Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues

Abstract

This article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4) “rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who may have ROGD.

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Archives of Sexual Behavior
https://doi.org/10.1007/s10508-019-01518-8
Adolescents withGender Dysphoria: Reections onSome
Contemporary Clinical andResearch Issues
KennethJ.Zucker1
Received: 27 June 2019 / Revised: 9 July 2019 / Accepted: 10 July 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
This article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of
gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4)
“rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who
may have ROGD.
Keywords Gender dysphoria· Gender identity· Rapid-onset gender dysphoria· Sex ratio· Suicidality· DSM-5
Increased Referrals ofAdolescents
toSpecialized Gender Identity Clinics
Eleven years ago, my colleagues and I published a Letter to
the Editor entitled “Is Gender Identity Disorder in Adolescents
Coming Out of the Closet?” (Zucker, Bradley, Owen-Anderson,
Kibblewhite, & Cantor, 2008). This rhetorical question was
based on the observation that, in our clinic, there had been a
sharp increase in the number of assessed adolescent patients for
the years 2004–2007, compared to prior 4-year intervals going
back to 1976–1979. In the Letter, we borrowed a line from
the 1967 song “For What It’s Worth” by Buffalo Springfield:
“There’s something happening here. What it is ain’t exactly
clear.”
The increase in the number of assessed adolescent patients
rose sharply for the subsequent 4-year interval (2008–2011)
(Wood etal., 2013), suggesting that the prior increase was not a
fluke fluctuation. Over the past several years, the increase in the
number of adolescents referred to specialized gender identity
clinics/programs has become an international phenomenon,
observed all across North America, Europe, Scandinavia, and
elsewhere (e.g., Beard, 2019; de Graaf, Giovanardi, Zitz, &
Carmichael, 2018b; Frisén, Söder, & Rydelius, 2017; Kaltialo-
Heino etal., in press). Beard noted that at a specialized gender
identity service in Ottawa, Ontario, there were 189 referrals in
2018 compared to “one or two patients” a decade prior. de Graaf
etal. reported that at the Gender Identity Development Service
in London, England the number of referred adolescents in 2009
was 39 but in 2016 had risen to 1497 (see also Gilligan, 2019)!
This increase in adolescent referrals has been characterized by
Marchiano (2017) as an “outbreak.”
Several, likely interconnected, explanations have been
offered to explain this increase: (1) the visibility given to
transgender issues in print media, television, etc.; (2) the
Internet, which provides innumerable sites to read about
gender dysphoria and transgender care; (3) the gradual
depathologization/stigma reduction with regard to gender
dysphoria and a transgender identity; and (4) the availability
of biomedical treatment, including hormonal delay or sup-
pression of somatic pubertal development (de Vries, Klink,
& Cohen-Kettenis, 2016). Taken together, perhaps all of these
factors have made it psychologically easier to seek out mental
health care by adolescents and their families (reflected in the
“affirmative” care model adopted by many gender identity
clinics and teams [see, e.g., Edwards-Leeper, Leibowitz, &
Sangganjanavich, 2016]).
Alteration intheSex Ratio ofAdolescents
withGender Dysphoria
During the same time period in which the number of adoles-
cents referred for gender dysphoria began to increase, there
has been another development: a shift in the sex ratio from one
favoring birth-assigned males to one favoring birth-assigned
* Kenneth J. Zucker
ken.zucker@utoronto.ca
1 Department ofPsychiatry, University ofToronto, Toronto,
ONM5T1R8, Canada
SPECIAL SECTION: CLINICAL APPROACHES TOADOLESCENTS WITHGENDER DYSPHORIA

Archives of Sexual Behavior
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females (Aitken etal., 2015). Aitken etal. reported on the sex
ratio of adolescents from two gender identity clinics: one in
Toronto and the other in Amsterdam. In Toronto, the male-to-
female sex ratio for the years 1999–2005 was 2.11:1, whereas
for the years 2006–2013 it was 1:1.76. For these same two
time periods, the male-to-female sex ratio for adolescents
referred for any other reason to the same hospital-based child
and youth program favored males: 2.21:1 (1999–2005) and
1.96:1 (2006–2013).1 In Amsterdam, the male-to-female sex
ratio for the years 1989–2005 was 1.41:1, whereas for the years
2006–2013 it was 1:1.72.
