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In Support of Research Into Rapid-Onset Gender Dysphoria

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Archives of Sexual Behavior
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
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
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though dicult, conversation about how to continue to do our
best for all of those who seek our help.
Ashley, F. (2019). Thinking an ethics of gender exploration: Against
delaying transition for transgender and gender creative youth.
Clinical Child Psychology and Psychiatry, 24, 223–236. https :// 04519 83646 2.
Bechard, M., VanderLaan, D. P., Wood, H., Wasserman, L., & Zucker,
K. J. (2017). Psychosocial and psychological vulnerability in
adolescents with gender dysphoria: A “proof of principle” study.
Journal of Sex and Marital Therapy, 43, 678–688. https ://doi.
org/10.1080/00926 23X.2016.12323 25.
Butler, G., de Graaf, N., Wren, B., & Carmichael, P. (2018). Assessment
and support of children and adolescents with gender dysphoria.
Archives of Disease in Childhood, 103, 631–636.
Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid o the box’:
The value of extended clinical assessment for adolescents presenting
with gender identity diculties. Clinical Child Psychology and Psy-
chiatry, 24, 338–352. https :// 04518 82528 8.
Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An analysis of all
applications for sex reassignment surgery in Sweden, 1960–2010:
Prevalence, incidence, and regrets. Archives of Sexual Behavior,
43, 1535–1545. https :// 8-014-0300-8.
Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015).
Two years of gender identity service for minors: Overrepresentation
of natal girls with severe problems in adolescent development. Child
and Adolescent Psychiatry and Mental Health, 9(1), 9. https ://doi.
org/10.1186/s1303 4-015-0042-y.
Levine, S. B. (2018). Transitioning back to maleness. Archives of
Sexual Behavior, 47, 1295–1300. https ://
Littman, L. (2018). Parent reports of adolescents and young adults per-
ceived to show signs of a rapid onset of gender dysphoria. PLoS ONE,
13(8), e0202330. https :// al.pone.02023 30.
Restar, A. J. (2019). Methodological critique of Littman’s (2018) parental-
respondents accounts of “rapid-onset gender dysphoria [Commen-
tary]. Archives of Sexual Behavior. https ://
Steensma, T. D., Biemond, R., de Boer, F., & Cohen-Kettenis, P. T.
(2011). Desisting and persisting gender dysphoria after childhood:
A qualitative follow-up study. Clinical Child Psychology and Psy-
chiatry, 16, 499 –51 6. https :// 04510 37830 3.
Steensma, T. D., & Cohen-Kettenis, P. T. (2015). More than two develop-
mental pathways in children with gender dysphoria? [Letter to the
Editor]. Journal of the American Academy of Child and Adolescent
Psychiatry, 54, 147 –14 8. https ://
Turban, J. L., & Keur roghlian, A. S. (2018). Dyna mic gender pr esenta-
tions: Understanding transition and “de-transition” among transgen-
der youth. Journal of the American Academy of Child and Adolescent
Psychiatry, 57, 451 –45 3. https ://
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional aliations.
... 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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Sex is defined functionally, in terms of gamete production, which is strictly binary and immutable. Traits thought sex-derived (or related), in being at some remove may not be sex-specific, utilising systems common across sex; however, apparently sex-overlapping traits serve to reinforce, not compromise sex binarity. Sexual identification and orientation might be expected to show degrees of sex non-separation, but seemingly through their very closeness in derivation from sex are themselves binary and immutable. Sexual orientation is of discrete (one majority and one minority aberrant) form; with bisexuality merely ostensible: male hypersexuality and female non-sexual tension reduction. Notions of sexual identity are chimeric: sex dysphoria is mostly latent homosexuality; the remainder intensified sexual self-orientation or psychopathology-driven social contagion of a condition imaginarily possessed.
... This discussion has occurred primarily in the context of data from a single online parental survey. (10,11) Although this parental study has generated controversy,(13) methodological and social critique, (12,14,15) and calls for additional research, (16,17) its hypotheses have not yet been tested on data from youth themselves. ...
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Although emergence of gender dysphoria at puberty is long established, a distinct pathway of rapid onset gender dysphoria was recently hypothesized based on parental data. Using adolescent clinical data, we tested a series of associations that would be consistent with this pathway, however, our results did not support the rapid onset gender dysphoria hypothesis.
