ArticlePDF Available

Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents

Authors:

Abstract

In recent years, the use of gonadotropin-releasing hormone (GnRH) analogues in adolescents with gender dysphoria (GD) to suppress puberty has been adopted by an increasing number of gender clinics, generating controversial debate. This short essay provides an overview of the difficulties associated with this heterogeneous group of adolescents and discusses arguments for and against the suspension of puberty. Further, it reviews the main follow-up studies conducted in some of the world's largest clinical centres for gender-variant children and adolescents.
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
Porto
Biomedical
Journal
ht
tp
:
/
/
www.portobiomedicaljournal.com/
Rostrum
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents
Guido
Giovanardi
Department
of
Dynamic
and
Clinic
Psychology,
Faculty
of
Medicine
and
Psychology,
Sapienza
University
of
Rome,
Rome,
Italy
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
10
June
2017
Accepted
14
June
2017
Available
online
xxx
Keywords:
Gender
dysphoria
Hormone
blockers
GnRH
analogues
Puberty
Transgender
a
b
s
t
r
a
c
t
In
recent
years,
the
use
of
gonadotropin-releasing
hormone
(GnRH)
analogues
in
adolescents
with
gender
dysphoria
(GD)
to
suppress
puberty
has
been
adopted
by
an
increasing
number
of
gender
clinics,
gener-
ating
controversial
debate.
This
short
essay
provides
an
overview
of
the
difficulties
associated
with
this
heterogeneous
group
of
adolescents
and
discusses
arguments
for
and
against
the
suspension
of
puberty.
Further,
it
reviews
the
main
follow-up
studies
conducted
in
some
of
the
world’s
largest
clinical
centres
for
gender-variant
children
and
adolescents.
©
2017
PBJ-Associac¸ ˜
ao
Porto
Biomedical/Porto
Biomedical
Society.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
How
long
have
I
been
here,
what
a
question,
I’ve
often
wondered.
And
often
I
could
answer,
An
hour,
a
month,
a
year,
a
century,
depending
on
what
I
meant
by
here,
and
me,
and
being.
-Samuel
Beckett
Gender-variant
children
and
adolescents
compose
a
heteroge-
neous
group
of
persons
who
present
an
incongruence
between
their
perceived
gender
identity
and
the
gender
to
which
they
were
assigned
at
birth.
This
incongruence
can
cause
significant
distress
(gender
dysphoria)
and
may
require
clinical
intervention.
The
com-
plex
phenomenon
of
gender
dysphoria
(GD)
is
described
in
detail
in
the
5th
edition
of
the
Diagnostic
and
Statistical
Manual
of
Mental
Disorders
(DSM-5).1
Over
the
last
20
years,
youth
referrals
to
gender
clinics
have
dramatically
increased.
In
Europe,
the
two
largest
gender
clinics
for
children
and
adolescents
are
the
Gender
Identity
Development
Service
(GIDS)
in
London
and
the
VU
University
Medical
Center
in
Amsterdam.
Both
centres
have
witnessed
a
significant
increase
in
referrals
over
the
past
10
years
(e.g.
in
London,
referrals
increased
from
97
to
more
than
2000
between
2009/2010
and
2016/2017a),
along
with
an
impressive
decrease
in
the
mean
age
of
referred
clients
and
an
inversion
in
the
sex
ratio
of
referrals
to
favour
natal
females.2,3 Research
on
children
and
adolescents
with
GD
or
gender
variance
(GV)
is
sparse.
However,
some
findings
are
emerging.4,5 It
E-mail
address:
guido.giovanardi@uniroma1.it
aData
presented
by
Bernadette
Wren
at
the
conference
‘Hot
Topics
in
Child
Health:
Transgender
and
Gender
Diverse
Children
and
Adolescents’
held
at
the
Royal
College
of
Paediatrics
and
Child
Health,
London,
June
2017.
is
now
acknowledged,
for
instance,
that
children’s
GD/GV
persists
after
puberty
in
only
10–30
per
cent
of
all
cases;
when
it
does
not,
the
children
are
referred
to
as
‘desisters’.1,5 At
present,
there
is
no
way
to
predict
which
individuals
will
or
will
not
suffer
from
GD
into
adolescence
or
adulthood.
However,
‘persisters’,
whose
GD
contin-
ues
into
adolescence,
are
more
likely
to
experience
GD
in
adulthood
(to
a
degree
of
almost
80
per
cent).6,7
Whether
or
not
GD
persists,
gender-variant
children
are
at
risk
of
suffering
many
psychological
adversities,
mostly
linked
to
body
dissatisfaction
(e.g.8)
and
a
lack
of
acceptance
within
the
family
and
social
environment
(e.g.9).
Children
with
GD
have
been
shown
to
be
more
psychologically
vulnerable
in
comparison
to
the
gen-
eral
population
(e.g.10–12).
Their
psychological
problems
seem
to
be
of
a
more
internalised
nature
(e.g.
depression,
anxiety,
eating
disorders)
than
an
externalising
nature.10,12,13 However,
there
is
considerable
variability
across
studies
(for
an
overview,
see14).
For
these
children,
family
and
peer
relations
are
generally
poorer
than
for
non-referred
children
(e.g.10,15).
As
Bandini
and
colleagues16
point
out,
it
has
been
demonstrated
that
children
showing
gender
variance
are
at
higher
risk
for
maltreatment
and
abuse.17,18 More-
over,
some
studies
have
reported
a
high
frequency
in
trans
persons
of
childhood
sexual
and
physical
abuse,
perpetrated
by
parents
and
caregivers
(e.g.19–21).
Finally,
research
has
shown
that
trans
youth
are
at
higher
risk
of
self-harm,
suicidal
ideation
and
suicidal
attempts
(e.g.22–24).
To
address
the
clinical
needs
of
such
a
complex
population
and
to
reduce
their
risk,
specialised
centres
have
developed
var-
ious
models
of
intervention.
One
of
those,
on
which
this
short
essay
focuses,
is
the
use
of
hormone
blockers
to
suppress
puberty.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
2444-8664/©
2017
PBJ-Associac¸ ˜
ao
Porto
Biomedical/Porto
Biomedical
Society.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
2
G.
Giovanardi
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
This
methodology
is
becoming
increasingly
common
in
several
specialised
centres.
The
intervention
was
developed
by
Dutch
clini-
cians
in
the
framework
of
a
combined
approach,
including
medical
therapies
as
well
as
psychotherapy,
social
intervention
and
family
work.25–28 It
consists
of
a
fully
reversible
medical
therapy
that
sus-
pends
pubertal
development.