A subsequent meta-analysis by Zucker and Aitken (2019)
has shown that this altered sex ratio cuts across many other
clinic-referred samples, suggesting strong generalizability (cf.
Ashley, 2019; Zucker, VanderLaan, & Aitken, 2019). In some
clinics, the male-to-female sex ratio is remarkably skewed in
favor of females (e.g., Hamburg, Germany: 1:4.29 [Levitan,
Barkmann, Richter-Appelt, Schulte-Markwort, & Becker-
Hebly, 2019]; Helsinki, Finland: 1:6.83 [Sumia, Lindberg,
Työläjärvi, & Kaltiala-Heino, 2017]). The sex ratio favor-
ing females is even stronger when youth who self-identify as
transgender, gender queer, or other alternative gender identity
labels that depart from the binary are recruited from (non-
representative) community samples. For example, in the U.S.,
the Human Rights Campaign (2018) LGBTQ report sampled
adolescents between the ages of 13–17years. Of those who
self-identified as transgender (N = 1589), the male-to-female
sex ratio was 1:7.58; of those who self-identified as non-binary
(N = 4048), the male-to-female sex ratio was 1:7.52 (R. J. Wat-
son, personal communication, May 22, 2018). However, the
female-biased sex ratio is much less skewed in representative
samples of high school students who self-identify as transgen-
der or with some other gender-variant identity label. For exam-
ple, Eisenberg etal. (2017) found a male-to-female sex ratio
of 1:2.13 among Grade 9 and 11 students (N = 2141) in Min-
nesota and Kaltialo-Heino and Lindberg (2019) found a male-
to-female sex ratio of 1:2.09 among high school students in
Finland (N = 781).
How might we understand this shift in the sex ratio? To some
extent, the answer to this question depends on what is known
about the “true prevalence” of gender dysphoria, taking into
account natal sex. Unfortunately, there are really no good epi-
demiological studies on the prevalence of a DSM-based diagno-
sis of gender dysphoria among adolescents (or its predecessor
diagnostic label, gender identity disorder) (Zucker, 2017). The
few new representative samples of high school students who
self-identify as transgender or who adopt some other alternative
gender identity label to the binary suggest a higher prevalence
in birth-assigned females, but it is very likely that not all of
these youth would meet formal diagnostic criteria for gender
dysphoria. Thus, one needs to be cautious in assuming that
the true prevalence of gender dysphoria favors birth-assigned
females or if there are social factors that might account for the
disparity. One possibility pertains to stigma. For example, per-
haps behavioral masculinity (or behavioral “androgyny”) in
birth-assigned females is subject to less social ostracism than
behavioral femininity in birth-assigned males. If this conjecture
is correct, then perhaps fewer birth-assigned males feel com-
fortable coming out as transgender and, therefore, are less likely
to present at specialized gender identity clinics. It is conceiva-
ble, therefore, that, with further destigmatization, it will become
easier for birth-assigned males to “come out” as transgender
and the sex ratio will move closer to parity. Another possibility
is related to the observation that gender-variant/gender noncon-
forming behavior is more common in birth-assigned females
than in birth-assigned males (from childhood onwards). If this
is, in fact, the case, then it would imply that there would be a
greater percentage of birth-assigned females at the “gender-
atypical” side of the bell curve. In the contemporary era of
increased destigmatization, perhaps more of these females are
self-identifying as transgender or some other gender-variant
self-identity and, as a result, more are presenting at specialized
gender identity clinics.
