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‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties
Abstract
As the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress. From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.
... One of the only available alternative approaches to the highly medicalised affirmative model of care for gender dysphoria in youth is psychotherapy. However, the evidence supporting psychotherapy for gender dysphoria is even more limited than that for medical treatments, consisting primarily of case reports and small case series (eg, [43][44][45][46][47][48][49][50]. Nevertheless, despite the limited evidence for their efficacy for gender dysphoria, individual and family psychological interventions, including psychodynamic, cognitive-behavioural and systemic approaches, are generally considered safe and are the established foundations of child and adolescent mental healthcare. ...
... Dealing with these issues sometimes dramatically alters selfexperience in a broad range of ways, including the experience of gender dysphoria. [43][44][45][46][47][48][49][50] This cannot occur without a detailed inquiry that questions and explores the patient's presenting difficulties and convictions. Unquestioning affirmation is in itself a form of influence that forecloses a thoroughgoing exploration and potentially compromises autonomy. ...
Opinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth. Proponents claim that these treatments are well supported, while critics claim the poor-quality evidence base warrants extreme caution. Psychotherapy is one of the only available alternatives to the gender-affirming approach. Discussion of the treatment of gender dysphoria in young people is generally framed in terms of two binary approaches: affirmation or conversion. Psychotherapy/exploratory therapy offers a treatment option that lies outside this binary, although it is mistakenly conflated with conversion therapies. Psychotherapy does not impose restrictive gender stereotypes, as is sometimes claimed, but critically examines them. It empowers young people to develop creative solutions to their difficulties and promotes agency and autonomy. Importantly, an exploratory psychotherapeutic process can help to clarify whether gender dysphoria is a carrier for other psychological or social problems that may not be immediately apparent. Psychotherapy can therefore make a significant contribution to the optimal, ethical care of gender-dysphoric young people by ensuring that patients make appropriate, informed decisions about medical interventions which carry risks of harm and have a contested evidence base.
... The minority stress theory as the sole explanatory mechanism for co-occurring mental health illness has also been questioned in light of the evidence that psychiatric symptoms frequently predate the onset of gender dysphoria (Bechard, VanderLaan, Wood, Wasserman, & Zucker, 2017;Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, 2015;. Other clinicians recognize the limits of gender-affirmative care and are aware that youth with underlying psychiatric issues are likely to continue to struggle post-transition (Kaltiala, Heino, Työläjärvi, & Suomalainen, 2020), but, unaware of alternative approaches such as gender-exploratory psychotherapy or watchful waiting (Bonfatto & Crasnow, 2018;Churcher Clarke & Spiliadis, 2019;Spiliadis, 2019), these well-meaning professionals continue to treat youth with gender-affirmative interventions despite lingering doubts. ...
... It is equally important to realize that to date, research about alternative approaches, such as psychotherapy or watchful waiting, shares the scientific limitations of the research of more invasive interventions: there are no control groups, nor is there systematic follow-up at predetermined intervals with predetermined means of measurement (Bonfatto & Crasnow, 2018;Churcher Clarke & Spiliadis, 2019;Spiliadis, 2019). Parents and patients need to be informed of this as well. ...
In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent processes can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.
... Clinicians working in the field of child and adolescent gender identity development have to navigate through differing and competing narratives and beliefs that professionals, families, third sector organisations or even the media might have, in terms of persistence and desistance of gender dysphoria across the lifespan and the relevance of any clinical intervention. There is ongoing debate about whether professionals supporting gender questioning young people (and their families) can predict with confidence which young people will 'persist' in their gender identification and/or their wish for medical/hormonal interventions and which will 'desist'; in the case of 'desistence' it could either mean that young people come to understand their gender identity (and possible associated distress) in different ways or cease wishing to pursue hormonal interventions (Churcher Clarke & Spiliadis, 2019). ...
... In this domain, Cecchin's (1987) 'curiosity' is privileged, as well as ideas around alternative narratives and the possibility for these. In GIDS, it can be hypothesised that such a domain offers the opportunity to explore ideas around diverse gender identity pathways and developmental outcomes (Churcher Clarke & Spiliadis, 2019), which are not uncommon within a child and adolescent gender identity service. Within a wider social constructionist approach, clinicians should continuously reflect on their own relationship to medical interventions and perhaps challenge dominant narratives around their necessity. ...
... Some authors argue that children and adolescents experiencing gender dysphoria/ incongruence present with complex and diverse needs so a developmental approach is necessary to understand the multiple factors that might be contributing to social and emotional distress. [12][13][14] There is also evidence that the experience of being in a minority group can have a negative impact on development and well-being. 15 16 Meyer's minority ...
Background
National and international guidelines recommend that psychosocial support should be a key component of the care offered to children and adolescents experiencing gender dysphoria/incongruence. However, specific approaches or interventions are not recommended.
Aim
To identify and summarise evidence on the outcomes of psychosocial support interventions for children and adolescents (age 0-18) experiencing gender dysphoria/incongruence.
Methods
Systematic review and narrative synthesis. Database searches (MEDLINE; EMBASE; CINAHL; PsycINFO; Web of Science) were performed in April 2022, with results assessed independently by two reviewers. Peer-reviewed articles reporting the results of studies measuring outcomes of psychosocial support interventions were included. Quality was assessed using the Mixed Methods Appraisal Tool.
Results
Ten studies were included. Half were conducted in the US, with others from Australia, Canada, New Zealand and the UK. Six were pre–post analyses or cohort studies, three were mixed methods, and one was a secondary analysis of intervention data from four trials. Most studies were of low quality. Most analyses of mental health and psychosocial outcomes showed either benefit or no change, with none indicating negative or adverse effects.
Conclusions
The small number of low-quality studies limits conclusions about the effectiveness of psychosocial interventions for children/adolescents experiencing gender dysphoria/incongruence. Clarity on the intervention approach as well as the core outcomes would support the future aggregation of evidence. More robust methodology and reporting is required.
PROSPERO registration number
CRD42021289659.
... Rights reserved. separation anxiety, depression, anorexia, homophobia, or trauma (Bockting et al., 2006;Churcher-Clarke & Spiliadis, 2019;Evans & Evans, 2021;Parkinson, 2014;Withers, 2020), conditions frequently present in the current large adolescent cohort (Kaltiala-Heino et al., 2018). Exploratory psychotherapy (Ayad et al., 2022;Evans & Evans, 2021), group therapy (Withers, 2020), and other supportive mental health interventions sometimes resolve gender dysphoria without medical intervention. ...
... Clothes, haircuts, colors, mannerisms, etc., do not have a sex. The original Dutch protocol for transition of minors emphasized the role of psychotherapy in fostering self-acceptance of gender-nonconformity prior to contemplating medical interventions (de Vries et al., 2006) and a growing body of literature describes an exploratory psychotherapeutic approach that can help people expand their definition of what it means to be a man or a woman, thereby potentially eliminating the need for transition-related medical interventions (Bonfatto & Crasnow, 2018;Churcher Clarke & Spiliadis, 2019;Evans, 2022;Hakeem, 2018). ...
Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.
... 82 In particular, care for gender dysphoria is not synonymous with medical intervention. Some with gender dysphoria have had it resolve [83][84][85] with mental health support such as psychotherapy 86,87 and others have medically transitioned and found that it did not alleviate their distress or gender dysphoria; 88,89 in particular, some have been badly harmed. 90 (The number who detransition, regret, and/or have been harmed is unknown due to the lack of adequate longterm outcome studies. ...
The 2022 article “Legislation restricting gender-affirming care for transgender youth: Politics eclipse healthcare” by K. L. Kraschel et al. implies that attempts in the United States to restrict medical interventions for gender dysphoria are due to political motivations. Although there are likely some whose stance on these interventions is based upon politics, there are sound medical reasons, independent of politics, for advocating for more cautious medical intervention protocols. Neglecting mention of these reasons obscures the fact that medical intervention outcomes are difficult to predict and that serious risks and irreversible consequences are present. In other countries, following extensive evidence review, supportive alternatives to medical intervention are being prioritized instead. Here, several claims of Kraschel et al. regarding the state of medical intervention healthcare are compared to the research evidence and shown to fall short. Healthcare issues alone justify challenging current United States medical treatment protocols.
