No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
„Trans* ist plural“: Behandlungsverläufe bei Geschlechtsdysphorie in einer deutschen kinder- und jugendpsychiatrischen Spezialambulanz
Abstract
Zusammenfassung
Einleitung Für die kontrovers diskutierte Diagnose Geschlechtsinkongruenz (GI) / Geschlechtsdysphorie (GD) im Kindes- und Jugendalter werden international steigende Zahlen in der Inanspruchnahme sowie zunehmend heterogene Verläufe für trans* Entwicklungen berichtet. Bisher existieren nur wenige Studien, welche die Zuweisungszahlen und Behandlungsverläufe in auf trans* Kinder und Jugendliche spezialisierten Sprechstunden in Deutschland beschreiben.
Forschungsziele In der vorliegenden Studie werden deshalb die demografischen und klinischen Merkmale der vorstelligen trans* Kinder und Jugendlichen sowie die in der Hamburger Spezialsprechstunde für Geschlechtsidentität bzw. GI/GD (Hamburger GIS) erfolgte Diagnostik und Behandlung untersucht.
Methoden Deskriptive Angaben zum Zuweisungsgeschlecht und Alter, zur sozialen Vornamensänderung, zum Behandlungsverlauf (Verlauf zwischen Zeitpunkt der Erstvorstellung und der Auswertung), zur Diagnose im Bereich einer GI/GD (gemäß ICD-10) und zum Behandlungsstatus von N = 680 Kindern und Jugendlichen (Zeitraum: 2013–2018) wurden retrospektiv erfasst.
Ergebnisse Die Mehrheit der insgesamt 680 vorstelligen Kinder und Jugendlichen hatte ein weibliches Zuweisungsgeschlecht (74 %; 1:3, M:F) und war bereits im Jugendalter (≥ 12 Jahre; 87 %). Eine soziale Vornamensänderung war zum Zeitpunkt der Erstvorstellung häufig bereits erfolgt (66 %). Eine Diagnose im Bereich einer GI/GD erhielten 85 % der Fälle. Bei 75 % der Kinder und Jugendlichen war der Behandlungsverlauf bekannt, während der Behandlungsverlauf in 25 % der Fälle nicht nachvollzogen werden konnte. Es zeigten sich deskriptive Unterschiede zwischen den beiden Gruppen (bekannter vs. unbekannter Behandlungsverlauf) in Bezug auf alle untersuchten Variablen. 66 % der Jugendlichen, bei denen Angaben zum Behandlungsverlauf vorlagen, hatten eine geschlechtsangleichende körpermedizinische Behandlung erhalten.
Schlussfolgerung Die Ergebnisse der Auswertung verdeutlichen, dass trans* Kinder und Jugendliche, die sich in spezialisierten Sprechstunden für GI/GD vorstellen, eine heterogene Gruppe mit unterschiedlichen Merkmalen und Behandlungsverläufen darstellen. Geschlechtsangleichende körpermedizinische Behandlungen waren in vielen, aber nicht in allen Fällen indiziert. Aus der Heterogenität der Entwicklungs- und Behandlungsverläufe resultiert die zunehmende Bedeutung individualisierter, einzelfallbasierter Entscheidungen in einem interdisziplinären Behandlungssetting.
... However, Lett et al. warned against an overinterpretation of these data, pointing to methodological difficulties (small size samples, great variability of the sex ratio between states and between years, and overrepresentation of northeastern states) [9]. In contrast, other data from gender identity clinics and population studies have pointed to sex ratios favouring AFAB over AMAB youth in London [10], Toronto [11], Amsterdam [11], Paris [12], Hamburg [13], Catalonia [14], Sweden [15], Norway [16], Belgium [17], and Canada [18]. This AFAB predominance in trans youth mostly covers the adolescence period, and is less marked in childhoodwhich exhibits sometimes an AMAB predominance [12,16]. ...