Individuals
who
have
reached
Tanner
stage
2
or
329 and
are
considered
eligible
for
treatmentbare
admin-
istered
gonadotropin-releasing
hormone
(GnRH)
analogues,
which
temporarily
suspend
pubertal
development.
These
analogues
act
on
the
pituitary
gland,
inhibiting
hormone
secretion
and
tempo-
rarily
suppressing
the
endogenous
production
of
oestrogen
in
girls
and
testosterone
in
boys.
These
hormones
are
sometimes
called
‘blockers’,
because
they
prevent
the
development
of
secondary
sex
characteristics.
During
this
stage
of
treatment,
in
the
absence
of
pubertal
physical
changes,
the
child
is
guided
through
an
explo-
ration
of
other
gender
roles,
in
order
to
experience
congruence
with
the
presumed
innate
gender
identity.
As
Steensma
and
colleagues30
point
out,
the
suspension
provides
adolescents
with
GD
‘time
and
rest
before
making
definite
decisions
on
gender
reassignment
without
the
distress
of
developing
secondary
sex
characteristics’.
Cohen-Kettenis
and
colleagues27 consider
it
an
extended
diagnos-
tic
phase,
in
which
the
distress
that
the
physical
feminisation
or
masculinisation
was
producing
is
significantly
reduced.
For
these
authors,
the
early
suppression
entails
great
advantages
for
transi-
tioning
to
the
desired
role
throughout
one’s
life,
and
thus
minimises
the
harm
to
youth
and
maximises
their
opportunity
for
good
social
and
sexual
relationships.
The
process
of
passing
to
the
other
gender
is
made
significantly
easier.
The
child
normally
also
receives
psychological
assistance
in
determining
whether
or
not
to
proceed
to
hormone
therapy
specifically,
the
administration
of
cross-sex
hormones,
which
is
the
first
step
in
irreversible
gender
reassignment.
Alternatively,
she
or
he
may
interrupt
therapy
and
revert
to
the
assigned
gender.
Once
endogenous
sex
hormone
production
is
resumed,
the
pubertal
development
is
thought
to
restart
normally.31,32
Although
the
use
of
puberty
suppressants
is
described
in
inter-
national
guidelines,
there
is
no
consensus
in
the
Endocrine
Society
Guidelines
and
the
Standards
of
Care
of
the
World
Professional
Association
of
Transgender
Health.33,34 The
primary
risks
of
puber-
tal
suppression
include
adverse
effects
on
bone
mineralisation
(which
can
theoretically
be
reversed
with
cross-sex
hormone
treat-
ment)
and
compromised
fertility;
data
on
the
effects
on
brain
development
are
still
limited.26,35
Several
studies
have
proven
the
effectiveness
of
early
medical
interventions
and
the
safety
of
these
interventions
with
regard
to
physical
and
psychological
harm.
Overall,
research
has
shown
improved
psychological
functioning
during
suppression,
no
change
of
mind
in
terms
of
gender
identity
and
the
reduction
or
disap-
pearance
of
distress
related
to
GD;
in
addition,
several
studies
have
reported
an
increase
in
GD
and
harmful
behaviour
when
blockers
are
not
used.34,36
In
their
longitudinal
study
on
the
first
70
adolescents
to
receive
puberty
blockers,
de
Vries
and
colleagues37 reported
an
improve-
ment
in
general
functioning
after
two
years,
along
with
a
decrease
in
depression
and
behavioural
and
emotional
difficulties.
Fifty-five
of
these
70
individuals
were
assessed
later
in
early
adulthood,
after
cross-sex
hormones
had
been
administered
and
gender
bEligibility
criteria
for
hormone
blockers
are:
‘(i)
a
presence
of
gender
dyspho-
ria
from
early
childhood
on;
(ii)
an
increase
of
the
gender
dysphoria
after
the
first
pubertal
changes;
(iii)
an
absence
of
psychiatric
comorbidity
that
interferes
with
the
diagnostic
work-up
or
treatment;
(iv)
adequate
psychological
and
social
support
during
treatment;
and
(v)
a
demonstration
of
knowledge
and
understanding
of
the
effects
of
GnRH,
cross-sex
hormone
treatment,
surgery,
and
the
social
consequences
of
sex
reassignment’
(Cohen-Kettenis
et
al.,
2008,
p.
1894).
reassignment
surgery
had
been
performed.
Depressive
symptoms
had
decreased,
general
mental
health
functioning
had
improved
and
no
regret
about
transitioning
was
found.
Many
(about
70
per
cent)
reported
that
their
social
transition
had
been
‘easy’.
Cohen-Kettenis
and
colleagues,38 in
a
22-year
follow-up
of
the
first
described
adolescent
treated
with
GnRH
analogues
and
cross-sex
hormones,
reported
overall
improved
psychological
well-being
and
no
clinical
signs
of
adverse
effects
on
the
brain.
An
improvement
in
global
functioning
following
puberty
suppression
was
also
found
in
the
UK
study
of
Costa
and
colleagues39 in
their
follow-up
of
adolescents
at
the
GIDS
centre
in
London.
Consistent
with
the
Dutch
and
British
studies
was
Spack
and
colleagues’
report40 about
their
sample
of
97
patients
at
a
clinic
in
Boston,
MA,
in
which
no
adolescents
showed
regrets
regarding
puberty
blocking
or
subsequent
cross-sex
hormone
use.
However,
use
of
this
intervention
has
only
recently
begun,
so
no
other
follow-up
studies
are
available
and
many
questions
are
still
unanswered.
Thus,
many
professionals
remain
critical
about
the
puberty-blocking
treatment
(e.g.25,41,42).
The
primary
counter-
arguments
are
as
follows:
1.
At
Tanner
stage
2
or
3,
the
individual
is
not
sufficiently
mature
or
authentically
free
to
take
such
a
decision.25,41
2.
It
is
not
possible
to
make
a
certain
diagnosis
of
GD
in
adolescence,
because
in
this
phase,
gender
identity
is
still
fluctuating.25,41,42
3.
Moreover,
puberty
suppression
may
inhibit
a
‘spontaneous
formation
of
a
consistent
gender
identity,
which
sometimes
develops
through
the
“crisis
of
gender”’
(p.
375).43
4.
Considering
the
high
percentage
of
desisters,
early
somatic
treat-
ment
may
be
premature
and
inappropriate.25
5.
Research
about
the
effects
of
early
interventions
on
the
devel-
opment
of
bone
mass
and
growth
typical
events
of
hormonal
puberty
and
on
brain
development
is
still
limited,7so
we
can-
not
know
the
long-term
effects
on
a
large
number
of
cases.
6.
Although
current
research
suggests
that
there
are
no
effects
on
social,
emotional
and
school
functioning,
‘potential
effects
may
be
too
subtle
to
observe
during
the
follow-up
sessions
by
clinical
assessment
alone’
(p.