... Although 'ROGD' has only been recently suggested as a subtype, clinical expert papers on healthcare for transgender adolescents have since long suggested that there are different subgroups within the group of adolescents [13][14][15]. Some adolescents with gender incongruence present with a long history of gender nonconformity from early childhood on (pre-pubertal) but other transgender adolescents declare gender incongruence around or after puberty (peri/post-pubertal). ...
Transgender adolescents may present to gender identity specialty services earlier or later in adolescence. The aim of this study was to examine whether, ‘younger’ and ‘older’ presenters could be identified in a large cohort of transgender adolescents and if differences exist between the two groups. The study sample consisted of 1487 adolescents (506 birth-assigned males, 981 birth-assigned females) referred between 2000 and 2018. The distribution of age at intake was evaluated. Demographic, diagnostic, and treatment characteristics, the Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI) to measure childhood gender nonconformity and the Body Image Scale (BIS) to measure body image were collected. Based on a stem-and-leaf plot and a histogram, two groups were identified: adolescents presenting at ≤ 13.9 years (‘younger presenters’) and adolescents presenting at 14 years or older (‘older presenters’). The sex ratio was more extreme in the group of older presenters favoring birth-assigned females ( Χ ² (1, N = 1487) = 19.69, p < 0.001). Furthermore, more adolescents from the younger presenting group lived with both biological parents ( Χ ² (1, N = 1427) = 24.78, p < 0.001), were diagnosed with gender dysphoria and started with medical gender-affirming treatment ( Χ ² (1, N = 1404) = 4.60, p = 0.032 and Χ ² (1, N = 1487) = 29.16, p < 0.001). Younger presenters showed more gender nonconformity in childhood ( β 0.315, p < 0.001, 95% CI 0.224–0.407). Older presenters were more dissatisfied with various aspects of their bodies ( p < 0.001). The differences between older and younger presenting adolescents suggest that there may be different developmental pathways in adolescents that lead to seeking gender-affirming medical care and argues for more tailored care.
... This item was intentionally worded to be obviously true (i.e., some people do, of course, detransition). However, it is also the case that only a very small proportion of people actually do detransition (Clarke & Spilliadis, 2019) and so the item can be reasonably read as at least somewhat (or perhaps even largely) false in terms of its implication. Nonetheless, additional analyses excluding this item from the conservative proscience composite yielded nearly identical results to those reported above (see Tables S48 and S49). ...
Some theoretical models assume that a primary source of contention surrounding science belief is political and that partisan disagreement drives beliefs; other models focus on basic science knowledge and cognitive sophistication, arguing that they facilitate proscientific beliefs. To test these competing models, we identified a range of controversial issues subject to potential ideological disagreement and examined the roles of political ideology, science knowledge, and cognitive sophistication on science beliefs. Our results indicate that there was surprisingly little partisan disagreement on a wide range of contentious scientific issues. We also found weak evidence for identity-protective cognition (where cognitive sophistication exacerbates partisan disagreement); instead, cognitive sophistication (i.e., reasoning ability) was generally associated with proscience beliefs. In two studies focusing on anthropogenic climate change, we found that increased political motivations did not increase polarization among individuals who are higher in cognitive sophistication, which indicates that increased political motivations might not have as straightforward an impact on science beliefs as has been assumed in the literature. Finally, our findings indicate that basic science knowledge is the most consistent predictor of people’s beliefs about science across a wide range of issues. These results suggest that educators and policymakers should focus on increasing basic science literacy and critical thinking rather than on the ideologies that purportedly divide people.
... From the late 1990s, a group of girls with gender dysphoria only manifesting in their teenage years began to appear in statistics -a trend that overlapped with the general trend of increasing cases of gender dysphoria among adolescents. Currently, although gender dysphoria cases in childhood are predomi- nantly boys, girls predominate in the teenage years (Aitken et al. 2015;Clarke, Spiliadis, 2019;de Graaf, Carmichael, Steensma, Zucker, 2018;Littman, 2018;Steensma, Cohen-Kettenis, Zucker et al, 2018;Zucker, 2017). The rapidity of this process is captured in particular by the study of Aitken et al. (2015), where the ratio of boys to girls was 2.11:1 between 1999 and 2005, only to decrease to 1:1.76 between 2006 and 2013. ...
There is growing number of publications pointing to the global trend of a significant increase in people who identify differently to their biological sex. Children and adolescents are a particularly sensitive group here, as their identity is still under development. These trends are also reaching Poland. Parents and state services involved in the upbringing and education may be surprised and unprepared. There is small number of analyzes of these trends, especially in the context of the already available knowledge about gender identity disorders and further practical recommendations. The first part of the article presents epidemiological data illustrating the occurrence of gender identity disorders in the population. The methodological challenge was to define a reliable criterion illustrating the strength and scope of the observed changes in epidemiology among children and adolescents and at the same time enabling international comparisons of data from autonomous and world-wide clinics as the problem is the data availability at all. The article presents data on the explosion of gender identity disorders in children and adolescents based on the criterion of number of referrals to youth clinics from 8 countries: Sweden - an increase of 19,700%, Italy - 7,200%, Great Britain - 2,457%, the Netherlands - 904% and outside Europe: Australia - 12,650%, Canada - 538%, USA - 275%, and New Zealand - 187% (the article gives the exact time range). This data were also subjected to qualitative analysis (gender and age of reports, number of referrals versus diagnoses). The explanations given in the scientific literature were also collected and analyzed in relation to the available knowledge about the genesis of gender dysphoria, which, according to research, is predominantly of environmental origin. Both the scale of the trend and additional qualitative analyzes (change of the clinical picture and the inflow to clinics, especially of teenage girls), indicate that this trend cannot be explained only by an increase in social awareness, but also by the inducing influence of media and culture (additional studies that support these conclusions are mentioned). The article provides an overview of the available knowledge in the field of the epidemiology of gender identity disorders, especially in children and adolescents, and helps to define practical steps, especially in the neglected area of prevention, which is crucial from the point of view of parents.
... Some youth begin their gender transition process in adolescence (Churcher Clarke & Spiliadis, 2019). Such transitions can include using the school bathroom assigned to their gender and seeking access to gender-affirming hormone therapy. ...
Anti-transgender policies and state legislative initiatives that focus on school bathroom use and hormone use have emerged in recent years. These policies are generally written by and voted on by cisgender people, and as such, it is crucial to understand influences on nonaffirming attitudes toward policies that can impact trans youth. The present study aimed to extend research on transphobic attitudes in general to attitudes toward policies that impact youth undergoing transition. Latent variable covariances and structural equation modeling were used to test the relations between transphobia, genderism, homophobia, need for closure, sexual orientation, social dominance orientation, attitudes toward sexual minorities, beliefs about gender roles, aggression, religious fundamentalism, and contact with sexual and gender minority individuals, as they are related to attitudes toward hormone use and bathroom use for trans youth. Analyses of data from a sample of 248 cisgender adults indicated that genderism and transphobia was associated with attitudes toward gender-affirming hormone use and bathroom use for trans youth; need for closure was associated with gender-affirming attitudes toward bathroom use, but was not associated with hormone use. Sexual orientation was linked to attitudes toward gender-affirming policies, such that nonheterosexual participants had more affirming attitudes toward trans youths’ bathroom use, but not hormone use. Implications for future research, advocacy efforts to promote rights for trans youth, and clinical work with trans youth and/or parents/guardians of trans youth are discussed.
... But given the complexities of the gender dysphoria described in the current study, one might consider a low bar of "adequate" to be the exploration of factors that could be misinterpreted as non-temporary gender dysphoria as well as factors that could be underlying causes for gender dysphoria. The most recently emerging approach to gender dysphoria is called the "exploratory approach" which is a neutral psychotherapeutic approach to help individuals gain a deeper understanding of their gender distress and the factors contributing to their dysphoria (Churcher Clarke & Spiliadis, 2019;Spiliadis, 2019). The study's findings suggest that an exploratory type of approach may have been beneficial to some of the respondents. ...
