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In Support of Research Into Rapid-Onset Gender Dysphoria

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Archives of Sexual Behavior
https://doi.org/10.1007/s10508-019-01517-9
LETTER TOTHEEDITOR
In Support ofResearch Into Rapid-Onset Gender Dysphoria
AnnaHutchinson1 · MelissaMidgen2· AnastassisSpiliadis3
Received: 12 June 2019 / Revised: 9 July 2019 / Accepted: 10 July 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
As clinicians used to working in the field of child and adoles-
cent gender identity development, dealing directly with the very
significant distress caused by gender dysphoria, and considering
deeply its multifactorial and heterogeneous etiology, we note
the current debate arising from Littman’s (2018) description of
a phenomenon she described as Rapid-Onset Gender Dyspho-
ria. Littmans paper on the subject was methodologically cri-
tiqued in this journal recently (Restar, 2019). While some of us
have informally tended toward describing the phenomenon we
witness as “adolescent-onsetgender dysphoria, that is, without
any notable symptom history prior to or during the early stages
of puberty (certainly nothing of clinical significance), Littman’s
description resonates with our clinical experiences from within
the consulting room.
In our experience, it is commonplace for clinicians to engage
in conversations regarding this phenomenon (Churcher Clarke
& Spiliadis, 2019). Furthermore, from speaking with interna-
tional colleagues, it seems to us that this phenomenon is also
beingobserved in North America, Australia, and the rest of
Europe. In addition, we are witnessing high levels of distress
and comorbidity. Bechard, VanderLaan, Wood, Wasserman, and
Zucker (2017) carried out a cohort study of referrals made for
adolescents into a gender identity service which showed a high
level of comorbid psychological diculty as well as psychoso-
cial vulnerability. They concluded that this supported a “proof of
principle” for the importance of a comprehensive psychological
assessment extending its reach beyond gender dysphoria. This
is consistent with a previously published paper from Finland
(Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, 2015) which
identified the phenomenon of an over-representation of ado-
lescent females with particularly complex needs presenting at
gender clinics.
While there is an ongoing debate about how many young
people with gender dysphoria will go on to live their lives as
trans-identified adults, what is certain is that it will not be all of
them. Each existing and inclusive follow-up study has described
a group who stop pursuing treatment (Turban & Keurroghlian,
2018), and this again echoes our clinical experiences.
Due to recent changes in patient demographics (Butler, de
Graaf, Wren, & Carmichael, 2018), we cannot yet know how
many of today’s patients will desist or de-transition in the future.
Existing literature on both young people and adults tells us that
there are a number of possible outcomes. Of course, many young
people with gender dysphoria will persist and thrive (Steensma,
Biemond, De Boer, & Cohen-Kettenis, 2011). Others may per-
sist and struggle (Dhejne, Öberg, Arver, & Landén, 2014). Some
may no longer identify as transgender and find a way to adapt
and thrive despite, or even perhaps because of, the process they
have been through (Ashley, 2019), and some will likely move
between these states (Steensma & Cohen-Kettenis, 2015). How-
ever, there is another group of people with gender dysphoria who
desist or de-transition and who then express distress as a result of
the path and/or treatments they have taken (Levine, 2018). We
have to assume that today’s young patients will go on to follow
any or all of the pathways that their predecessors took. While we
cannot know yet who will take which one, we do know that each
young person is our patient. We have a duty of care to them all,
whatever the outcome. That is why more research which may
help clarify diering patient cohorts must be welcomed.
The burden of treatment for trans-identifying people is sig-
nificant, whichever path they take. Any clinician working in
the field of child and adolescent mental health struggles with
the responsibility to provide ethical, meaningful, and eective
care. When working with gender dysphoria, this already grave
responsibility is heightened by the nature of the significant medi-
cal interventions that many young people seek. Unless we are
free to discuss, explore, and research dierential presentations
of gender dysphoria, the range of interventions which might best
serve each young person may not be available to them. We do not
think that this is good enough for our patients. We are grateful
to the academics and researchers involved in this much needed,
* Anna Hutchinson
dr.anna.hutchinson@integrated-psychology-clinic.com
1 55 Queen Anne Street, LondonW1G9JR, UK
2 Private Practice, London, UK
3 Maudsley Centre forChild andAdolescent Eating Disorders,
Maudsley Hospital, London, UK
Archives of Sexual Behavior
1 3
though dicult, conversation about how to continue to do our
best for all of those who seek our help.
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Publisher’s Note Springer Nature remains neutral with regard to
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... This form is overwhelmingly female and may be femalespecific, though a very small proportion of diagnoses are of males. As established by Littman (2018, and, in trivial correction after non-cogent critique, 2019), whose findings are endorsed by clinicians (e.g., Hutchinson, Midgen & Spiliadis, 2019;Zucker, 2019), it's a classic social contagion. ...
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Youth explore their genders – both theirs and those of others. Exploration is not only a vessel of discovery and understanding but also of creation. Centring the notion of gender exploration, this article inquires into the ethical issues surrounding care for transgender youth. Arguing that exploration is best seen not as a precondition to transition-related care but as a process that can operate through transitioning, the article concludes that the gender-affirmative approach to trans youth care best fosters youth’s capacity for healthy exploration. Unbounded social transition and ready access to puberty blockers ought to be treated as the default option, and support should be offered to parents who may have difficulty accepting their youth.
Article
The following clinical scenarios are composite cases that illustrate clinically important phenomena based on several patients. Jamie is a 19-year-old who was assigned a female gender at birth and had a history of major depressive disorder in remission. She presented to her primary care physician, psychiatrist, and psychotherapist reporting dysphoria related to gender and requesting gender-affirming hormone therapy. Jamie had symptoms for at least 6 months consistent with DSM-5 criteria for gender dysphoria. After full clinical assessment by her therapist, psychiatrist, and primary care physician, her integrated care team initiated gender-affirming hormone therapy and provided close follow-up from her mental health providers. For 13 months, Jamie was treated with testosterone, changed her pronouns to he/him/his, and began wearing traditionally masculine clothing. Throughout this period, she remained engaged in regular care with her psychotherapist, who was experienced in providing gender-affirming care. Eventually, Jamie informed her care team that after the trial of testosterone and much reflection, she had come to understand her identity as a queer woman and wished to discontinue hormone therapy. Jamie reported being pleased about the hormone therapy trial, because this allowed her to clarify her gender identity. She did not regret her social affirmation or any physical changes that occurred during this process, such as fat redistribution and minor facial hair growth, in the context of otherwise being healthy. Lupita is a 23-year-old who was assigned a male gender at birth and had a history of major depressive disorder and panic disorder. At 18 years of age, after a comprehensive evaluation, she initiated gender-affirming hormone therapy with her primary care provider, changed her name to "Lupita," changed her pronouns to she/her/hers, and started wearing more traditionally feminine clothing. That following year, she started attending college and faced continual gender-based harassment from other students as a result of her gender-nonconforming physical appearance. Her college health services were not affirming of her gender and referred to her repeatedly by her birth name and with he-series pronouns. Lupita became demoralized and after 5 months decided to de-transition. She became progressively more depressed and attempted suicide in her sophomore year. Then she transferred colleges, found gender-affirming clinical providers, and resumed estradiol and spironolactone (an antiandrogen) therapy and her social affirmation through name, pronouns, and style of dress. Her mood improved dramatically and she was able to graduate from college. Lupita now presents seeking breast augmentation surgery.