OBJECTIVE Representatives of some pediatric gender clinics have reported an increase in transgender and gender diverse (TGD) adolescents presenting for care who were assigned female sex at birth (AFAB) relative to those assigned male sex at birth (AMAB). These data have been used to suggest that youth come to identify as TGD because of “social contagion,” with the underlying assumption that AFAB youth are uniquely vulnerable to this hypothesized phenomenon. Reported changes in the AMAB:AFAB ratio have been cited in recent legislative debates regarding the criminalization of gender-affirming medical care. Our objective was to examine the AMAB:AFAB ratio among United States TGD adolescents in a larger and more representative sample than past clinic-recruited samples. METHODS Using the 2017 and 2019 Youth Risk Behavior Survey across 16 states that collected gender identity data, we calculated the AMAB:AFAB ratio for each year. We also examined the rates of bullying victimization and suicidality among TGD youth compared with their cisgender peers. RESULTS The analysis included 91 937 adolescents in 2017 and 105 437 adolescents in 2019. In 2017, 2161 (2.4%) participants identified as TGD, with an AMAB:AFAB ratio of 1.5:1. In 2019, 1640 (1.6%) participants identified as TGD, with an AMAB:AFAB ratio of 1.2:1. Rates of bullying victimization and suicidality were higher among TGD youth when compared with their cisgender peers. CONCLUSION The sex assigned at birth ratio of TGD adolescents in the United States does not appear to favor AFAB adolescents and should not be used to argue against the provision of gender-affirming medical care for TGD adolescents.
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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.
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.
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Durante el siglo pasado, los profesionales de la medicina intentaron aliviar las tensiones internas de los transexuales ajustando su apariencia externa a sus identidades de género preferidas. En repetidos estudios se constató una reducción de la disforia de género mediante cirugías de reasignación de sexo y terapias hormonales. Aunque bienintencionados, estos esfuerzos fueron por sí solos insuficientes para aliviar la angustia subyacente causada por la disforia de género. Además, las personas transexuales, incluso después de los procedimientos de reasignación de sexo, tienen mayores riesgos de mortalidad, neoplasias, comportamientos suicidas y morbilidad psiquiátrica que la población general. Las terapias de conversión basadas en la fe duplican las tasas de morbilidad de los individuos transgénero. Un enfoque religioso no basado en la ciencia médica produce peores resultados que no proporcionar ningún tipo de apoyo. La falta de apoyo familiar y comunitario a los jóvenes transexuales conduce a un aumento de la falta de vivienda, la prostitución y el abuso de sustancias. El enfoque intransigente y de amor-duro no conduce a resultados positivos para muchos jóvenes transexuales. Las pruebas médicas de la década anterior sugieren una causa del neurodesarrollo para las identidades transgénero; sin embargo, los estudios sobre la disforia de género de inicio rápido apuntan a causas sociales para el pico de adolescentes que se identifican como transgénero. Mientras que las altas tasas de niños preadolescentes diagnosticados como transgénero desisten de su disforia, algunos estudios han demostrado que los adolescentes que toman bloqueadores hormonales no desisten hasta los veinte años. Se necesitan estudios de seguimiento a más largo plazo para conocer los efectos que tienen los bloqueadores hormonales en el desistimiento cuando se prescriben a tiempo. Los teóricos nominalistas del género han integrado las identidades transgénero en su ideología, según la cual el cuerpo, la mente y el espíritu no están esencialmente unidos. Aunque estas ideologías intentan liberar a los individuos de las restricciones del realismo biológico, esta ideología no ha ofrecido a las personas transgénero una sensación de paz interior. Según un estudio de la Campaña de Derechos Humanos de 2018, los individuos que se identifican como no binarios y otras identidades de género recién nombradas sufren los niveles más altos de depresión, ansiedad e intentos de suicidio. Bajo el paraguas transgénero se encuentran tres grupos de personas: (1) los que tienen disforia de género de inicio temprano, (2) los que tienen disforia de género de inicio rápido y (3) los teóricos del género que forman parte de la 4ª ola del feminismo. Las personas con disforia de género de inicio temprano padecen una condición médica que desiste en un 80% en la adolescencia; el 20% que persiste se beneficia de alguna forma de transformación social en el sexo opuesto. La gran mayoría de las personas que se autodenominan transgénero pertenecen a la segunda categoría, que son principalmente mujeres adolescentes. Al igual que las autolesiones y los trastornos alimentarios, este contagio social alcanza su punto álgido a los diecisiete años, desistiendo en la edad adulta. Los jóvenes autistas están muy afectados. Este grupo busca principalmente una identidad y una comunidad de apoyo. El teórico del género ha aprovechado este caos y ha presentado eficazmente la identidad transgénero como una forma de reinvención. Las personas con disforia de género necesitan apoyo, las que tienen confusión de género necesitan orientación y los teóricos del género necesitan ser desafiados filosóficamente. El realismo tomista ofrece recursos adicionales para los individuos transgénero, que la ciencia secular no puede ofrecer por sí sola. El tomismo abarca todas las disciplinas de la ciencia y las humanidades para presentar una expresión holística de la verdad. La heurística tomista utiliza la ciencia médica y busca restaurar la naturaleza por los medios menos invasivos, al tiempo que depende de las virtudes y la gracia para proporcionar sabiduría y carácter para superar los obstáculos. Este libro sostiene que el uso de una heurística tomista en consonancia con la enseñanza de la Iglesia es mejor que las terapias médicas por sí solas, la terapia de conversión basada en la fe o la adopción de una ideología de teoría de género basada en el nominalismo.
