated with their reduction of some high-risk behaviors, but it does not result in adherence to standard of care recommendations for transgender individuals.
Clinician judgment methodology was used to explore the influence of gender nonconformity and gender dysphoria on the diagnosis of children with Gender Identity Disorder (GID). A convenience sample of 73 licensed psychologists randomly received a vignette to diagnose. Vignettes varied across sex of child, gender conforming behavior, and gender dysphoria (including all possible permutations). Eight percent of respondents given a vignette involving a child who met purely behavioral criteria for GID diagnosed the child with GID. When additional information was provided, which in addition to gender nonconforming behavior the child also self-reported a cross-gender identity, this increased to 27% (significant at 5%).
This study described HIV prevalence, risk behaviors, health care use, and mental health status of male-to-female and female-to-male transgender persons and determined factors associated with HIV.
We recruited transgender persons through targeted sampling, respondent-driven sampling, and agency referrals; 392 male-to-female and 123 female-to-male transgender persons were interviewed and tested for HIV.
HIV prevalence among male-to-female transgender persons was 35%. African American race (adjusted odds ratio [OR] = 5.81; 95% confidence interval [CI] = 2.82, 11.96), a history of injection drug use (OR = 2.69; 95% CI = 1.56, 4.62), multiple sex partners (adjusted OR = 2.64; 95% CI = 1.50, 4.62), and low education (adjusted OR = 2.08; 95% CI = 1.17, 3.68) were independently associated with HIV. Among female-to-male transgender persons, HIV prevalence (2%) and risk behaviors were much lower. Most male-to-female (78%) and female-to-male (83%) transgender persons had seen a medical provider in the past 6 months. Sixty-two percent of the male-to-female and 55% of the female-to-male transgender persons were depressed; 32% of each population had attempted suicide.
High HIV prevalence suggests an urgent need for risk reduction interventions for male-to-female transgender persons. Recent contact with medical providers was observed, suggesting that medical providers could provide an important link to needed prevention, health, and social services.
This study examined the relationship between exposure to transphobia--societal discrimination and stigma of individuals who do not conform to traditional notions of gender--and risk for engaging in unprotected receptive anal intercourse (URAI) among 327 transgendered women of color. Overall, 24% of participants had engaged in URAI at least once in the past 30 days. Individuals who self-identified as pre-operative transsexual/transgendered women were significantly more likely than self-identified females to have engaged in URAI. Although exposure to transphobia was not independently related to URAI, an interaction between age and experiencing discrimination was observed. Among transgendered women 18-25 years old, those reporting higher levels of exposure to transphobia had a 3.2 times higher risk for engaging in URAI compared to those reporting lower levels. Findings from this study corroborate the importance of exposure to transphobia on HIV risk, particularly among transgendered young adults.
To assess the risk of development of hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Design Description of cases of transsexuals who have developed a hormone-related malignancy observed in their own clinic or reported in the literature. Recommendations for early diagnosis and prevention are presented.
Review of the literature in PubMed.
In male-to-female transsexuals receiving estrogen administration, lactotroph adenomas, breast cancer, and prostate cancer have been reported. In female-to-male transsexuals receiving treatment with testosterone, a single case of breast carcinoma and several cases of ovarian cancer have been reported. So far endometrial cancer has not been encountered though it remains a potential malignant development.
There are so far only a few cases of hormone-related cancer in transsexuals. There may be an underreporting. The probability of a hormone-related tumor increases with the duration of exposure to cross-sex hormones and the aging of the population of transsexuals.
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