Mental Health inAdolescents withGender
Dysphoria: The Suicidality Discourse
Based on a variety of measurement approaches (e.g., standard-
ized parent or self-report questionnaires, structured psychiatric
diagnostic interview schedules, etc.), it has been found that
adolescents referred for gender dysphoria have, on average,
more behavioral and emotional problems than non-referred
adolescents, but are more similar than different when compared
to adolescents referred for other mental health concerns (e.g.,
Becerra-Culqui etal., 2018; Chiniara, Bonifacio, & Palmert,
2018; Connolly, Zervos, Barone, Johnson, & Joseph, 2016;
de Graaf etal., 2018a; de Vries, Doreleijers, Steensma, &
Cohen-Kettenis, 2011; de Vries, Noens, Cohen-Kettenis, van
Berckelaer-Onnes, & Doreleijers, 2010; de Vries, Steensma,
Cohen-Kettenis, VanderLaan, & Zucker, 2016; Fisher etal.,
2017; Kuper, Mathews, & Lau, 2019; Shiffman etal., 2016;
Steensma etal., 2014; van der Miesen, de Vries, Steensma, &
Hartman, 2018; Zucker etal., 2012; for reviews, see Russell &
Fish, 2016; Spivey & Edwards-Leeper, 2019; Zucker, Wood,
& VanderLaan, 2014).
There are several ways to conceptualize the elevated rate
of co-occurring mental health issues among adolescents with
gender dysphoria. In some instances, it may be that the gen-
der dysphoria has emerged as secondary to another, more
1 Aitken et al. (2015) also reported on the sex ratio of adolescents
seen in the Toronto clinic between 1976 and 1998, where the male-
to-female sex ratio was 1.51:1 (but corresponding clinical control data
were not available).

Archives of Sexual Behavior
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“primary” mental health diagnosis, such as autism spectrum
disorder or borderline personality disorder, or as a result of
a severe trauma (e.g., sexual abuse). Another explanation is
that gender dysphoria is inherently distressing, i.e., the marked
incongruence between one’s felt gender and somatic sex—even
within psychosocial milieus that are largely “affirming/support-
ive”—which leads to clinically significant symptoms such as
anxiety or depression. A more common explanation (and one
that is often favored by “gender-affirming” clinicians and theo-
rists) is that the co-occurring mental health issues are simply
secondary to factors such as family rejection or social ostracism
within the peer group vis-à-vis the gender dysphoria (see, e.g.,
Grossman, Park, & Russell, 2016; Janssen & Leibowitz, 2018;
McDermott, Hughes, & Rawlings, 2017).
In this broader context of co-occurring mental health issues,
concern about suicide risk has become a topic of intense focus
in recent years (see, e.g., Tanis, 2016). On the Internet, for
example, one might come across the comment made by some
parents “I would rather have a trans kid than a dead kid” (see,
e.g., Biggs, 2018; Digitale, 2017; “I’d Rather Have a Living
Son Than a Dead Daughter,” 2016) and instances of completed
suicide receive intense media scrutiny (e.g., Bever, 2016; Savva
& Small, 2019). Indeed, Karasic and Ehrensaft (2015) asserted
that completed suicides are “alarmingly high”—a statement
which, in my view, has no formal and systematic empirical
basis. In fact, I would argue that the statement itself is alarming.
So, what do we know about suicidality among adolescents
with gender dysphoria? In addition to the case report litera-
ture (e.g., Acosta, Qayyum, Turban, & van Schalkwyk, 2019;
Alastanos & Mullen, 2017; Rice etal., 2016), a number of
studies from specialty gender identity clinics have reported on
the percentage of adolescents with gender dysphoria with a his-
tory of suicidal ideation and/or self-harm and suicide attempts.
These studies have relied on clinical chart information, parent’s
report or self-report. For example, in one clinical chart study
(N = 69), Di Ceglie, Freedman, McPherson, and Richardson
(2002) found a history of self-harm and self-injurious behavior
in 23% and 22% of the adolescents, respectively. Subsequent
studies have also provided descriptive data on the percentage
of patients where suicidality (thoughts and behaviors) has been
endorsed, with sample sizes ranging from 34 to 203 (Becker,
Gjergji-Lama, Romer, & Möller, 2014; Holt, Skagerberg, &
Dunsford, 2016; Kaltiala-Heino, Sumia, Työläjärvi, & Lind-
berg, 2015; Khatchadourian, Amed, & Metzger, 2014; Olson,
Schrager, Belzer, Simons, & Clark, 2015; Peterson, Matthews,
Copps-Smith, & Conrad, 2017; Skagerberg, Parkinson, & Car-
michael, 2013; see also Mann, Taylor, Wren, & de Graaf, 2019).