1895).25
7.
The
impact
on
sexuality
has
not
yet
been
studied,
but
the
restriction
of
sexual
appetite
brought
about
by
blockers
may
pre-
vent
the
adolescent
from
having
age-appropriate
socio-sexual
experiences.41
8.
In
light
of
this
fact,
early
interventions
may
interfere
with
the
patient’s
development
of
a
free
sexuality
and
may
limit
her
or
his
exploration
of
sexual
orientation.41,42
9.
Finally,
for
trans
girls
(natal
boys
with
a
female
gender
identifi-
cation),
the
blockage
of
phallic
growth
may
result
in
less
genital
tissue
available
for
an
optimal
vaginoplasty.44
Vrouenraets
and
colleagues45 conducted
a
remarkable
study
interviewing
various
professionals
of
17
treatment
teams
of
chil-
dren
and
adolescents
worldwide,
finding
that
the
majority
of
professionals
recognised
the
distress
of
teens
with
GD/GV
and
felt
that
early
intervention
was
urgently
needed.
At
the
same
time,
though
many
teams
embraced
the
so-called
‘Dutch
approach’,
a
general
feeling
of
unease
was
expressed,
due
to
the
lack
of
long-
term
physical
and
psychological
outcome
studies.
One
of
the
main
arguments
in
support
of
early
intervention
was
limiting
suicidal
risk.
Subsequently,
the
same
group46 interviewed
trans
adoles-
cents.
Surprisingly,
the
adolescents
also
seemed
cautious.
Many
had
doubts
about
the
ability
of
a
person
so
young
to
make
such
a
sig-
nificant
decision,
but
they
also
emphasised
the
capital
importance
of
preventing
the
development
of
secondary
sexual
characteristics.
The
adolescents
seriously
weighed
the
short-
and
long-term
con-
sequences
of
treatment,
but
this
awareness
did
not
stop
them
from
wanting
to
suspend
puberty.
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
G.
Giovanardi
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
3
Finally,
a
warning
comes
from
Alessandra
Lemma,
a
psychoana-
lytic
author
who
has
contributed
important
and
innovative
insights
into
transsexualism.47,48 In
a
recent
paper,
she
worryingly
suggests
that
in
some
instances
puberty
suppression
can
“result
in
a
marked
distortion
in
the
young
person’s
relationship
to
time”
(p.
361)49 that
will
negatively
impact
the
adaptation
and
integration
of
identity
following
gender
transition.
Conclusion
I
hope
that
this
brief
excursus
has
clarified
the
supporting
and
opposing
arguments
with
respect
to
the
use
of
hormone
blockers
to
suppress
puberty.
On
the
one
hand,
the
treatment
might
impede
experiences
that
are
seriously
traumatic
for
individuals
with
pro-
fessionally
and
accurately
diagnosed
GD,
limiting
suicidal
risk
and
preventing
other
adverse
psychological
consequences.
On
the
other
hand,
the
treatment
risks
hindering
the
individual’s
development
of
a
free
personality,
sexuality
and
identity,
thus
disconnecting
the
young
person
from
the
typical
experiences
of
her
or
his
age,
with
no
certainty
of
the
long-term
effects
on
physical
health.
Suppression
of
puberty
may
suggest
that
the
person
is
deprived
of
adolescence
the
crucial
time
to
deal
with
identity
issues,
experiment
and
pur-
sue
unstable
convictions
regarding
the
self.
However,
as
Bernadette
Wren
suggests,
there
is
no
evidence
that
“young
people’s
conviction
about
their
gender
identity
is,
typically,
as
unstable
as
other
value-
laden
convictions”
(p.
224).50 From
a
psychological
perspective,
the
main
dilemma
is
to
understand
whether
buying
time
at
such
a
precocious
age
truly
enables
children
to
explore
deep
personal
meanings,
or
whether
it
freezes
youngsters
in
a
prolonged
child-
hood,
secluding
them
from
certain
aspects
of
reality
and
isolating
them
from
peer
groups.
This
is
a
rather
difficult
issue
to
confront
in
quantitative
follow-up
studies
(which
of
course
are
crucial
for
mon-
itoring
physical
and
psychological
outcomes).
Thus,
qualitative
and
clinical
studies
may
have
a
great
deal
to
offer,
especially
when
con-
ducted
by
expert
clinicians
who
know
these
children
very
well.
In
any
case,
as
for
many
other
aspects
of
gender
identity
development,
it
is
crucial
that
a
person-by-person
approach
is
adopted
(as
per-
formed
by
the
abovementioned
gender
clinics)
to
tailor
effective
and
appropriate
interventions
according
to
individual
needs.
Conflicts
of
interest
The
author
declares
no
conflicts
of
interest.
References
1.
American
Psychiatric
Association.
Diagnostic
and
statistical
manual
of
mental
disorders.
5th
ed.
Arlington,
VA:
American
Psychiatric
Publishing;
2013.
2.
Aitken
M,
Steensma
TD,
Blanchard
R,
VanderLaan
DP,
Wood
H,
Fuentes
A,
et
al.
Evidence
for
an
altered
sex
ratio
in
clinic-referred
adolescents
with
gender
dys-
phoria.
J
Sex
Med.
2015;12:756–63,
http://dx.doi.org/10.1111/jsm.12817.
3.
Di
Ceglie
D.
Gender
dysphoria
in
young
people.
In:
Huline-Dickens
S,
editor.
Clinical
topics
in
child
and
adolescent
psychiatry.
London:
The
Royal
College
of
Psychiatrists
Publications;
2014.
p.
349–64.
4.
Drescher
J,
Byne
W.
Gender
dysphoric/gender
variant
(GD/GV)
children
and
ado-
lescents:
summarizing
what
we
know
and
what
we
have
yet
to
learn.
J
Homosex.
2012;59:501–10,
http://dx.doi.org/10.1080/00918369.2012.653317.
5.
Drescher
J,
Pula
J.
Ethical
issues
raised
by
the
treatment
of
gender-
variant
prepubescent
children.
Hastings
Cent
Rep.
2014;44:17–22,
http://dx.doi.org/10.1002/hast.365.
6.
de
Vries
AL,
Steensma
TD,
Doreleijers
TA,
Cohen-Kettenis
PT.
Puberty
suppression
in
adolescents
with
gender
identity
disor-
der:
a
prospective
follow-up
study.
J
Sex
Med.
2011;8:2276–83,
http://dx.doi.org/10.1111/j.1743-6109.2010.01943.x.
7.
Drummond
KD,
Bradley
SJ,
Peterson-Badali
M,
Zucker
K.
A
follow-up
study
of
girls
with
gender
identity
disorder.