The study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.
... In summary, the findings from the current study suggest that gender dysphoria in children arises in association with developmental pathways-reflected in at-risk patterns of attachment and high rates of unresolved loss and trauma-that are shaped by disruptions to family stability and cohesion, ACEs (including maltreatment), and SES (Golden and Oransky, 2019;Meyer-Bahlburg, 2019;Alonso-Zaldivar, 2020). Alongside other studies and perspectives (Bechard et al., 2017;Giovanardi et al., 2018;Churcher Clarke and Spiliadis, 2019;de Graaf and Carmichael, 2019;D'Angelo, 2020), this study confirms the importance of conceptualizing gender dysphoria by using a broad lens that takes into account the multiple factors that contribute to the child's distress, difficulties with adaptation, multimorbidity, and loss of health and well-being. From this broader perspective, neurobiological explanatory models of gender dysphoria must account for the child's lived experience-and that of preceding generations-in shaping brain development and in shaping brain networks involved in "own-body and self " (Altinay and Anand, 2020) experiences. ...
The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (χ² = 52.66; p < 0.001) and had a high rate of unresolved loss/trauma (χ² = 18.64; p < 0.001). Comorbid psychiatric diagnoses (n = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25–95/100; mean = 54.88; SD = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (χ² = 2.43; p = 0.30) and rates of unresolved loss and trauma (χ² = 0.70; p = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs—including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)—increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs.
... Si bien diversos profesionales e investigadores han mostrado su apoyo al estudio de Littman en tanto coincide con sus propias observaciones clínicas (p. ej., Clarke y Spiliadis, 2019;Hutchinson et al., 2019;Zucker, 2019), un importante sector del activismo trans ha disputado la existencia de la ROGD y ha acusado a Littman de promover una agenda política que deniega y menoscaba las identidades de muchos jóvenes trans (p. ej., ...
El objetivo de este trabajo consiste en examinar el desarrollo de la ciencia en torno a la disforia de género (DG) a través del marco analítico de la filosofía de la ciencia. En concreto, mi intención es estudiar qué factores han contribuido a la politización progresiva de la ciencia producida en este ámbito. Para ello utilizaré el modelo propuesto por la filósofa estadounidense Heather Douglas, para quien los valores no epistémicos sólo deben desempeñar un rol indirecto en los procesos de inferencia científica. Hablamos de ciencia politizada cuando dichos valores juegan un papel directo en el funcionamiento interno de la ciencia, siendo los únicos determinantes de la aceptación o el rechazo de hipótesis. Aplicando este modelo al caso específico de la tipología de la transexualidad de Blanchard, la disforia de género de inicio rápido (ROGD) y el tratamiento de niños y adolescentes con DG, trataré de demostrar que la ciencia en torno a la DG está politizada, de modo que son los valores no epistémicos de los profesionales e investigadores los que determinan qué ideas y procedimientos terapéuticos resultan aceptables. Todo ello tiene implicaciones para la disciplina en su conjunto y plantea importantes desafíos de cara al futuro.
... Rev Esp Salud Pública. 2020; 94: 16 de noviembre e202011123 detransición (42,43,44,45,46,47) . Detransicionar supone revertir los cambios médicos/quirúrgicos y administrativos conseguidos (42) . ...
Health care for transgender people in Spain has been progressively established since 1999 when the first multidisciplinary unit for the treatment of sex reassignment was created in Andalusia. In this document, the social changes, the demands and debates of users and professionals, the new models of health care for trans people, and reflections on the current situation, have been analysed. The social openness in Spain regarding sexual and gender diversity has evolved quite positively. The health demands of the transgender users are not uniform and do not always match with the criteria of the professionals. In some Spanish regions, health care is distancing itself from the internationally recommended multidisciplinary model. The new healthcare models have been established under the aegis of primary care and/or endocrinologist in the area, without a required psychological assessment. The main contributing factors for this change of model have been the pressure from some associations with demands for "depathologization" and "decentralization". The professionals of gender units, while recognizing the need for a broader vision of trans reality, warn of the risk of treating trans people without the involvement of mental health specialists or by professionals in proximity with little experience. Moreover, the decentralization would not allow acting on large cohorts, which hinders the advance of knowledge and contrasted evaluations with neighbouring countries. In summary, the new health models, although intended to facilitate care through proximity, do not guarantee improvements in quality and difficult to make a comparative evaluation of the results.
... Rev Esp Salud Pública. 2020; 94: 16 de noviembre e202011123 detransición (42,43,44,45,46,47) . Detransicionar supone revertir los cambios médicos/quirúrgicos y administrativos conseguidos (42) . ...
Health care for transgender people in Spain has been progressively established since 1999 when the first multidisciplinary unit for the treatment of sex reassignment
was created in Andalusia. In this document, the social changes, the demands and debates of users and professionals, the new models of health care for trans people, and
reflections on the current situation, have been analysed.
The social openness in Spain regarding sexual and gender diversity has evolved quite positively. The health demands of the transgender users are not uniform and do
not always match with the criteria of the professionals. In some Spanish regions, health care is distancing itself from the internationally recommended multidisciplinary model. The new healthcare models have been established under the aegis of primary care and/or endocrinologist in the area, without a required psychological assessment. The main contributing factors for this change of model have been the pressure from some associations with demands for “depathologization” and “decentralization”.
The professionals of gender units, while recognizing the need for a broader vision of trans reality, warn of the risk of treating trans people without the involvement of mental health specialists or by professionals in proximity with little experience. Moreover, the decentralization would not allow acting on large cohorts, which hinders the advance of knowledge and contrasted evaluations with neighbouring countries. In summary, the new health models, although intended to facilitate care through proximity, do not guarantee improvements in quality and difficult to make a comparative evaluation of the results.
... These individuals, searching for ways to understand and remedy their distress, can incorrectly attribute their discomfort to being transgender. Several case reports (Churcher Clarke & Spiliadis, 2019;Lemma, 2018;Spiliadis, 2019) indicate that the distress of young people with GD can lessen or resolve with appropriate psychotherapeutic interventions that address the central issues. ...
... Weder national noch international besteht ein Konsens über den Beginn einer (pubertätsunterdrückenden und/ oder geschlechtsangleichenden) Hormonbehandlung sowie über die zugrunde liegende ethische Auslegung der Problematik (Churcher Clarke & Spiliadis, 2019;Möller et al., 2018;Vrouenraets, Fredriks, Hannema, Cohen-Kettenis & de Vries, 2015). Die Diskussion bewegt sich im Spannungsfeld zwischen dem Persönlichkeitsrecht auf geschlecht liche Zeitschrift für Kinder-und Jugendpsychiatrie und Psychotherapie (2020), 48 (2), 93-102 © 2020 Hogrefe Da Geschlechtsidentität ein tiefes inneres, individuelles Erleben ist, das nicht objektiviert werden kann (Güldenring, 2015), erscheint die in der Populärwissenschaft aufgeworfene Frage nach "echten" und "Neo-Transsexuellen" nicht hilfreich. ...
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.
... If what has preliminarily been referred to as rapid onset gender dysphoria (ROGD) represents a new developmental pathway to gender dysphoria and transgender identification, one where psychosocial factors including social influence, trauma, homophobia, maladaptive coping mechanisms, and psychiatric disorders are contributing factors or even causal to identifying as transgender, it would disprove the premise that psychological issues can only be responses to negative experiences, not intrinsic to the process. If it is confirmed that one population of gender dysphoric individuals is harmed by approaches that affirm gender identity without questioning and benefits from extended clinical assessment (Clarke & Spiliadis, 2019) and a gender exploratory model (GEM) approach (Spiliadis, 2019), the evaluation process for gender dysphoric Gender dysphoria refers to the persistent discomfort from the incongruence between a person's experienced gender identity and their natal sex. The term gender incongruence refers to the difference between experienced gender identity and natal sex but discomfort or distress is not required. ...