Not surprisingly, it is almost always the case that there were
higher rates for suicidal ideation than for self-harm and/or sui-
cide attempts. There is also a literature on suicidality among
non-clinic-based samples of adolescents with gender dysphoria
or who self-identify as transgender (e.g., Butler etal., 2019;
Johns etal., 2019; Katz-Wise, Ehrensaft, Vetters, Forcier, &
Austin, 2018; Kidd, Gaetz, & O’Grady, 2017; Perez-Brumer,
Day, Russell, & Hatzenbuehler, 2017; Toomey, Syvertsen, &
Shramko, 2018; Veale, Watson, Peter, & Saewyc, 2017). These
studies also report what would appear to be high rates of sui-
cidal ideation and of self-harm or suicide attempts.
Apart from measurement issues (most of these studies used
fairly crude metrics of suicidality), there are at least two other
methodological issues that deserve some reflection. First, in
general, the clinic-based samples did not employ any type of
comparison group, such as a group of adolescents referred
for any other type of mental health concern or even a non-
referred comparison group. Second, in the non-clinic-based
samples, when a comparison group was used, it was limited
to “cisgender” adolescents, but without taking into account
the mental health status of these youth. For example, Perez-
Brumer etal. (2017) reported that the past 12-month rate of
self-reported suicidal ideation among transgender adolescents
was 33.73% (N = 280) compared to 18.85% of non-transgender
adolescents (N = 25,213) (see Perez-Brumer etal.’s Table1 for
their weighted subsample data). Toomey etal. (2018) reported
a very high rate of self-reported lifetime suicide attempts
among transgender birth-assigned females (50.8%) compared,
for example, to a 17.6% rate among cisgender birth-assigned
females. If one wanted to make the argument that at least some
of the transgender students would meet the criteria for a mental
health diagnosis of gender dysphoria, then one would want
to make a comparison with the cisgender or non-transgender
students who also had one mental health diagnosis (say, for
example, anxiety or depression). This would allow for a more
nuanced comparative analysis to see whether or not suicidal-
ity is higher, similar, or lower among adolescents with gender
dysphoria when compared to some type of clinical comparison
group.
de Graaf etal. (2019) measured suicidal ideation and self-
harm/suicide attempts using two items from the Child Behavior
Checklist (CBCL) or the Youth Self-Report Form (YSR) (Item
91: “Talks about killing self”; Item 18: “Deliberately harms
self or attempts suicide”). Both items were rated on a 0–2-point
scale (“Not true,” “Somewhat or sometimes true,” “Very true”),
with the time frame “now or within the past 6months.” The
sample consisted of adolescents referred for gender dysphoria
from three clinics: Toronto, Amsterdam, and London (total
N = 2065). In addition to between-clinic comparisons, the per-
centage of adolescents in which these two items were endorsed
was compared with the CBCL/YSR referred and non-referred
U.S. standardization samples (Achenbach & Rescorla, 2001).
Although there was, at times, significant between-clinic
variation in the percentage of adolescents for whom these two
items were rated as either a 1 or a 2, the key point that I wish to
make here is that the rate of suicidality was, in general, much
more similar to that of the referred adolescents than to the non-
referred adolescents from the CBCL/YSR standardization sam-
ples. For example, on CBCL Item 91 for birth-assigned females

Archives of Sexual Behavior
1 3
from the three gender identity clinics, the percentages were as
follows: Toronto (32.5%), Amsterdam (26.9%), and London
(33.3%). The corresponding percentages from the standardiza-
tion samples were: referred (34.9%) and non-referred (2.7%).
Thus, it was very clear that on the CBCL/YSR, adolescents
referred for gender dysphoria show higher rates of suicidality
when compared to non-referred adolescents, but are much more
similar to referred adolescents (presumably, the vast major-
ity were cisgender) in general. In multiple regression analysis,
the strongest predictor of a composite sum score of the two
suicidality metrics was the number of other behavioral and
emotional problems rated as a 1 or a 2 on the CBCL or YSR.