Dev
Psychol.
2016;44:34–45,
http://dx.doi.org/10.1037/0012-1649.44.1.34.
8.
Testa
RJ,
Rider
GN,
Haug
NA,
Balsam
KF.
Gender
confirming
medical
interven-
tions
and
eating
disorder
symptoms
among
transgender
individuals.
Health
Psychol.
2017,
http://dx.doi.org/10.1037/hea0000497.
9.
Ristori
J,
Steensma
TD.
Gender
dysphoria
in
childhood.
Int
Rev
Psychiatry.
2016;28:13–20,
http://dx.doi.org/10.3109/09540261.2015.1115754.
10.
Cohen-Kettenis
PT,
Owen
A,
Kaijser
VG,
Bradley
SJ,
Zucker
KJ.
Demographic
char-
acteristics,
social
competence,
and
behavior
problems
in
children
with
gender
identity
disorder:
a
cross-national,
cross-clinic
comparative
analysis.
J
Abnorm
Child
Psychol.
2003;31:41–53,
http://dx.doi.org/10.1023/A:1021769215342.
11.
Singh
D,
Bradley
SJ,
Zucker
K.
Commentary
on
“An
affirmative
intervention
for
families
with
gender
variant
children:
parental
ratings
of
child
mental
health
and
gender”
by
Hill,
Menvielle,
Sica,
and
Johnson
(2010).
J
Sex
Marital
Ther.
2011;37:151–7,
http://dx.doi.org/10.1080/0092623X.2011.547362.
12.
Steensma
TD,
Zucker
KJ,
Kreukels
BPC,
VanderLaan
DP,
Wood
H,
Fuentes
A,
et
al.
Behavioral
and
emotional
problems
on
the
Teacher’s
Report
Form:
a
cross-national,
cross-clinic
comparative
analysis
of
gender
dysphoric
children
and
adolescents.
J
Abnorm
Child
Psychol.
2014;42:635,
http://dx.doi.org/10.1007/s10802-013-9804-2.
13.
Zucker
KJ,
Bradley
SJ.
Gender
identity
disorder
and
psychosexual
problems
in
children
and
adolescents.
New
York,
NY:
Guilford
Press;
1995.
14.
Zucker
KJ,
Wood
H,
VanderLaan
DP.
Models
of
psychopathology
in
children
and
adolescents
with
gender
dysphoria.
In:
Kreukels
BC,
Steensma
TD,
de
Vries
AC,
editors.
Gender
dysphoria
and
disorders
of
sex
development:
progress
in
care
and
knowledge.
New
York,
NY:
Springer
Science
+
Business
Media;
2014.
p.
171–92.
15.
Zucker
KJ,
Bradley
SJ,
Owen-Anderson
A,
Kibblewhite
SJ,
Wood
H,
Singh
D,
et
al.
Demographics,
behavior
problems,
and
psychosexual
characteristics
of
ado-
lescents
with
gender
identity
disorder
or
transvestic
fetishism.
J
Sex
Marital
Therapy.
2012;38:151–89,
http://dx.doi.org/10.1080/0092623X.2011.611219.
16.
Bandini
E,
Fisher
AD,
Ricca
V,
Ristori
J,
Meriggiola
MC,
Jannini
EA,
et
al.
Childhood
maltreatment
in
subjects
with
male-to-female
gender
identity
disorder.
Int
J
Impot
Res.
2011;23:276,
http://dx.doi.org/10.1038/ijir.2011.39.
17.
Corliss
HL,
Cochran
SD,
Mays
VM.
Reports
of
parental
maltreatment
dur-
ing
childhood
in
a
United
States
population-based
survey
of
homosexual,
bisexual,
and
heterosexual
adults.
Child
Abuse
Negl.
2002;26:1165–78,
http://dx.doi.org/10.1016/S0145-2134(02)00385-X.
18.
Nuttbrock
L,
Hwahng
S,
Bockting
W,
Rosenblum
A,
Mason
M,
Macri
M,
et
al.
Psychiatric
impact
of
gender-related
abuse
across
the
life
course
of
male-to-female
transgender
persons.
J
Sex
Res.
2010;47:12–23,
http://dx.doi.org/10.1080/00224490903062258.
19.
Gehring
D,
Knudson
G.
Prevalence
of
childhood
trauma
in
a
clinical
population
of
transsexual
people.
Int
J
Transgenderism.
2005;8:23–30,
http://dx.doi.org/10.1300/J485v08n01
03.
20.
Lingiardi
V,
Giovanardi
G,
Fortunato
A,
Nassisi
V,
Speranza
AM.
Per-
sonality
and
attachment
in
transsexual
adults.
Arch
Sex
Behav.
2017,
http://dx.doi.org/10.1007/s10508-017-0946-0.
21.
Veale
JF,
Clarke
DE,
Lomax
TC.
Biological
and
psychosocial
correlates
of
adult
gender-variant
identities:
new
findings.
Personal
Individ
Differ.
2010;49:252–7,
http://dx.doi.org/10.1016/j.paid.2010.03.045.
22.
Grossman
AH,
D’augelli
AR.
Transgender
youth:
invisible
and
vulnerable.
J
Homosex.
2006;51:111–28,
http://dx.doi.org/10.1300/J082v51n01
06.
23.
Skagerberg
E,
Parkinson
R,
Carmichael
P.
Self-harming
thoughts
and
behaviors
in
a
group
of
children
and
adolescents
with
gender
dysphoria.
Int
J
Transgenderism.
2013;14:86–92,
http://dx.doi.org/10.1080/15532739.2013.817321.
24.
Wallien
MS,
Cohen-Kettenis
PT.
Psychosexual
outcome
of
gender-
dysphoric
children.
J
Am
Acad
Child
Adolesc
Psychiatry.
2008;47:1413–23,
http://dx.doi.org/10.1097/CHI.0b013e31818956b9.
25.
Cohen-Kettenis
PT,
Delemarre-van
de
Waal
HA,
Gooren
LJG.
The
treatment
of
adolescent
transsexuals:
changing
insights.
J
Sex
Med.
2008;5:1892–7,
http://dx.doi.org/10.1111/j.1743-6109.2008.00870.x.
26.
de
Vries
AC,
Cohen-Kettenis
PT.
Clinical
management
of
gender
dysphoria
in
children
and
adolescents:
the
Dutch
approach.
J
Homosex.
2012;59:301–20,
http://dx.doi.org/10.1080/00918369.2012.653300.
27.
Cohen-Kettenis
PT,
Steensma
TD,
de
Vries
AC.
Treatment
of
adolescents
with
gender
dysphoria
in
the
Netherlands.
Child
Adolesc
Psychiatr
Clin
N
Am.