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Throughout the previous century, medical professionals aimed to ease the inner tensions found within transgender individuals by conforming their outer appearances to their preferred gender identities. Repeated studies have found a reduction of gender dysphoria through sex reassignment surgeries and hormone therapies. Although well-intentioned, these efforts were on their own insufficient for relieving the underlying distress caused by gender dysphoria. Moreover, transgender individuals, even after sex reassignment procedures, have higher risks of mortality, neoplasms, suicidal behaviors, and psychiatric morbidity than the general population. Faith-based conversion therapies double the morbidity rates of transgender individuals. A religious approach not based on medical science produces worse outcomes than providing no support at all. A lack of family and communal support of transgender youths leads to increased homelessness, prostitution, and substance abuse. The uncompromising, tough-love approach does not lead to positive outcomes for many transgender youths. Medical evidence from the previous decade suggests a neurodevelopmental cause for transgender identities; however, studies on Rapid-Onset Gender Dysphoria point to social causes for the spike of adolescents identifying as transgender. While high rates of pre-adolescent children diagnosed as transgender desist in their dysphoria, some studies have shown that adolescents who take hormone blockers do not desist into their early twenties. Longer-term follow-up studies are needed to know the effects hormone blockers have on desisting when prescribed early. Nominalist gender theorists have integrated transgender identities into their ideology, whereby the body, mind, and spirit are not essentially united. Although these ideologies attempt to liberate individuals from restrictions of biological realism, this ideology has not offered transgender people an inner sense of peace. According to a 2018 Human Rights Campaign study, individuals who identify as non-binary and other newly named gender identities suffer from the highest levels of depression, anxiety, and suicide attempts. Under the transgender umbrella are three groups of people: (1) those with early-onset gender dysphoria, (2) those with Rapid Onset Gender Dysphoria, and (3) gender theorists who are part of the 4th wave of feminism. Those with early-onset gender dysphoria suffer from a medical condition that desists at a rate of 80% by adolescence—the 20% who persist benefit from some form of social transformation into the opposite sex. The vast majority of people calling themselves transgender are from the second category who are mostly adolescent females. Like self-harm and eating disorders, this social contagion peaks at seventeen years of age, desisting in adulthood. Autistic young people are significantly affected. This group is primarily looking for an identity and supportive community. The gender theorist has capitalized on this chaos and effectively presented the transgender identity as a way of reinvention. Those with gender dysphoria require support, those with gender confusion need guidance, and gender theorists need to be philosophically challenged. Thomistic realism offers additional resources for transgender individuals, which secular science cannot offer on its own. Thomism embraces all disciplines of science and the humanities to present a holistic expression of the truth. The Thomistic heuristic utilizes medical science and seeking to restore nature by the least invasive means while depending on virtues and grace to provide wisdom and character to overcome obstacles. This book argues that using a Thomistic heuristic in line with church teaching is better than medical therapies alone, faith-based conversion therapy, or adopting a nominalist-based gender theory ideology.
Rational cognitive capacity is mostly completely acquired by the mid-teens. However, the auto-regulatory mental processes necessary to convert rational understanding to wise decisions—known as executive function—mature 10 years later. Legal capacity tends to be linked to ability to comprehend a problem rationally. In the US, the age of medical decisional competence is usually 18, though not in areas that have been carved out for public health reasons. In the UK it is 16, but earlier if rational understanding is demonstrable. Certainly, the question of deferring legal competence until the age of emotional maturity is a political non-starter in all developed nations, regardless of the emotional maturity of the older adolescent or the young adult. This chapter discusses important facets of decision-making under these conditions. This includes the role of parents.