Thus, one could argue that the presence of suicidal ideation or
behavior among adolescents with gender dysphoria should con-
textualize an understanding of it in relation to broader mental
health issues that these youth may be struggling with.
The risk of suicidality is obviously not unique to adolescents
with gender dysphoria but is a risk among referred adolescents
in general. Thus, it is likely the case that both groups share
certain factors that make them vulnerable to suicidal feelings
and behavior. For example, in the Perez-Brumer etal. (2017)
study, self-reported depression over the past 12months and
self-reported school-based “victimization” experiences (of
various types) increased the odds of suicidal ideation in both
the transgender students and the non-transgender students.
However, I would not want to make the argument that the path-
ways that lead to suicidality are fully identical in both groups
of students. In this regard, the concept of equifinality should be
considered (Cicchetti & Rogosch, 1996), i.e., that there are sev-
eral pathways leading to the same outcome, and some of these
pathways may be unique to adolescents with gender dysphoria.
From a treatment perspective, therefore, one can consider
both non-specific and specific factors that might reduce the
risk of suicidality. Regarding the latter, for example, it has
been argued that (perceived) social support of an adolescent’s
transgender identity reduces the risk of suicidality (Bauer,
Scheim, Pyne, Travers, & Hammond, 2015). In another com-
munity-based study, it was found that the number of social
settings in which adolescents felt comfortable in using their
preferred name was associated with less suicidal ideation and
behavior (Russell, Pollitt, Li, & Grossman, 2018). Lastly, in
a clinic-based study, Allen, Watson, Egan, and Moser (2019)
reported that commencement of “gender-affirming” hormonal
treatment was related to a decrease in self-reported suicidal
feelings.
“Rapid‑Onset” Gender Dysphoria: ANew
Developmental Pathway?
It has long been known that there are at least two developmental
pathways that lead to gender dysphoria. In early-onset gender
dysphoria, the signs and symptoms are apparent from an early
age (e.g., the preschool years, if not even a bit earlier). In late-
onset gender dysphoria, the signs and symptoms do not appear
until puberty, if not later. Early-onset gender dysphoria occurs
in both birth-assigned males and birth-assigned females and is
strongly associated with a same-sex sexual orientation (andro-
philia in birth-assigned males and gynephilia in birth-assigned
females). In the older clinical literature, late-onset gender dys-
phoria was delimited to birth-assigned males, in association
with transvestic fetishism and/or autogynephilia (Blanchard,
1991, 1993; Lawrence, 2010, 2017). Since the 1990s, however,
there have been more reports of birth-assigned female adults
who appear to have the late-onset form of gender dysphoria
and, among this subgroup, an androphilic sexual orientation is
not uncommon (see Lawrence, 2010); however, to my knowl-
edge, there is little indication that this subgroup shows signs
of transvestic fetishism or the mirror image of autogynephilia,
namely, autoandrophilia. Moreover, I would argue that, in a
comparative perspective, late-onset gender dysphoria contin-
ues to be much more common in birth-assigned males than in
birth-assigned females. In the older clinical literature on adults,
there was more hesitancy in recommending gender-affirming
treatments for late-onset patients, particularly gender-affirming
surgery, but this is much less the case nowadays although there
is still some caution (for a reflective consideration, see, e.g.,
Sevlever & Meyer-Bahlburg, 2019).
Over the past dozen or so years, it is my view (and that of
others) that a new subgroup of adolescents with gender dyspho-
ria has appeared on the clinical scene. This subgroup appears
to be comprised—at least so far—of a disproportionate per-
centage of birth-assigned females who do not have a history
of gender dysphoria in childhood or even evidence of marked
gender-variant or gender nonconforming behavior. As noted by
Littman (2018), a push to start thinking about these adolescents
has come from online discussion groups formed by parents,
such as the U.S.-based listserve 4thwavenow (https ://4thwa
venow .com). Because many of these parents were of the view
that their adolescent child’s gender dysphoria appeared “out-of-
the-blue,” it has been given the provisional label of “rapid-onset
gender dysphoria” (ROGD).