... Self-injurious behaviors, suicidal ideation, and/or suicide attempts were common across the majority of cases reported. In 13 cases, current or past suicidality and/or self-harm were reported [18,19,20 [29]; however, trans youth with eating disorders appear to be a particularly high-risk group. Researchers who conducted a national survey of American college students found that trans youth with eating disorders were more than 20 times as likely to have attempted suicide in the past year than cisgender female youth with eating disorders or trans individuals who did not report eating disorder diagnoses [23•]. ...
Purpose of Review
This scoping review includes recent literature on eating disorder diagnoses and evaluation of eating disorder symptom presentation among transgender youth (ages 8–25).
Recent Findings
A total of 20 publications from the previous 5 years were identified, including case reports, retrospective chart reviews, and surveys. Significantly higher rates of eating disorder symptoms were documented in transgender youth compared to cisgender youth. Similarly, some studies reported transgender youth were more likely to be diagnosed with an eating disorder than cisgender youth, though the proportion of youth with eating disorder diagnoses varied across studies. A consistent theme across case studies was engagement in food restriction and/or compensatory eating behaviors to prevent puberty onset or progression, suggesting that for some transgender youth, these behaviors may be understood as a means of coping with gender-related distress.
Summary
Clinical care could be enhanced through establishment of best practices for screening in settings offering eating disorder treatment and gender-affirming care, as well as greater collaboration among these programs. Research is needed to validate eating disorder measures for use with transgender youth and evaluate the effects of eating disorder treatment and gender-affirming medical interventions on the well-being of transgender youth.
... In our experience, it is commonplace for clinicians to engage in conversations regarding this phenomenon (Churcher Clarke & Spiliadis, 2019). Furthermore, from speaking with international colleagues, it seems to us that this phenomenon is also being observed in North America, Australia, and the rest of Europe. ...
... However, in these populations, many young people have intersecting difficulties that could in themselves result in higher rates of self-harm. Many would meet the criteria for an Autism Spectrum Condition (ASC) (Glidden, Bouman, Jones, & Arcelus, 2016), with rates as high as 48% recently reported for those whose parents completed the Social Responsiveness Scale (Clarke & Spiliadis, 2019). Young people with an ASC have been found to have higher than average rates of self-harm (Minshawi, Hurwitz, Fodstad, Biebl, Morriss, & McDougle, 2014). ...
Background: Trans youth have been reported to have high rates of self-harm, depression and bullying, and find it difficult to seek support. However, much of this research comes from gender identity clinics; non-clinical samples and those who reject gender binaries remain under-researched.
Aims: This study investigated the experiences of a community school-based sample of Trans, identifying youth, Other, and cis-gendered adolescents in relation to their experiences of low mood, bullying, associated support, self-harm ideation and peer-related self-harm.
Methods: An online survey was completed by 8440 13–17 year olds (3625 male, 4361 female, 227 Other, and 55 Trans).
Results: Trans and Other students had significantly higher rates of self-harm ideation and peer self-harm, in comparison to cis-gendered students. These Trans and Other students reported significantly higher rates of bullying and self-reported depression and significantly less support from teachers and staff at school, in fact these students did not know where to go to access help.
Discussion: This community sample confirms findings of high rates of self-harm ideation, self-reported depression and bullying for Trans youth as previously reported in clinic-based samples. However, by accessing a community sample, the salience of the category “Other” was established for young people today. While Other and Trans identified students both struggled to find support, those who identified as Trans were more likely to have been bullied, and have experienced self-reported depression and thoughts of self-harm. Thus, those who identify as transgender represent a high-risk group that needs targeted support within schools and by statutory and nonstatutory community services. Unpacking the category of Other would be beneficial for future research, as well as exploring resilience within this group and intersecting identities such as sexuality, Autism, or experiences such as earlier abuse.
... Research also informs us that while there are stable young people whose gender incongruence is profound and long-standing, there are also young people now coming forward whose subjective beliefs about their gender identity may be held right now with extreme conviction -including meeting criteria for diagnosis of 'Gender Dysphoria' (American Psychiatric Association, 2013) -compared with more fluidity later in life (Churcher-Clarke & Spiliadis, 2019). Although it may be argued that the confident and sure knowledge of the lasting value of physical transition can be established unequivocally in early or mid-childhood, there is as yet little or no research evidence to underpin this claim. ...
The care of children and adolescents whose experience of the body is at odds with their gender feelings raises a number of questions that are as much ethical as medical or psychological. In this article I highlight some areas of ethical concern from the point of view of a senior clinician at the nationally commissioned UK Gender Identity Development Service (GIDS). I make the assumption that ethical deliberation is relational and grounded in the natural, social, political and institutional worlds in which the ethical questions arise. I try to show how matters of empirical fact, alongside an appreciation of broad social contexts, and historic and current power relations, provide an essential framework for the ways that ethical choices are framed by key groups of people as they take up different, sometimes opposing, ethical positions. I argue that practising ethically in such a service is not helpfully reduced to a single event, a treatment decision aimed at achieving the morally ‘right’ outcome, but an extended process in time. In the charged debate surrounding the recognition of these young people’s needs, we must do more to promote responsible debate about the scope of sound ethical practice.
This paper presents a composite case based on a group of female-to-male transitioners with a history of trauma due to early separation or family illness. These early traumas may interfere with the process of integrating the mind and body. Symptoms of gender dysphoria often arise from, or increase in response to, subsequent separations later in life, as individuals transition from childhood to adulthood. Increased referrals to gender clinics are noted at puberty or the point of separation from the family, as individuals face the prospect of leaving home to go to university. Affected by anxieties associated with the onset of puberty or separation anxieties, these individuals sometimes seek a medical transition to gain control over their bodies. Exploring underlying psychoanalytic issues can help clinicians assess various conscious and unconscious influences, and help patients make more informed decisions on whether to pursue a medical transition. A focus on defence mechanisms and forms of thinking can help clinicians find ways of working with individuals who may be highly defensive and concrete in their thinking and feel threatened by the functioning of their minds.
Is there a legitimate basis for religious exemptions from laws that prohibit gender identity discrimination on the basis of people’s beliefs? The author argues that much depends upon how gender dysphoria is understood. If it is seen as a problem requiring medical diagnosis and treatment, then arguably there is no religious basis for discrimination, except in a few situations where being a biological male or female is theologically essential to a particular role. Transgender identification, understood as a medical issue, fits within a belief system that God created two sexes of human beings, male and female. Within that belief system one can make room for an understanding that there are those who experience disorders of sex development and those who have such a profound sense of being born in the wrong body that they undertake steps toward medical transition to align their bodies, as far as possible, with the opposite sex. However, recent reinterpretations of what it means to be transgender involve an assertion that it should not be seen as a medical issue, that affirmation of a person’s self-declared gender identity, with or without having hormonal treatment or surgery, is a matter of human rights and that the law should recognize that people may have a gender that, however described, is nonbinary. These views rely on certain beliefs and positions that have a very weak basis in science. They challenge religious beliefs, which accord with mainstream scientific understanding, that human beings are intrinsically a sexually dimorphic species. People of faith need the freedom to reject beliefs that are incompatible with their worldviews. That does not mean that ill-treatment of someone on the basis of their gender identity can ever be justified; but it does support a religious exemption from a legal obligation to accept someone else’s self-declared gender identity. It is one thing to ask me to respect your beliefs about yourself. It is another to ask me to act toward you as if I share your beliefs.
There is significant disagreement about how to support trans-identified or gender-dysphoric young people. Different experts and expert bodies make strikingly different recommendations based upon the same (limited) evidence. The US-originating "gender-affirmative" model emphasizes social transition and medical intervention, while some other countries, in response to evidence reviews of medical intervention outcomes, have adopted psychological interventions as the first line of treatment. A proposed model of gender-affirming care, comprising only medical intervention for "eligible" youth, is described in Rosenthal (2021). Determining eligibility for these medical interventions is challenging and engenders considerable disagreement among experts, neither of which is mentioned. The review also claims without support that medical interventions have been shown to clearly benefit mental health, and leaves out significant risks and less invasive alternatives. The unreliability of outcome studies and the corresponding uncertainties as to how gender dysphoria develops and responds to treatment are also unreported.