2011;20:689–700,
http://dx.doi.org/10.1016/j.chc.2011.08.001.
28.
Di
Ceglie
D.
Engaging
young
people
with
atypical
gender
identity
develop-
ment
in
therapeutic
work:
a
developmental
approach.
J
Child
Psychother.
2009;35:3–12,
http://dx.doi.org/10.1080/00754170902764868.
29.
Marshall
WA,
Tanner
JM.
Variations
in
pattern
of
pubertal
changes
in
girls.
Arch
Dis
Child.
1969;44:291–303,
http://dx.doi.org/10.1136/adc.45.239.13.
30.
Steensma
TD,
McGuire
JK,
Kreukels
BP,
Beekman
AJ,
Cohen-Kettenis
PT.
Factors
associated
with
desistence
and
persistence
of
childhood
gender
dys-
phoria:
a
quantitative
follow-up
study.
J
Am
Acad
Child
Adolesc
Psychiatry.
2013;52:582–90,
http://dx.doi.org/10.1016/j.jaac.2013.03.016.
31.
Delemarre-van
de
Waal
HA.
Early
medical
intervention
in
adolescents
with
gender
dysphoria.
In:
Kreukels
BC,
Steensma
TD,
de
Vries
AC,
editors.
Gender
dysphoria
and
disorders
of
sex
development:
progress
in
care
and
knowledge.
New
York,
NY:
Springer
Science
+
Business
Media;
2014.
p.
193–204.
32.
Giordano
S.
Medical
treatment
for
children
with
gender
dysphoria:
conceptual
and
ethical
issues.
In:
Kreukels
BC,
Steensma
TD,
de
Vries
AC,
editors.
Gender
dysphoria
and
disorders
of
sex
development:
progress
in
care
and
knowledge.
New
York,
NY:
Springer
Science
+
Business
Media;
2014.
p.
205–30.
33.
Coleman
E,
Bockting
W,
Botzer
M,
Cohen-Kettenis
P,
DeCuypere
G,
Feldman
J,
et
al.
Standards
of
care
for
the
health
of
transsexual,
transgender,
and
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
4
G.
Giovanardi
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
gender-nonconforming
people,
version
7.
Int
J
Transgenderism.
2012;13:165–232,
http://dx.doi.org/10.1080/15532739.2011.700873.
34.
Hembree
WC.
Guidelines
for
pubertal
suspension
and
gender
reassignment
for
transgender
adolescents.
Child
Adolesc
Psychiatr
Clin
N
Am.
2011;20:725–32,
http://dx.doi.org/10.1016/j.chc.2011.08.004.
35.
Klink
D,
Caris
M,
Heijboer
A,
van
Trotsenburg
M,
Rotteveel
J.
Bone
mass
in
young
adulthood
following
gonadotropin-releasing
hormone
analog
treatment
and
cross-sex
hormone
treatment
in
adolescents
with
gender
dysphoria.
J
Clin
Endocrinol
Metab.
2015;100:E270–5,
http://dx.doi.org/10.1210/jc.2014-2439.
36.
Kreukels
BC,
Cohen-Kettenis
PT.
Puberty
suppression
in
gender
identity
disorder:
the
Amsterdam
experience.
Nat
Rev
Endocrinol.
2011;7:466–72,
http://dx.doi.org/10.1038/nrendo.2011.78.
37.
de
Vries
AL,
McGuire
JK,
Steensma
TD,
Wagenaar
EC,
Doreleijers
TA,
Cohen-Kettenis
PT.
Young
adult
psychological
outcome
after
puberty
suppression
and
gender
reassignment.
Pediatrics.
2014;134:1–9,
http://dx.doi.org/10.1542/peds.2013-2958.
38.
Cohen-Kettenis
PT,
Schagen
SE,
Steensma
TD,
de
Vries
AL,
Delemarre-
van
de
Waal
HA.
Puberty
suppression
in
a
gender-dysphoric
adolescent:
a
22-year
follow-up.
Arch
Sex
Behav.
2011;40:843–7,
http://dx.doi.org/10.1007/s10508-011-9758-9.
39.
Costa
R,
Dunsford
M,
Skagerberg
E,
Holt
V,
Carmichael
P,
Colizzi
M.
Psychological
support,
puberty
suppression,
and
psychosocial
function-
ing
in
adolescents
with
gender
dysphoria.
J
Sex
Med.
2015;12:2206–14,
http://dx.doi.org/10.1111/jsm.13034.
40.
Spack
NP,
Edwards-Leeper
L,
Feldman
HA,
Leibowitz
S,
Mandel
F,
Dia-
mond
DA,
et
al.
Children
and
adolescents
with
gender
identity
disor-
der
referred
to
a
pediatric
medical
center.
Pediatrics.
2012;129:418–25,
http://dx.doi.org/10.1542/pedS.2O11-0907.
41.
Korte
A,
Goecker
D,
Krude
H,
Lehmkuhl
U,
Grueters-Kieslich
A,
Beier
KM.
Gender
identity
disorders
in
childhood
and
adolescence:
currently
debated
concepts
and
treatment
strategies.
Dtsch
Aerzteblatt
Int.
2008;105:834–41,
http://dx.doi.org/10.3238/arztebl.2009.0318b.
42.
Stein
E.
Commentary
on
the
treatment
of
gender
variant
and
gender
dysphoric
children
and
adolescents:
common
themes
and
ethical
reflections.
J
Homosex.
2012;59:480–500,
http://dx.doi.org/10.1080/00918369.2012.653316.
43.
Giordano
S.
Gender
atypical
organisation
in
children
and
adolescents:
ethico-legal
issues
and
a
proposal
for
new
guidelines.
Int
J
Child
Rights.
2007;15:365–90,
http://dx.doi.org/10.1163/092755607X262793.
44.
Milrod
C.
How
young
is
too
young:
ethical
concerns
in
genital
surgery
of
the
transgender
MTF
adolescent.
J
Sex
Med.
2014;11:338–46,
http://dx.doi.org/10.1111/jsm.12387.
45.
Vrouenraets
LJ,
Fredriks
AM,
Hannema
SE,
Cohen-Kettenis
PT,
de
Vries
MC.
Early
medical
treatment
of
children
and
adolescents
with
gender
dysphoria:
an
empirical
ethical
study.
J
Adolesc
Health.
2015;57:367–73,
http://dx.doi.org/10.1016/j.jadohealth.2015.04.004.
46.
Vrouenraets
LJ,
Fredriks
AM,
Hannema
SE,
Cohen-Kettenis
PT,
de
Vries
MC.
Perceptions
of
sex,
gender,
and
puberty
suppression:
a
qualita-
tive
analysis
of
transgender
youth.