To my knowledge, only the study by Littman (2018) has, to
date, attempted to examine this putatively new phenomenon in a
systematic manner. Littman’s online study recruited 256 parents
(82.8% were parents of birth-assigned females) by advertising
on three websites where parents had reported ROGD. Littman
identified several factors that were deemed to be associated with
ROGD, including “clusters” of gender dysphoria within a group
of peers and intense immersion in social media pertaining to
what could be called transgender subculture (which Littman
characterized as “social and peer contagion”), a high rate of
mental health diagnoses and various psychosocial stressors that
preceded the onset of gender dysphoria, and a worsening of
psychosocial functioning and parent–child relationships after
“coming out” as transgender. From Littman’s (2018) Table2,

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1 3
it appears that the sexual orientation of these youth is much
more variable if one compared the percentage with the sexual
orientation of early-onset youth with gender dysphoria.
The response to Littman’s (2018) study has been quite
intense, including considerable media attention, both within
and outside the scientific community (Wadman, 2018). In
Google, the search term “rapid onset gender dysphoria” yielded
a mere 310,000 “results” (on June 26, 2019). On the one hand,
parents of these adolescents have felt “validated” in the sense
that their personal observations and experiences have led to an
initial empirical study and some clinicians have welcomed the
discourse, as Littman’s study is consistent with their own clini-
cal observations (e.g., Hutchinson, Midgen, & Spiliadis, 2019).
On the other hand, it has elicited methodological critique (e.g.,
Restar, 2019) and charges of “bad science” (Ashley & Baril,
2018) (for a summary, see https ://en.wikip edia.org/wiki/Rapid
_onset _gende r_dysph oria_contr overs y). One well-known clini-
cian in the specialty world of gender dysphoria even went so far
as to criticize the method of sampling in Littman’s study as akin
to “…recruiting from Klan or alt-right sites to demonstrate that
blacks really are an inferior race” (“Why Are So Many Teen-
age Girls Appearing in Gender Clinics?”, 2018). Complaints
to the journal where the paper was published led to a request
that Littman modify some of the interpretations of the data, in
the form of a “corrected” version (Littman, 2019). Moreover,
one Editor of the journal issued an apology “…to the trans and
gender variant community for oversights that occurred during
the original assessment of the study” (Heber, 2019) and an
invited commentary (post-peer review) was published (Bran-
delli Costa, 2019). One could say, therefore, that the paper has
indeed had an impact.
In my view, there are at least three distinct issues that ROGD
raise: First, is this really a new clinical phenomenon? Second,
if it is, how do we understand it? Third, as a new clinical phe-
nomenon, does it call for revisions to what are considered best
practice therapeutics for adolescents with gender dysphoria?
With regard to the first question, it is my view that this is a
new clinical phenomenon. I was seeing such adolescents in the
mid-2000s in Toronto (I just didn’t have a label for them) and,
at present, they comprise the majority of my private practice
adolescent patients. (Of course, I make no claim that my cli-
ents are representative of the adolescent population with gender
dysphoria in general.) In moving forward, what I believe needs
to be done is to try and replicate Littman’s observations by
documenting, using multiple informants and multiple meth-
ods, the core clinical phenomenology. It is not entirely clear
to me why some clinician and “armchair” critics have been
so skeptical about the possible veridicality of ROGD. Perhaps
because Littman (2018) advanced a set of hypotheses about
predisposing psychosocial factors in its genesis, the objection
is that this disrupts an essentialist model of gender dysphoria
and, therefore, has therapeutic implications.