This chapter addresses phenomena seen in children that represent departure from a gender essentialist viewpoint. This is the idea that normal people can be categorized as male or female, and that social behavior should ordinarily follow from biological sex. Gender essentialism is integral to most traditional religious and philosophical systems, but is now almost excluded from many academic and professional forums. This chapter discusses gender incongruity, and disorders of sexual differentiation, as examples of challenges to the gender essentialist viewpoint.
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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.
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Purpose In on-line forums, parents have been reporting that their children are experiencing what is described here as “rapid-onset gender dysphoria,” appearing for the first time during puberty or even after its completion. The onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity. The purpose of this study was to document and explore these observations and describe the resulting presentation of gender dysphoria, which is inconsistent with existing research literature. Methods Recruitment information with a link to a 90-question survey, consisting of multiple-choice, Likert-type and open-ended questions, was placed on three websites where parents had reported rapid onsets of gender dysphoria. Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. Data were collected anonymously via SurveyMonkey. Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. Open-ended responses from two questions were targeted for qualitative analysis of themes. Results There were 256 parent-completed surveys that met study criteria. The adolescent and young adult (AYA) children described were predominantly female sex at birth (82.8%) with a mean age of 16.4 years. Forty-one percent of the AYAs had expressed a non-heterosexual sexual orientation before identifying as transgender. Many (62.5%) of the AYAs had been diagnosed with at least one mental health disorder or neurodevelopmental disability prior to the onset of their gender dysphoria (range of the number of pre-existing diagnoses 0–7). In 36.8% of the friendship groups described, the majority of the members became transgender-identified. The most likely outcomes were that AYA mental well-being and parent-child relationships became worse since AYAs “came out”. AYAs expressed a range of behaviors that included: expressing distrust of non-transgender people (22.7%); stopping spending time with non-transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and only trusting information about gender dysphoria from transgender sources (46.6%). Conclusion Rapid-onset gender dysphoria (ROGD) describes a phenomenon where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood. ROGD appears to represent an entity that is distinct from the gender dysphoria observed in individuals who have previously been described as transgender. The worsening of mental well-being and parent-child relationships and behaviors that isolate AYAs from their parents, families, non-transgender friends and mainstream sources of information are particularly concerning. More research is needed to better understand this phenomenon, its implications and scope.
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Thirty-one years after living full time as a woman, a 53-year-old skilled machinist returned to have therapy with me, a psychiatrist, because of a decision to return to living as a man. As our work together continued, I suggested to this would-be published novelist that others might benefit from his experience. This led to his posting an extensive account of his life in September 2016 on Gender Trender. Now living in good mental and physical health as a male, he has given me permission to discuss his initial presentation, my understanding of his motivations, and to reflect on the broader questions that his life rises for the field of transgenderism. This report describes regret, defenses against regret, and a dramatic 3-day catharsis followed by the patient’s first loving relationship. He now ironically reflects that he escaped from the sensed inauthenticity of his youthful maleness only to create a felt inauthentic feminine social psychological state. The professional literature about the long-term outcome of the transgendered who do not have surgery is largely nonexistent in English. Anecdotal accounts, however, are readily accessible on the Internet.
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For adolescents with gender dysphoria, it has become common to be offered hormonal treatment to either delay or suppress pubertal development and/or to masculinize or feminize the body. At the same time, it has been our clinical impression that the psychological vulnerability of at least some of these youth has been overlooked. Fifty consecutive referrals of adolescents with a DSM-IV-TR diagnosis of Gender Identity Disorder (GID) constituted the sample. Information obtained at intake was coded for the presence or absence of 15 psychosocial and psychological vulnerability factors. The mean number of psychosocial/psychological vulnerability factors coded as present was 5.56 (range, 0-13). Over half of the sample had 6 or more of the vulnerability factors. The number of factors coded as present was significantly correlated with behavioral and emotional problems on the Youth Self-Report form and the Child Behavior Checklist, but not with demographic variables or IQ. The findings supported the clinical impression that a large percentage of adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability, thus supporting a "proof of principle" for the importance of a comprehensive psychologic/psychiatric assessment that goes beyond an evaluation of gender dysphoria per se.
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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.
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.
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.