Arch
Sex
Behav.
2016;45:1697–703,
http://dx.doi.org/10.1007/s10508-016-0764-9.
47.
Lemma
A.
Research
off
the
couch:
re-visiting
the
trans-
sexual
conundrum.
Psychoanal
Psychother.
2012;26:263–81,
http://dx.doi.org/10.1080/02668734.2012.732104.
48.
Lemma
A.
The
body
one
has
and
the
body
one
is:
understanding
the
transsexual’s
need
to
be
seen.
Int
J
Psychoanal.
2013;94:277–92,
http://dx.doi.org/10.1111/j.1745-8315.2012.00663.x.
49.
Lemma
A.
Present
without
past:
the
disruption
of
temporal
inte-
gration
in
a
case
of
transsexuality.
Psychoanal
Inq.
2016;36:360–70,
http://dx.doi.org/10.1080/07351690.2016.1180908.
50.
Wren
B.
Early
physical
intervention
for
young
people
with
atypical
gen-
der
identity
development.
Clin
Child
Psychol
Psychiatry.
2000;5:220–31,
http://dx.doi.org/10.1177/1359104500005002007.
... Finally, some studies have reported increasingly harmful behavior when blockers are not used, and this is important when speaking of the principle of non-maleficence (12). This last point is also relevant for the economic resources assignment principle. ...
... While previous data before GnRHa treatment availability showed that the majority of patients were "desisters", recent evidence shows that up to 100% of treated patients will eventually opt for a transgender identity (11). Finally, some studies have reported increasingly harmful behavior when blockers are not used, and this is important when speaking of the principle of non-maleficence (12). This last point is also relevant for the economic resources assignment principle. ...
... Due to all the above considerations, while it appears mandatory that the presence of a pervasive and persistent GD pattern should be confirmed in highly specialized settings (12), it is worth mentioning that GnRHa effects are primarily reversible overall. Since strong evidence show that a great deal of distress accompanies GD, providing no-treatment might be more harmful. ...
... Pubertal suppression with GnRHa blocks the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland, preventing production of testosterone and estradiol from the testes and ovaries respectively (16). Without testosterone or estradiol, sex-specific secondary sex characteristics, such as breast development in those AFAB or voice deepening in those AMAB, do not progress (16). ...
... Pubertal suppression with GnRHa blocks the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland, preventing production of testosterone and estradiol from the testes and ovaries respectively (16). Without testosterone or estradiol, sex-specific secondary sex characteristics, such as breast development in those AFAB or voice deepening in those AMAB, do not progress (16). In this way, for many trans adolescents, puberty blockers can help prevent an exacerbation of GD and the attendant anxiety that often accompanies typical progression through puberty (17). ...
... Finally, significant brain and cognitive development occurs during adolescence. Although it is unclear to what extent pubertal hormones positively influence this development, it stands to reason that puberty suppression might impact this process (16,17,21). ...
Article
Full-text available
Gender dysphoria describes the distress associated with having a gender identity that differs from one’s birth-assigned sex. To relieve this distress, transgender, and gender diverse (henceforth, trans) individuals commonly undergo medical transition involving hormonal treatments. Current hormonal treatment guidelines cater almost exclusively for those who wish to transition from male to female or vice versa. In contrast, there is a dearth of hormonal options for those trans individuals who identify as non-binary and seek an androgynous appearance that is neither overtly male nor female. Though prolonged puberty suppression with gonadotrophin releasing hormone agonists (GnRHa) could in theory be gender-affirming by preventing the development of unwanted secondary sex characteristics, this treatment option would be limited to pre- or peri-pubertal adolescents and likely have harmful effects. Here, we discuss the theoretical use of Selective Estrogen Receptor Modulators (SERMs) for non-binary people assigned male at birth (AMAB) who are seeking an androgynous appearance through partial feminization without breast growth. Given their unique range of pharmacodynamic effects, SERMs may represent a potential gender-affirming treatment for this population, but there is a lack of knowledge regarding their use and potentially adverse effects in this context.
... Referrals to the service at Tavistock and Portman NHS Foundation Trust have grown exponentially, with an increase from 100 referrals in 2009 to a peak of 2700 in 2019 (Biggs, 2022). Lack of capacity has meant that waiting lists exceeded 5300 people in April 2021 (Giovanardi, 2017;Biggs, 2020). From 2010-20, four patients are known to have died by suicide out of the 15 000 on the waiting list during that period (Biggs, 2022), but this figure is likely to underestimate the true number, as around half of transgender young people attempt suicide before the age of 21 years (Jennings and Jennings, 2016). ...
Article
Full-text available
Professor Bryan McIntosh and Ellie Koseda provide an overview of the review into the NHS's only gender identity development service, led by Dr Hilary Cass, following the publication of the interim report in February 2022. Key issues in this complex and developing field are discussed.
... Most of the research on TGNC youth and clinical needs has been quantitative, consisting of questionnaires on psychiatric symptoms and livelihood measurements (Giovanardi, 2017;Olson-Kennedy et al., 2016). At the same time, experiential qualitative analyses of individual TGNC youth's experiences that "give voice" to their perspectives are also needed in order to more fully understand GD among the TGNC adolescents referred to medical treatment (McLeod, 2013). ...
Article
Full-text available
A growing number of adolescents are seeking medical care to alleviate gender dysphoria (GD). This qualitative study explored the subjective experiences of GD among help-seeking transgender and gender nonconforming (TGNC) youth in order to develop a more nuanced conceptualization of the phenomenon. Fifteen life-mode interviews were conducted with newly referred youth between the ages of 13 and 19. All participants were assigned female at birth. The data were analyzed using thematic analysis. The participants targeted five major themes that characterize GD: (1) Bodily sensations were constant reminders of GD throughout the day, (2) emotional memories from the past of being different and outside triggered GD, (3) the process of coming out was a transformative experience that changed how the participants understood themselves, (4) GD both increased and decreased in relation to others, (5) everyday life required careful negotiation to feel whole without developing new forms of GD. Based on the results, we suggest a more conceptually nuanced model of GD, one which accounts for how bodily sensations and emotional memories from the past were sources that elicited GD. The sources were mediated through the process of coming out and relating to others, and this resulted in the negotiation of GD today. The conceptual model suggested in the present study could ideally shed light on preexisting knowledge on TGNC youth struggling with GD. In addition, an improved understanding of GD could ideally help clinicians when addressing individual treatment needs.