The second question, in my view, is much more complex
since it requires an answer about causal mechanisms, which is a
formidable task. At the very least, it should be possible to study
correlates of ROGD and see how these correlates are similar
to, or different from, what one might find in early-onset gender
dysphoria. Littman argued for the influence of peers and social
media in inducing gender dysphoria in these adolescents, but
it is far from clear why these adolescents are so “susceptible”
to such influences. For example, is it possible that these ado-
lescents are struggling with identity formation in general and
are searching for a social environment/milieu in which they
feel supported and accepted? In other times in the postmodern
West, would such adolescents have found a different subcultural
space in which they felt such support? Littman also argued for
generic mental health vulnerabilities in these adolescents that
preceded the development of ROGD, but this strikes me as too
non-specific. There would be many young adolescents with the
same types of mental health vulnerabilities who do not develop
ROGD. With regard to the third question, I discuss this in the
next section.
Best Practice: Sites ofDebates
Since the mid-1990s, one model of therapeutic care, devel-
oped by Dutch clinicians and researchers, has been to initi-
ate the biomedical aspects of sex/gender transition in early to
mid-adolescence, rather than waiting for the legal age of adult-
hood. Adolescents deemed appropriate for such treatment are
prescribed hormonal medication (GnRH agonists) to delay or
suppress somatic puberty (prior to the age of 16years). If the
gender dysphoria persists, then “gender-affirming” hormonal
therapy is offered at the age of 16years, and, if the adolescent
so desires, “gender-affirming” surgical sex change procedures
are offered at a lower bound age of 18years (Cohen-Kettenis,
Steensma, & de Vries, 2011; Zucker etal., 2011). One might
note, however, that these are only suggested guidelines and it
is well known that some (many?) clinicians endorse these pro-
cedures at younger ages (e.g., Milrod, 2014; Milrod & Karasic,
2017; Olson-Kennedy, Warus, Okonta, Belzer, & Clark, 2018).
Hembree etal. (2017) noted, for example, “that there may be
compelling reasons to initiate sex hormone treatment prior to
the age of 16years…even though there are minimal published
studies of gender-affirming hormone treatments before age
13.5–14years” (p. 3871). Similarly, Hembree etal. noted that
“There is insufficient evidence to recommend a specific age
requirement…” (p. 3872) for breast surgery in birth-assigned
females with gender dysphoria.
The rationale for this treatment protocol included the fol-
lowing assumptions: (1) for most adolescents, there is little
systematic empirical evidence that psychological interven-
tions can resolve the gender dysphoria, even if the adolescent

Archives of Sexual Behavior
1 3
desires it; (2) the use of puberty blockers can be helpful to
the adolescent because it reduces the incongruence between
the development of natal sex secondary physical character-
istics and the felt psychological gender; and (3) reduction in
the incongruence makes it easier for adolescents to present
socially in the cross-gender identity/role. Because the sup-
pression of the patient’s biological puberty is said to reduce
the preoccupation with it, it has been argued that this affords
the adolescent greater opportunity to explore their longer-
term gender identity options in psychosocial counseling or
psychotherapy in a more reflective and less pressured manner
(see, e.g., Costa etal., 2015).
In the Dutch model, several factors were identified in
deeming adolescent eligibility for early biomedical treat-
ment. According to Cohen-Kettenis, Delemarre-van de
Waal, and Gooren (2008), these included the following: (1)
the presence of gender dysphoria from early childhood on; (2)
an exacerbation of the gender dysphoria after the first signs
of puberty; (3) the absence of psychiatric comorbidity that
would interfere with a diagnostic evaluation or treatment; (4)
adequate psychological and social support during treatment;
and (5) a demonstration of knowledge of the sex/gender reas-
signment process.
Several studies have reported on the benefits of this thera-
peutic protocol in reducing gender dysphoria (e.g., de Vries
etal., 2014, which is the best study to date). Of course, one
should bear in mind some of the limitation to these outcome
studies, including the fact that not all assessed adolescents
were deemed eligible for the treatment protocol (and thus
we know relatively little about the longer-term outcomes of
these youth) and that study designs have not included alterna-
tive treatment options (such as psychosocial therapy) or even
being assigned to a wait-list control condition; however, it is
beyond the scope of this article to discuss these methodologi-
cal issues in their own right. I do, however, want to discuss
them in the context of best practice care for adolescents with
ROGD.