Within the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.
Objective
To examine laws in three Australian jurisdictions that prohibit therapy to change or suppress a person’s sexual orientation or gender identity.
Conclusions
The laws in Victoria and the ACT provide inadequate protection for clinically appropriate psychiatric practice and may deprive patients of mental health care.
An increasing amount of literature revealed a link between GD and ASD. Both GD and ASD are complex and heterogeneous conditions characterized by a large variety of presentations. Studies have reported that individuals with GD tend to have higher prevalence rates of autistic traits in comparison to the general population. The purpose of this commentary is to pro- vide, through the description of a clinical case, our reading and a possible interpretation of the correlation of these two condi- tions in light of the several methodological limitations found in literature. We hypothesize that the traits often classified as autistic could be more accurately related to the distress and discomfort evoked by GD. The autistic traits of individuals with GD as forms of psychological defenses and coping mechanisms aimed at deal- ing with socio-relational and identity problems are discussed.
Introduction
Health care demand by transsexual people has recently increased, mostly at the expense of young and adolescents. The number of people who report a loss of or change in the former identity feeling (identity desistance) has also increased. While these are still a minority, we face more and more cases of transsexual people who ask for detransition and reversal of the changes achieved due to regret.
Objective
To report our experience with a group of transsexual people in detransition phase, and to analyze their personal experience and their associated conflicts.
Material and methods
A cohort of 796 people with gender incongruence attending the Identity Gender Unit of Doctor Peset University Hospital from January 2008 to December 2018 was studied. Four of the eight documented cases of detransition and/or regret are reported as the most representative.
Results
Causes of detransition included identity desistance, non-binary gender variants, associated psicomorbidities, and confusion between sexual identity and sexual orientation.
Conclusion
Detransition is a growing phenomenon that implies clinical, psychological, and social issues. Inadequate evaluation and use of medicalization as the only means to improve gender dysphoria may lead to later detransition in some teenagers. Comprehensive care by a multidisciplinary and experienced team is essential. As there are no studies reporting the factors predictive of detransition, caution is recommended in cases of atypical identity courses.
Negli ultimi anni è aumentata progressivamente la quantità di ricerche sulla co-occorrenza della varianza di genere e dei tratti associati allo spettro autistico, che vengono sempre più spesso indicati con il termine “neurodiversità”. Il presente contributo si propone di offrire una sintesi di quanto emerso sinora in letteratura scientifica sul tema, tenendo lo sguardo alle ricadute sul lavoro clinico. Dopo una parte introduttiva, saranno presentati i principali dati emersi dagli studi sulla co-occorrenza delle due condizioni, e le ipotesi che sono state sviluppate per comprendere la natura di tale associazione. Successivamente saranno delineate le prime indicazioni per il lavoro clinico emerse da studi quantitativi, qualitativi e da studi di casi. Infine saranno presentate le “Linee guida preliminari per la co-occorrenza dello spettro autistico e della disforia o incongruenza di genere nelle persone adolescenti” (Strang et al., 2018a), che sono il primo documento formale su questo tema. Il lavoro clinico in questo ambito richiede la presenza di una competenza specifica in entrambi gli ambiti, oppure la possibilità per il professionista specializzato in uno solo dei due di avvalersi della consulenza di un collega esperto dell’altro. Il coinvolgimento dei caregiver e dei familiari in tutto il processo diventa fondamentale sia nel consentire alla persona di esplorare la propria identità di genere, sia nell’attivare dei meccanismi che riducano il rischio di stigmatizzazione e vittimizzazione cui sono esposti, maggiormente rispetto ai pari, i bambini e gli adolescenti che presentano questa concomitanza di condizioni. Come si illustrerà nell’articolo, in ambito clinico e scientifico vi è molto dibattito intorno ai temi della transizione sociale precoce e della capacità di prestare il consenso informato ai trattamenti medici.
L’eterogeneità dei dati di letteratura e delle ipotesi sulla natura di questa associazione, la pluralità delle posizioni sulle modalità di presa in carico più funzionali di queste situazioni rispecchiano la complessità del tema e la necessità di proseguire il lavoro clinico e di ricerca.
[In recent years there has been an increase of the amount of research on the co-occurrence of gender variance and autism spectrum traits - a condition which is always more frequently defined as “neurodiversity”. This article aims at offering a synthesis of what literature outlined on this issue up until now, looking at the relevance of the findings to the clinical work. Following the introduction, I will present the main studies on the co-occurrence of the two conditions, and the hypotheses developed to understand the nature of such association. Afterwards, some preliminary indications for the clinical care will be drawn from the results of recent quantitative and qualitative research, and from case-studies as well. Finally the “Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents” (Strang et al., 2018a), will be introduced, as it is the first official document on this issue. The care in this field requires either a clinician who is trained in both the specialties, or the cooperation of two clinicians, one from each specialty. The engagement of the caregivers and the family across all the process is very important in order to make it possible for the young person to feel safe and supported in exploring gender identity, and also in order to reduce the risk for stigmatization and victimization. This risk, in fact, compared to the other peers, is higher for children and adolescents who present with this co-occurrence. In the clinical and scientific community there is a debate on the issues of social transition and of the capacity to give an informed consent to begin medical treatments. Heterogeneity of the data from literature and of the hypotheses on the nature of such association, along with the multiple point of views on the approaches which most safeguard the wellbeing of these children and adolescents, reflect the complexity of this issue and the need to continue with clinical and research work.]
Le persone con varianza o disforia di genere non sono un gruppo omogeneo ed è quindi fondamentale che ciascuno possa accedere a percorsi diversificati e confezionati su misura. Alcune possono esprimere la loro specificità scegliendo un abbigliamento consono, un nome e i pronomi relativi secondo l’identità percepita. Altri invece avranno bisogno di rivolgersi alle cliniche specializzate. Alcuni potranno arrivare a chiedere di adeguare il corpo alla identità percepita con interventi medico chirurgici, altri avranno bisogno di essere sostenuti a esplorare la propria specificità e a viverla positivamente nel contesto sociale.
Il lavoro clinico con le persone adolescenti con varianza o disforia di genere è complesso e richiede che i professionisti abbiano competenza sia nell’ambito della Disforia di Genere che della psicologia evolutiva. Questo lavoro si colloca infatti in un’area dell’esperienza umana in cui si incontrano corpo e mente, in un momento evolutivo in cui il corpo risulta saliente nella definizione della propria identità. Mantenere l’equilibrio nella complessità, difendere lo spazio di pensiero e riflessione risulta quindi prioritario. La presa in carico richiede un atteggiamento di accettazione verso l’esperienza soggettiva dell’adolescente e della sua famiglia con l’obiettivo di massimizzare le possibilità di sviluppo e benessere. È contemporaneamente necessario sostenere la possibilità di tollerare il disallineamento esperito tra corpo e identità di genere, quel tanto che serve per poter esplorare i possibili diversi percorsi che si prospettano. Le scelte che implicano un intervento medico infatti non sono le uniche possibili e, nel caso siano considerate utili e appropriate, implicano la capacità di comprendere e valutare le conseguenze della scelta.
Questo lavoro presenterà i modelli di intervento possibili, le tematiche controverse che interrogano i professionisti, le famiglie e gli adolescenti. Saranno presentati alcuni casi tesi ad esemplificare le tematiche illustrate, con l’obiettivo di evidenziare che i diversi modi di vedere questo argomento riflettono l’eterogeneità del gruppo di giovani con varianza di genere che si rivolgono ai Centri Specializzati, piuttosto che rappresentare dei quadri diagnostici e modelli di presa in carico che si escludono a vicenda.
[Gender variant and gender dysphoric people do not constitute a homogeneous group, so it is essential that each person has access to pathways that are tailored to individual needs and life context. Some may express their gender identity by choosing clothings, names, pronouns which are consistent with their experienced gender identity. Others can feel the necessity of turning to specialized gender clinics. Some of them will come to request access to gender-affirming medical interventions; others will need to explore their unique gender identity and expression, and to find a positive adjustment within the social context.