... For example, an important goal of PS is to allow additional time for a TGD young person to further explore decisions about potential GAH use without the associated distress of ongoing incongruent pubertal development. Whether typical cognitive maturity and decision-making capacity is achieved in TGD adolescents in the absence of pubertal sex hormones (115) is unclear, although no impact of PS on cognition has been demonstrated in cisgender cohorts treated with GnRHa for either precocious puberty (116) or short stature (117). Another concern relates to the perception that hormonal interventions reflect the start of a "pathway" that an adolescent may find it difficult to get off (118). ...
Article
Full-text available
Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being employed. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, while short-term outcomes are encouraging, longer-term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender diverse adolescents.
... Many questions in respect of the safety, effectiveness and longterm impact on a range of outcomes remain unanswered. There is lack of evidence in respect to the short and long-term effects of puberty blockers and cross-sex hormones across a variety of health domains, which is probably linked to the fact that there is an ongoing debate on whether puberty blockers should or should not be used (Giovanardi, 2017). This research gap must be addressed using an interdisciplinary approach. ...
Book
Full-text available
Background: Since the 1990s, there has been a growing corpus of evidence on Lesbian, Gay, Bisexual, Trans, Intersex and other Sexual and Gender Minority (LGBTI+) youth. However, most of these studies were conducted in the North America, and it remains unclear whether their findings can be generalised to other countries and cultures. The third goal of the Irish LGBTI+ National Youth Strategy 2018-2020 was to develop the research and data environment to better understand the lives of LGBTI+ young people. This study aimed to draw the landscape of existing research on LGBTI+ youth in Ireland and other European countries, and identify research and data gaps that need to be addressed. Method: Using a scoping review technique, we employed a multi-method search to identify research outputs and databases on LGBTI+ young people in peer-reviewed and grey literature. Identified outputs were screened against pre-set inclusion criteria, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines; then, several types of information were extracted from studies meeting inclusion criteria. We used standardised methods to evaluate the quality of each outputs. Finally, research and data gaps were identified. Results: 4,603 records were found. Following screening, 126 outputs were entered to the analysis. The studies and databases varied largely in method and quality. Important evidence gaps were found on the health and needs of transgender and intersex youth; the sexual health of LGBTI+ youth; and their employment and career opportunities. The predominant ‘victim’ narrative in the vast majority of existing studies need to be balanced with investigating positive predictors of well-being and evidence-based good practice for improving LGBTI+ youth lives. Conclusion: Some areas of LGBTI+ youth lives have a thin or practically non-existent evidence base. Identified research and data gaps need to be addressed by methodologically sound studies.
... All recommendations and standards of care having been issued to this date include and suggest this treatment path. Many formerly critical clinicians came to the conclusion that this approach is the right one, not for all their patients but for those with severe persistent gender dysphoria (Giovanardi, 2017;Meyenburg et al., 2015). Only a minority is opposing puberty suppression. ...
Chapter
In this chapter, we analyse the discourse on the medical treatment of transgender adolescents in the German print media. Using the example of the controversy about puberty blockers, we show how conservative positions portray deviations from the cis-normative gender order as a "fashion" and "zeitgeist phenomenon" and thus attempt to delegitimise accepting treatment that is oriented towards the needs of adolescents and represents the current state of medical research.
... Clinically significant distress will not be considered as an inherent symptom of gender incongruence either [4]. Nevertheless, it should be noted that there is a real possibility that pre-pubertal children with gendervariant behaviors might be prematurely or mistakenly typified and treated as transgender individuals, with the consequent suspension of puberty [5]. Undoubtedly, the most important matter in mental health is treating sexually discordant persons of every age in an adequate and non-stigmatizing manner. ...
Article
Full-text available
Introduction. Currently, matters related to a person’s gender are of the utmost media and scientific validity. In this paper, we will aim to help clarify the relevant issues that affect mental health. Materials and methods. In accordance with the best, high-quality international literature, we will present a rough critical, global and local analysis of the state of the matter. Results and Discussion. In Spain, in order to rectify the register entries relating to intersexuality and transsexuality, a gender dysphoria diagnosis is required; that is, a sexual identity disorder diagnosis. The DSM-5 (American Psychiatric Association) classification of mental disorders, and equivalently, the ICD-10 (World Health Organization), both recognize the existence of the gender dysphoria diagnosis, and the upcoming ICD-11 will include, for gender disagreement, the so-called gender incongruence diagnosis. Issues associated with intersexuality and transsexuality are sufficiently and extensively addressed in scientific journals, and in many other journals that are exclusively informative. However, there is a risk of indiscriminately extending and even inadequately promoting everything related to the “transgender” concept, popularly abbreviated with the “trans” prefix. The psychiatric morbidity frequently associated or related to it is also commonly ignored or justified. Conclusion. Should there be, in certain cases, a comorbid mental pathology, its correct and early identification, dismissal or adequate health consultation would be crucial for the client. Often times, it would be appropriate to implement a specific psychotherapy, to be conducted only by psychiatrists or clinical psychologists.
Article
Objectives Some gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then to acquire the secondary sex characteristics of their identified gender using gender affirming hormones (GAH). However, little is known about the demographics of transgender adolescents accessing paediatric endocrinology services while under the specialist Gender Identity Development Service (GIDS) in England. Design Demographics of referrals from the GIDS to affiliated endocrinology clinics to start GnRHa or GAH between 2017 and 2019 (cohort 1), with further analysis of a subgroup of this cohort referred in 2017–2018 (cohort 2) were assessed. Results 668 adolescents (227 assigned male at birth (AMAB) and 441 assigned female at birth (AFAB)) were referred to endocrinology from 2017 to 2019. The mean age of first GIDS appointment for cohort 1 was 14.2 (±2.1) years and mean age of referral to endocrinology postassessment was 15.4 (±1.6) years. Further detailed analysis of the trajectories was conducted in 439 YP in cohort 2 (154 AMAB; 285 AFAB). The most common pathway included a referral to access GnRHa (98.1%), followed by GAH when eligible (42%), and onward referral to adult services when appropriate (64%). The majority (54%) of all adolescents in cohort 2 had a pending or completed referral to adult services. Conclusions This study highlights the trajectories adolescents may take when seeking endocrine treatments in child and adolescent clinical services and may be useful for guiding decisions for gender-diverse YP and planning service provision.
Article
Full-text available
The main aim of this study was to investigate the associations between personality features and attachment patterns in transsexual adults. We explored mental representations of attachment, assessed personality traits, and possible personality disorders. Forty-four individuals diagnosed with gender identity disorder (now gender dysphoria), 28 male-to-female and 16 female-to-male, were evaluated using the Shedler–Westen assessment procedure-200 (SWAP-200) to assess personality traits and disorders; the adult attachment interview was used to evaluate their attachment state-of-mind. With respect to attachment, our sample differed both from normative samples because of the high percentage of disorganized states of mind (50% of the sample), and from clinical samples for the conspicuous percentage of secure states of mind (37%). Furthermore, we found that only 16% of our sample presented a personality disorder, while 50% showed a high level of functioning according to the SWAP-200 scales. In order to find latent subgroups that shared personality characteristics, we performed a Q-factor analysis. Three personality clusters then emerged: Healthy Functioning (54% of the sample); Depressive/Introverted (32%) and Histrionic/Extroverted (14%). These data indicate that in terms of personality and attachment, GD individuals are a heterogeneous sample and show articulate and diverse types with regard to these constructs.