If these adolescents truly did not have gender dysphoria
in childhood, note that, as a result, they would not meet one
of the eligibility criteria originally formulated by the Dutch
team. An unknown percentage of parents of adolescents
with ROGD are skeptical that biomedical treatment is the
best way to address their child’s gender dysphoria; indeed,
many of them oppose it. Hence, this would seem to go against
another eligibility criterion, namely, adequate psychological
and social support during treatment. (On this point, there
is, of course, contemporary discussion about the “need” for
parental consent in instituting this type of treatment [see,
e.g., Priest, 2019]).
Because ROGD appears to be a new clinical phenome-
non, we know very little about its subsequent developmental
course, i.e., its “natural history.” For example, we know very
little about rates of persistence versus desistance, which, in
my view, is a critical issue in thinking about the applicabil-
ity of the Dutch model with regard to the therapeutic care of
these youth. At present, there are some compelling examples
of desistance or even “detransition,” but right now this is
largely in the form of individual testimony and parent’s report
(see, e.g., “It’s not conversion therapy to learn to love your
body: A teen desister tells her story,” 2017; Pique Resilience
Project at https ://www.piq ue r espr oject .com/; Rae, 2017; Wil-
liams, 2019). Thus, we urgently need systematic data on this
point in order to inform best practice clinical care.
In the absence of such data, what should the frontline cli-
nician do? On this point, my hunch is that there will be a
variety of perspectives. For example, one might argue in favor
of gender social transition and hormonal suppression along
with a course of psychosocial therapy in which the stability
of the patient’s gender identity can be explored, just as it is
in the case of treatment for early-onset gender dysphoria. If
the gender dysphoria remits, the gender social transition and
hormonal suppression can simply be stopped, as both are
fully reversible. Regarding the latter, I mean this in regard to
the re-institution of parameters such as the menstrual cycle
in birth-assigned females or in physical virilization in birth-
assigned males. It is less clear to what extent hormonal sup-
pression has completely reversible effects with regard to sex-
dimorphic neural regions of interest and correlated behavioral
parameters (see, e.g., Hoekzema etal., 2015; Schneider etal.,
2017; Staphorsius etal., 2015).
Alternatively, one might make the case that since we know
so little about ROGD that there should be a period of “watch-
ful waiting” or exploratory psychotherapy, i.e., without bio-
medical treatment, but, perhaps, with the recommendation
that the youth consider living in the felt gender role in order
to see whether this confers any reduction in the gender dys-
phoria and the associated distress. On this point, one could
take “advantage” of the very long waiting lists for an initial
assessment in some of the major gender identity clinics in
North America and Europe. These very long waiting lists
essentially nullify the idea that hormonal suppression can
be used to give adolescents “time and space” to continue
to explore their gender identity. Suppose, for example, an
adolescent had to wait for a year, if not longer, to be seen for
a baseline assessment. (Thus, they already have had time and
space to continue to think about their gender identity, albeit
without hormonal suppression and probably without ongoing
psychosocial therapeutic support.) If one collected baseline
data at the time of referral, and not the time of assessment,
one could argue that if the adolescent continued to experi-
ence gender dysphoria after sitting on a waiting list for a long
time, this would, perhaps, be an argument for the institution
of hormonal suppression. For those adolescents who, while
on a wait-list, remitted with regard to their gender dysphoria,
it is likely that they would not choose to even be seen for an
assessment. Thus, one could use long wait-list times as a

Archives of Sexual Behavior
1 3
type of control as a partial way to evaluate the stability of
the gender dysphoria.
Lastly, one could consider recommending exploratory
psychosocial treatment without social transition and hormo-
nal suppression, particularly if the case formulation is that
the gender dysphoria has emerged in the context of other psy-
chosocial factors or as a result of other mental health issues.
Given the substantial uncertainties about best practice care
for these youth, the frontline clinician will have to weigh
carefully the benefits and risks of various treatment options
and proceed with caution.
Compliance with Ethical Standards
Conflict of interest The author declares that he has no conflict of inter-
est. This article for the Special Section was handled by the Guest Edi-
tor, Heino F. L. Meyer-Bahlburg.
Ethical Approval This article does not contain any studies with human
participants performed by the author.
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