The clinical work with gender variant and gender dysphoric adolescents is complex and requires professionals to be well-trained both in relation to gender identity issues and to developmental psychology. Such work pertains to an area of human experience where body and mind meet, at a moment of life in which body plays a crucial role in the process of identity definition. Thus it is a priority to keep a balance and to create a thinking space; to be open and accept the subjective experience of the adolescents and their families, with the goal of maximizing the developmental potential and the personal and familial wellbeing. At the same time it is important to support the capacity of tolerating the perceived misalignment between body and gender identity as much as needed to explore the possible pathways of care. The approach which requires medical interventions, in fact, are not the only possible, and, when they are the choice, they entail the ability to understand and evaluate the consequences of the therapies.
This paper describes the possible intervention approaches, the controversies which challenge professionals, adolescents and their families. We will also use some clinical vignettes to exemplify the issues outlined in the article and to show how the many different ways of approaching this issue reflect the heterogeneity of adolescents with gender variance/gender dysphoria, rather than representing models of care that mutually exclude each other.]
This thesis focuses on understanding gender identity development in gender variant birthassigned female adolescents with Autism Spectrum Conditions (ASC), with the aim of elucidating the association between ASC and gender dysphoria identified by Gender Identity Development (GID) services worldwide. Part 1: This section presents a systematic review of the literature investigating the characteristics of children and adolescents referred to GIDs and other specialist services with gender dysphoria. The review focused specifically on demographics, psychiatric comorbidity and associated risks. There were 24 articles that met the criteria for review. The review indicates that there could be a notable delay between reported age of onset of gender dysphoric feeling and presentation to clinical services; shows that more birth-assigned females, compared to birth-assigned males, have been referred in recent years; more referrals come from white, compared to non-white, ethnic backgrounds proportional to what would be expected given the countries’ demographics; and the majority are sexually attracted to individuals of the same birth-assigned sex. There is also a high level of co-occurring mental health difficulties among gender dysphoric children and adolescents, and they are at elevated risk of self-harming and suicidal behaviour. Part 2: This section shows the results of a qualitative study using Constructivist Grounded Theory method. Interviews were conducted with ten clinically-referred gender variant adolescents aged between 15 and 18, who were birth-assigned female and had a diagnosis of ASC. Analysis of the semi-structured interviews identified a core category of ‘Journey Towards Understanding’, which consisted of three major categories that represent the consecutive stages of this journey: ‘Awareness of Difference’, ‘Experience of Incongruence’, and ‘Understanding Difference’. A final major category ‘Neurodiversity as a Facilitator of Change’ reflected the intrapersonal and interpersonal processes associated with having ASC that may have enabled the participants to make the transition towards living as (trans) males. Part 3: This section presents a critical appraisal outlining the political, socio-cultural and clinical context for the research, and how this influenced the researcher’s position. It also includes reflections on the conceptual and practical challenges faced by the researcher in designing and conducting qualitative research with gender variant young people with ASC. It demonstrates how specific methodological challenges, arising during four phases of the research process, were (or could have been) addressed: study design; recruitment; interviews with participants, and transcription and data analysis. Further implications for future research and clinical services are also considered.
Resumen
Introducción
La demanda de atención sanitaria a personas transexuales o con incongruencia de género ha aumentado en los últimos años, sobre todo a expensas de jóvenes y adolescentes. También en paralelo ha aumentado el número de personas que refieren una pérdida o modificación en el sentimiento de género inicialmente expresado. Aunque siguen siendo minoría, nos enfrentamos cada vez más a casos complejos de personas transexuales que solicitan detransicionar y revertir los cambios conseguidos por arrepentimientos.
Objetivo
Relatar nuestra experiencia con un grupo de personas transexuales en fase de detransición. Analizar su experiencia personal y los conflictos generados y reflexionar sobre estos procesos nunca antes descritos en España.
Material y métodos
Cohorte de 796 personas con incongruencia de género atendidas desde enero de 2008 hasta diciembre de 2018 en la Unidad de Identidad de Género del departamento Valencia Doctor Peset. De los 8 casos documentados de detransición y/o desistencia se relatan los 4 más representativos y que consideramos más ilustrativos de esta realidad.
Resultados
Las causas observadas que motivaron su detransición fueron la desistencia identitaria, las variantes de género no binarias, la psicomorbilidad asociada y la confusión entre identidad y orientación sexual.
Conclusión
La detransición es un fenómeno de presentación creciente que conlleva problemas clínicos, psicológicos y sociales. Una incorrecta evaluación y recurrir a la medicalización como única vía de mejora de la disforia en algunos jóvenes puede conducir a posteriores detransiciones.
Es fundamental una atención integral dentro de un equipo multidisciplinar con experiencia. A falta de más estudios que determinen posibles factores predictivos de detransición, es recomendable proceder con prudencia en casos de historias identitarias atípicas.
The number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological well‐being (Paediatrics, 2014, 134, 696). However, some people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231). Certainly, despite their presence in all follow‐up studies of young people who have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.
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.
Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.
The current literature shows growing evidence of a link between gender dysphoria (GD) and autism spectrum disorder (ASD). This study reviews the available clinical and empirical data. A systematic search of the literature was conducted using the following databases: PubMed, Web of Science, PsycINFO and Scopus; utilizing different combinations of the following search terms: autism, autism spectrum disorder (ASD), Asperger's disorder (AD), co-morbidity, gender dysphoria (GD), gender identity disorder (GID), transgenderism and transsexualism. In total, 25 articles and reports were selected and discussed. Information was grouped by found co-occurrence rates, underlying hypotheses and implications for diagnosis and treatment. GD and ASD were found to co-occur frequently - sometimes characterized by atypical presentation of GD, which makes a correct diagnosis and determination of treatment options for GD difficult. Despite these challenges there are several case reports describing gender affirming treatment of co-occurring GD in adolescents and adults with ASD. Various underlying hypotheses for the link between GD and ASD were suggested, but almost all of them lack evidence.
The present article maps out understandings about embodied distress among gender non-conforming youth. Feminist bioethics and queer-inflected clinical perspectives are used to inform thinking about ethical, non-pathologizing health care in the case of gender-related distress. Specific attention is directed at self-harming among gender variant and trans youth. This is contextualised in relation to the role that self harm plays for some LGBT youth, where it may be seen as a rite of passage or as reasonable and inevitable way of coping. The particular complexities of self harm among trans youth seeking clinical intervention are examined. Queer bioethics is proposed as potentially facilitating productive uncertainty with regard to the diverse imagined futures of gender variant and trans youth.
The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions. The aim of this study was to explicate the considerations of proponents and opponents of puberty suppression in GD to move forward the ethical debate.
Qualitative study (semi-structured interviews and open-ended questionnaires) to identify considerations of proponents and opponents of early treatment (pediatric endocrinologists, psychologists, psychiatrists, ethicists) of 17 treatment teams worldwide.
Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-)availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived. Strikingly, the guidelines are debated both for being too liberal and for being too limiting. Nevertheless, many treatment teams using the guidelines are exploring the possibility of lowering the current age limits.
As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.
Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.
Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013.
The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.
The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
In this review, we briefly summarize much of the existing literature on gender-related concerns and autism spectrum disorders (ASD), drawing attention to critical shortcomings in our current understanding and potential clinical implications. Some authors have concluded that gender identity disorder (GID), or gender dysphoria (GD), is more common in individuals with ASD, providing a range of potential explanations. However, existing literature is quantitatively limited, and our capacity to draw conclusions is further complicated by conceptual challenges regarding how gender identity is best understood. Discourses that emphasize gender as a component of identity formation are gaining prominence and seem particularly salient when applied to ASD. Individuals with ASD should enjoy equal rights with regard to treatment for gender dysphoria. Clinicians may be able to assist individuals in understanding this aspect of their identity by broadening the social frame and facilitating an exploration of gender roles.
The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females.
We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria.
The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006-2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam.
Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems.
Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria. Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries ALC, Kreukels BPC, and Zucker KJ. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med **;**:**-**.
© 2015 International Society for Sexual Medicine.