Article
Full-text available
International guidelines recommend the use of Gonadotropin-Releasing Hormone (GnRH) agonists in adolescents with gender dysphoria (GD) to suppress puberty. Little is known about the way gender dysphoric adolescents themselves think about this early medical intervention. The purpose of the present study was (1) to explicate the considerations of gender dysphoric adolescents in the Netherlands concerning the use of puberty suppression; (2) to explore whether the considerations of gender dysphoric adolescents differ from those of professionals working in treatment teams, and if so in what sense. This was a qualitative study designed to identify considerations of gender dysphoric adolescents regarding early treatment. All 13 adolescents, except for one, were treated with puberty suppression; five adolescents were trans girls and eight were trans boys. Their ages ranged between 13 and 18 years, with an average age of 16 years and 11 months, and a median age of 17 years and 4 months. Subsequently, the considerations of the adolescents were compared with views of clinicians treating youth with GD. From the interviews with the gender dysphoric adolescents, three themes emerged: (1) the difficulty of determining what is an appropriate lower age limit for starting puberty suppression. Most adolescents found it difficult to define an appropriate age limit and saw it as a dilemma; (2) the lack of data on the long-term effects of puberty suppression. Most adolescents stated that the lack of long-term data did not and would not stop them from wanting puberty suppression; (3) the role of the social context, for which there were two subthemes: (a) increased media-attention, on television, and on the Internet; (b) an imposed stereotype. Some adolescents were positive about the role of the social context, but others raised doubts about it. Compared to clinicians, adolescents were often more cautious in their treatment views. It is important to give voice to gender dysphoric adolescents when discussing the use of puberty suppression in GD. Otherwise, professionals might act based on assumptions about adolescents’ opinions instead of their actual considerations. We encourage gathering more qualitative research data from gender dysphoric adolescents in other countries. Electronic supplementary material The online version of this article (doi:10.1007/s10508-016-0764-9) contains supplementary material, which is available to authorized users.
Article
Objective: Studies indicate that transgender individuals may be at risk of developing eating disorder symptoms (EDS). Elevated risk may be attributed to body dissatisfaction and/or societal reactions to nonconforming gender expression, such as nonaffirmation of a person's gender identity (e.g., using incorrect pronouns). Limited research suggests that gender-confirming medical interventions (GCMIs) may prevent or reduce EDS among transgender people. Method: Participants included 154 transfeminine spectrum (TFS) and 288 transmasculine spectrum (TMS) individuals who completed the Trans Health Survey. Serial multiple mediation analyses controlling for age, education, and income were used to examine whether body satisfaction and nonaffirmation mediate any found relationships between various GCMIs (genital surgery, chest surgery, hormone use, hysterectomy, and hair removal) and EDS. Results: For TFS individuals, the nonaffirmation to body satisfaction path mediated relationships between all GCMIs and EDS, although body satisfaction alone accounted for more of the indirect effects than this path for chest surgery. For TMS individuals, relationships between all GCMIs and EDS were mediated by the nonaffirmation to body satisfaction path. Conclusion: Findings support the hypothesis that GCMIs reduce experiences of nonaffirmation, which increases body satisfaction and thus decreases EDS. Among TFS participants, the relationship between chest surgery and lower levels of EDS was mediated most strongly by body satisfaction alone, suggesting that satisfaction with one's body may result in lower EDS even if affirmation from the external world is unchanged. Implications of these findings for intervention, policy, and legal efforts are discussed, and future research recommendations are provided. (PsycINFO Database Record
Article
In this article, I examine the impact of extensive modification of the body on the temporal link, which is an important feature of human identity, as it provides continuity between different representations of the self over time. I illustrate this with a case of a young boy who underwent sex reassignment surgery in late adolescence after the artificial suspension of puberty through sex hormones. I argue that when hormones are used in this way, one can observe in some cases not only the desired suspension of physical time during which the body's given biological trajectory is artificially halted, but also of psychological time. In some instances, this biological and psychic detour can result in a marked distortion in the young person's relationship to time and impacts on their psychological adaptation following surgery.
Chapter
There are various treatment approaches available for children and adolescents with gender identity disorder (GID). This chapter offers an overview of these, with a focus on bringing to light their underlying assumption and treatment goals. After such an account, the chapter focuses on the combined approach, which involves early medical treatment for children and adolescents with GID. This treatment has raised and may raise important ethical and legal concerns: this chapter disentangles and analyzes such concerns. The conclusion is not only that there is nothing unethical with providing transgender children and adolescents with early medical treatment but that it may be unethical not to do so.
Article
Gender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.
Article
Introduction: Puberty suppression by gonadotropin-releasing hormone analogs (GnRHa) is prescribed to relieve the distress associated with pubertal development in adolescents with gender dysphoria (GD) and thereby to provide space for further exploration. However, there are limited longitudinal studies on puberty suppression outcome in GD. Also, studies on the effects of psychological support on its own on GD adolescents' well-being have not been reported. Aim: This study aimed to assess GD adolescents' global functioning after psychological support and puberty suppression. Methods: Two hundred one GD adolescents were included in this study. In a longitudinal design we evaluated adolescents' global functioning every 6 months from the first visit. Main outcome measures: All adolescents completed the Utrecht Gender Dysphoria Scale (UGDS), a self-report measure of GD-related discomfort. We used the Children's Global Assessment Scale (CGAS) to assess the psychosocial functioning of adolescents. Results: At baseline, GD adolescents showed poor functioning with a CGAS mean score of 57.7 ± 12.3. GD adolescents' global functioning improved significantly after 6 months of psychological support (CGAS mean score: 60.7 ± 12.5; P < 0.001). Moreover, GD adolescents receiving also puberty suppression had significantly better psychosocial functioning after 12 months of GnRHa (67.4 ± 13.9) compared with when they had received only psychological support (60.9 ± 12.2, P = 0.001). Conclusion: Psychological support and puberty suppression were both associated with an improved global psychosocial functioning in GD adolescents. Both these interventions may be considered effective in the clinical management of psychosocial functioning difficulties in GD adolescents. Costa R, Dunsford M, Skagerberg E, Holt V, Carmichael P, Colizzi M. Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. J Sex Med **;**:**-**.