In this paper, I explore how postmodern ideas about gender may impact on clinicians working with gender variant children and adolescents. The postmodern turn has built on the feminist rejection of the idea of 'essential' gender, to further interrogate accepted conceptions of sex and gender and the stability of all identity categories. Some queer theorists have taken a further step, viewing all gender as fictional and artificial and celebrating the subversive potential of transgender identities. However, those working clinically with trans adolescents may experience a troubling tension between, on the one hand, a view of sex and gender categorisations as undecidable and fragmented (as postmodern theory suggests), and, on the other hand, the apparent need of many for a coherent and settled sense of self. In particular, how do we justify supporting trans youngsters to move towards treatment involving irreversible physical change, while ascribing to a highly tentative and provisional account of how we come to identify and live as gendered? I conclude that the meaning of trans rests on no demonstrable foundational truths but is constantly being shaped and re-shaped in our social world. Clinicians must be accountable in this process; far from succumbing to a paralysing relativism, the task for clinicians is to be highly attuned to our young clients' complex narratives and to question our complex investments in the positions we adopt. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Gender identity disorders (GID) in young people are complex and often distressing conditions. The paper starts by examining the experience of the professional worker resulting from the interaction with this group of young people and their families. This is frequently characterised by a sense of being under pressure and in danger. The view put forward is that the position of professionals often mirrors the mental state of these young people, which is described by the metaphor ‘working at the edge’. The issue of how to move to a position of safety for the young person and the professional is addressed. The paper describes a developmental model of care based on psychodynamic understanding, and distinguishes between conditions that are transient and conditions that persist during the course of development. Possible factors involved in the persistence of the ‘atypical gender identity organisation’ are considered based on Baron-Cohen's concepts of systemising and empathising. The therapeutic aims in working with these young people are revisited 10 years on from the first publication. Two contrasting cases are used to illustrate the persistence or desistence of the GID in the course of development. The paper concludes that while there is a tendency to move to provide hormonal interventions early for adolescents who are considered not amenable to change in their atypical gender identity, the integration of psychological, social and, when appropriate, hormonal interventions remains central to the provision of good standards of care.
Professionals working in a service for young people with Gender Identity Disorder (GID) often experience a particular type of pressure in the course of the work which makes thinking and decision-making very difficult. The paper suggests that an examination of the position of the professional and of the service, within the system may bring some relief and be a starting point to direct thinking and possibly action. The perceived position of the professional and of the Gender Identity Development Service within the wider organization of a psychotherapy and mental health trust is discussed. The paper makes reference to the model developed by Rom Harre et al. as described by Campbell and Groenbaek in their book Taking positions in the organisation. The position taken by the professional or the service is also explored as a possible re-enactment of the psychological dynamics of the young people with GID and their families. This view is based on Britton's paper on the re-enactment of individual and family dynamics in the professional network. A view is put forward that this dynamic leads the professional or the service to the risky position of “working at the edge”. The paper discusses processes which could facilitate the move from a position of being psychologically at an edge to the more secure position of being in the mainland. This involves exploration of the model of care and the relationship of the professional to the wider organization in which the service is located and to self-help organizations.
This study provided a descriptive and quantitative comparative analysis of data from an assessment protocol for adolescents referred clinically for gender identity disorder (n = 192; 105 boys, 87 girls) or transvestic fetishism (n = 137, all boys). The protocol included information on demographics, behavior problems, and psychosexual measures. Gender identity disorder and transvestic fetishism youth had high rates of general behavior problems and poor peer relations. On the psychosexual measures, gender identity disorder patients had considerably greater cross-gender behavior and gender dysphoria than did transvestic fetishism youth and other control youth. Male gender identity disorder patients classified as having a nonhomosexual sexual orientation (in relation to birth sex) reported more indicators of transvestic fetishism than did male gender identity disorder patients classified as having a homosexual sexual orientation (in relation to birth sex). The percentage of transvestic fetishism youth and male gender identity disorder patients with a nonhomosexual sexual orientation self-reported similar degrees of behaviors pertaining to transvestic fetishism. Last, male and female gender identity disorder patients with a homosexual sexual orientation had more recalled cross-gender behavior during childhood and more concurrent cross-gender behavior and gender dysphoria than did patients with a nonhomosexual sexual orientation. The authors discuss the clinical utility of their assessment protocol.
The use of gonadotropin-releasing hormone analogs (GnRHa) to suppress puberty in adolescents with gender dysphoria is a fairly new intervention in the field of gender identity disorders or transsexualism. GnRHa are used to give adolescents time to make balanced decisions on any further treatment steps, and to obtain improved results in the physical appearance of those who opt to continue with sex reassignment. The effects of GnRHa are reversible. However, concerns have been raised about the risk of making the wrong treatment decisions, as gender identity could fluctuate during adolescence, adolescents in general might have poor decision-making abilities, and there are potential adverse effects on health and on psychological and psychosexual functioning. Proponents of puberty suppression emphasize the beneficial effects of GnRHa on the adolescents' mental health, quality of life and of having a physical appearance that makes it possible for the patients to live unobtrusively in their desired gender role. In this Review, we discuss the evidence pertaining to the debate on the effects of GnRHa treatment. From the studies that have been published thus far, it seems that the benefits outweigh the risks. However, more systematic research in this area is needed to determine the safety of this approach.
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.
4 modes of reacting to the late adolescent identity crisis were described, measured, and validated. Criteria for inclusion in 1 of 4 identity statuses were the presence of crisis and commitment in the areas of occupation and ideology. Statuses were determined for 86 college male Ss by means of individual interviews. Performance on a stressful concept-attainment task, patterns of goal setting, authoritarianism, and vulnerability to self-esteem change were dependent variables. Ss higher in ego identity performed best on the concept-attainment task; those in the status characterized by adherence to parental wishes set goals unrealistically high and subscribed significantly more to authoritarian values. Failure of the self-esteem condition to discriminate among the statuses was attributed to unreliability in self-esteem measurement.
The care of children and adolescents whose experience of the body is at odds with their gender feelings raises a number of questions that are as much ethical as medical or psychological. In this article I highlight some areas of ethical concern from the point of view of a senior clinician at the nationally commissioned UK Gender Identity Development Service (GIDS). I make the assumption that ethical deliberation is relational and grounded in the natural, social, political and institutional worlds in which the ethical questions arise. I try to show how matters of empirical fact, alongside an appreciation of broad social contexts, and historic and current power relations, provide an essential framework for the ways that ethical choices are framed by key groups of people as they take up different, sometimes opposing, ethical positions. I argue that practising ethically in such a service is not helpfully reduced to a single event, a treatment decision aimed at achieving the morally ‘right’ outcome, but an extended process in time. In the charged debate surrounding the recognition of these young people’s needs, we must do more to promote responsible debate about the scope of sound ethical practice.
Inside Lives belongs to the heart of the thinking and working of the Tavistock Clinic. Its aim is to bring psychoanalytic theory to life, to make it accessible to a much wider range of readers, both lay and professional, than would normally be familiar with this kind of approach. In the simplest of terms it tells the most complex of stories: the story of the internal development of a person from infancy to old age. In so doing, it reflects and encompasses the generational structure of the clinic as a whole, tracing the interacting influences - between infant, child, adolescent and adult - on the nature and quality of emotional growth and development. This book provides a perspective on the relationship between psychoanalytic theory and the nature of human development, which is not currently available in written form. Following the major developmental phases from infancy to old age, the author lucidly explores those vital aspects of experience, which promote mental and emotional growth and those which impede it.
Studies of the broader autism phenotype, and of subtle changes in autism symptoms over time, have been compromised by a lack of established quantitative assessment tools. The Social Responsiveness Scale (SRS—formerly known as the Social Reciprocity Scale) is a new instrument that can be completed by parents and/or teachers in 15–20 minutes. We compared the SRS with the Autism Diagnostic Interview-Revised (ADI-R) in 61 child psychiatric patients. Correlations between SRS scores and ADI-R algorithm scores for DSM-IV criterion sets were on the order of 0.7. SRS scores were unrelated to I.Q. and exhibited inter-rater reliability on the order of 0.8. The SRS is a valid quantitative measure of autistic traits, feasible for use in clinical settings and for large-scale research studies of autism spectrum conditions.
Adolescents presenting with gender-related concerns are increasingly seeking support from providers from a variety of disciplines within health care settings across the world. For those treating young people who meet the criteria for the DSM 5 diagnosis of gender dysphoria (GD), complex decisions in clinical care are common. Defining best practice with this population with respect to interventions that span mental health, physical, and surgical domains can be challenging, given a relative dearth of empirical data available; yet practice guidelines have emerged from different professional organizations which can aid with this. For this review paper, a broad literature search was performed to identify relevant studies pertaining to the care of adolescents with GD. In addition, an overview of trends in clinical practice, including shifts in conceptualization of how clinicians and patients define care that is considered affirming when working with this population, is described. This paper explores the characteristics of referral patterns to specialized clinics, provides a brief overview of gender identity development in adolescence, and then describes the phenomenology of known aetiological factors and co-occurring psychiatric issues in adolescents with GD. Additionally, clinical management considerations that detail assessment aims and common treatment interventions across disciplines will be explored.
Purpose of review:
The review summarizes relevant research focused on prevalence and natural history of gender nonconforming/transgender youth, and outcomes of currently recommended clinical practice guidelines. This review identifies gaps in knowledge, and provides recommendations foci for future research.
Recent findings:
Increasing numbers of gender nonconforming youth are presenting for care. Clinically useful information for predicting individual psychosexual development pathways is lacking. Transgender youth are at high risk for poor medical and psychosocial outcomes. Longitudinal data examining the impact of early social transition and medical interventions are sparse. Existing tools to understand gender identity and quantify gender dysphoria need to be reconfigured to study a more diverse cohort of transgender individuals. Increasingly, biomedical data are beginning to change the trajectory of scientific investigation.
Summary:
Extensive research is needed to improve understanding of gender dysphoria, and transgender experience, particularly among youth. Recommendations include identification of predictors of persistence of gender dysphoria from childhood into adolescence, and a thorough investigation into the impact of interventions for transgender youth. Finally, examining the social environments of transgender youth is critical for the development of appropriate interventions necessary to improve the lives of transgender people.
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.
Introduction:
There is a growing clinical recognition that a significant proportion of patients with gender dysphoria have concurrent autism spectrum disorder (ASD).
Aim:
The purpose of this review is to systematically appraise the current literature regarding the co-occurrence of gender dysphoria and ASD.
Methods:
A systematic literature search using Medline and PubMed, PsycINFO, and Embase was conducted from 1966 to July 2015.
Main outcome measures:
Fifty-eight articles were generated from the search. Nineteen of these publications met the inclusion criteria.
Results:
The literature investigating ASD in children and adolescents with gender dysphoria showed a higher prevalence rate of ASD compared with the general population. There is a limited amount of research in adults. Only one study showed that adults attending services for gender dysphoria had increased ASD scores. Another study showed a larger proportion of adults with atypical gender identity and ASD.
Conclusion:
Although the research is limited, especially for adults, there is an increasing amount of evidence that suggests a co-occurrence between gender dysphoria and ASD. Further research is vital for educational and clinical purposes.
This paper explores multi-agency working and some lessons learnt when working with young people with complex presentations. Examples are offered from the work at the gender identity development service (GIDS) where the authors are based.
Accounts of the experiences of gender variant individuals that have recently received attention in the popular and psychoanalytic literature have led to an increased appreciation for the complex nature of identity; gender development; and the interaction of mind, body, and the social environment. Although there is still a great deal to be learned about the developmental trajectories of transgender identities that fall within what is a more familiar, male/female binary-based landscape, even less is known about developmental pathways for individuals whose gender identities remain neither comfortably male nor female. In this article, we present selected episodes reflecting our experiences as a family, drawn from over a 25-year period in which a gender variant individual, along with the rest of us, grew up. We tell this storyour family's storyto better understand what we have been through and learned, to help other families going through similar experiences, and as a thought-piece to clinicians and students of gender. The result is both a narrative and a meditation on the nature of gender identity and gender development.
This paper explores the place of certainty and uncertainty in therapeutic practice. It suggests that, for many, there has been a theoretical shift in the field of family therapy from a first to a second order perspective. To remain coherent with this shift in thinking requires a shift in practice in relation to this different way of thinking. The paper proposes one way of working towards this coherence through the use of a simple framework for working with uncertainty and highlights its application for a number of different contexts including training.
Foreword Arlene Vetere 1. Structural Family Therapy 2. A Family in Formation 3. A Family Model 4. A Kibbutz Family 5. Therapeutic Implications of a Structural Approach 6. The Family in Therapy 7. Forming the Therapeutic System 8. Restructuring the Family 9. A "Yes, But" Technique 10. A "Yes, And" Technique 11. The Initial Interview 12. A Longitudinal View Epilog
Research on internalized homophobia (IH) has linked it to both mental and physical health outcomes. Extant research indicates that IH and mental health are related in a variety of different subgroups of lesbian, gay and bisexual (LGB) persons. However, much of this research has suffered from methodological issues. Studies have frequently substituted distress-related constructs (e.g., self-esteem and general well-being) for measures of internalizing mental health problems. Furthermore, many studies have misapplied measures of IH designed for gay men with lesbian samples. The current study used Hierarchical Linear Modeling to perform meta-analysis. Effect sizes were combined across multiple studies that used dimensional measures of internalizing mental health problems (i.e., depression and anxiety). The use of multilevel modeling techniques allowed for the evaluation of moderating effects on these relationships, including those of gender, year of data collection, mean age of the sample, publication type, and type of symptomatology measured. Thirty-one studies were meta-analyzed for the relationship between IH and mental health (N=5831), revealing a small to moderate overall effect size for the relationship between the two variables. Higher levels of IH were associated with higher scores on dimensional measures of internalizing mental health problems. Significant moderating effects were also found for mean age of the sample and the type of symptomatology measured in each study. The relationship between IH and internalizing mental health problems was stronger in studies with a higher mean age. The relationship between IH and depressive symptomatology was stronger than the relationship between IH and symptoms of anxiety. Limitations and future research directions are discussed as well as implications for clinical practice.
Using detailed case examples, we contrast first- and second-order cybernetics approaches to family problems involving somatic symptoms in a family member. A second-order cybernetics approach views the reality of the problem as linguistically shaped by those interacting around it, including the therapist and observing team members. This co-constructed reality, the story of the problem, inadvertently contributes to the problem's endurance by narrowing the choice of more effective solutions. In our approach, the therapist elicits from each person his or her story about the illness in the family. The therapist then facilitates a therapeutic conversation that provides a context for new linguistic distinctions to be drawn, including the way mind and body may interact to generate the symptoms. Shifts in beliefs and behaviors follow, and more innovative solutions to the problem can then emerge. Unlike the approach in our previously published work based upon ecosystemic patterns as "system diagnoses," this approach uses only descriptions and explanations of the problem as are collaboratively constructed within this therapeutic conversation.
Studies of the broader autism phenotype, and of subtle changes in autism symptoms over time, have been compromised by a lack of established quantitative assessment tools. The Social Responsiveness Scale (SRS-formerly known as the Social Reciprocity Scale) is a new instrument that can be completed by parents and/or teachers in 15-20 minutes. We compared the SRS with the Autism Diagnostic Interview-Revised (ADI-R) in 61 child psychiatric patients. Correlations between SRS scores and ADI-R algorithm scores for DSM-IV criterion sets were on the order of 0.7. SRS scores were unrelated to I.Q. and exhibited inter-rater reliability on the order of 0.8. The SRS is a valid quantitative measure of autistic traits, feasible for use in clinical settings and for large-scale research studies of autism spectrum conditions.
In this article, we discuss the role of the therapist in change in couple and family therapy. We argue that the therapist is a key change ingredient in most successful therapy. We situate our discussion in the common factors debate and show how both broad and narrow common factor views involve the therapist as a central force. We review the research findings on the role of the therapist, highlight the strengths and weaknesses of this literature, and provide directions for future research. We then use this review as a foundation for our recommendations for theory integration, training, and practice.
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