Trans youth reports reveal a predominance of assigned female at birth (AFAB) people (i.e. transmasculine people) over assigned male at birth (AMAB) people (i.e. transfeminine people). It has been suggested that “social contagion” through social media could be more frequent in AFAB people, causing a hypothesized “rapid-onset gender dysphoria” (ROGD) in adolescence, with detrimental correlates to health. We aim to test (1) whether the suggested effect of ROGD on an AFAB predominance in adolescence could have an alternative explanation such as the effect of national LGBT policies; (2) the suggested effects of ROGD by which transmasculine people who had a more rapid development of their trans identity in adolescence would use more often social media to connect to peers and would have a lower health status. Regarding our methods, we used the cross-sectional LGTI Survey II (2019) of the European Union Agency for Fundamental Rights (137,553 LGBT people) and the ILGA-Europe’s Rainbow Index (2019) of national LGBT policy scores. We calculated the chances to recognize and share an LGBT identity for AFAB/AMAB cis/trans people, expected sex ratios for cis/trans people at every age given equal total AFAB and AMAB populations, and national AFAB vs. AMAB differences in ages of LGBT identity-sharing adjusted by their ages of self-perception. We tested among adolescent respondents whether belonging to the hypothesized ROGD population was associated with social media use or poorer self-assessed health. As regards our findings, we predicted a predominance of AFAB trans adolescents as well as AFAB LGB cis adolescents in accordance with our observation that AMAB youth shared their identity later than AFAB youth in all 30 countries, their age of self-perception being held equal. We found that national differences in ages of identity-sharing significantly correlated with ILGA-Europe’s Rainbow Index. We did not find that transmasculine people who had a rapid development of a trans identity in adolescence used more social media or had worse health. However, when we restricted the sample to those who were adolescents in the survey (N = 6209), we found that transmasculine youth who had a more rapid affirmation (< 1 year) used more frequently social media, though they did not have poorer health. To conclude, the AFAB predominance in adolescence may not be trans-specific. The effect of social influence on the emergence of LGBT identities in adolescence may exist at the micro level (social media use by transmasculine adolescents) but also at the macro level (state laws). These findings give support to some of the ROGD hypothesis features but contradict others, and plead for more research on how gender minority stress affects the likelihood of LGBT people to disclose their identity.
... Die Anzahl der bei Mädchen im Alter von 12 bis 17 durchgeführten Mastektomien hat sich einer U.S.-Studie zufolge zwischen 2013 und 2020 verdreizehntfach (Tang et al., 2022). Gleichzeitig verdichten sich die Hinweise, dass es auch in anderer Hinsicht zu einer Veränderung der Inanspruchnahmeklientel gekommen ist -mit, wie mittlerweile mehrfach gezeigt wurde, einer deutlichen Zunahme der psychiatrischen Komorbidität (Herrmann et al., 2022;Kaltiala-Heino, Holttinen & Tuisku, 2023;Kaltiala-Heino, Sumia, Työläjärvi & Lindberg, 2015;Twist & de Graaf, 2019). ...
... Wenngleich es für den deutschsprachigen Raum wegen des dezentralisierten Systems der Gesundheitsversorgung keine vergleichbare Erfassung der Fallzahlen gibt, bestreitet mittlerweile niemand mehr, dass die Entwicklung hierzulande die gleiche ist (vgl. Herrmann et al., 2022). Dies betrifft auch die Inversion der Sex-Ratio, also die Umkehrung des Verhältnisses von betroffenen geburtsgeschlechtlichen Jungen zu geburtsgeschlechtlichen Mädchen: Heute sind die mit Abstand meisten Patienten weibliche Jugendliche in der frühen und mittleren Adoleszenz (de Graaf et al., 2018;Kaltiala-Heino, Bergman, Työläjärvi & Frisén, 2018;Kaltiala-Heino, Sumia, Työläjärvi & Lindberg, 2015;Zhang et al., 2021) mit einer -und auch das ist neu -zuvor geschlechtsnormativen Kindheit, deren Transidentifizierung und Outing erst während der Pubertät erfolgten (Aitken, Steensma & Blanchard, 2015;Chen, Fuqua & Euqster, 2016;de Graaf et al., 2018;Biggs, 2020;Hutchinson, Midgen, M. & Spiliadis, 2020;Littman 2018;Kaltiala-Heino et al., 2015van der Loos et al., 2023;Zucker, 2019). ...
Media's Stranglehold on Storm and Stress - The Sorrows of Generation Z about Sex and Gender Abstract: The feeling of not belonging to one's birth sex is not new; one can trace this phenomenon back even to ancient mythology. Although it has always been rare, there has recently been a sharp increase in gender identity deviations among adolescents. This text addresses this problem by asking to what extent this development also results from upheavals in the cultural landscape and, above all, in media technology. Do they cause young people to believe they are in the "wrong gender" and, in extreme cases, to strive for transition? We present the most salient cornerstones of the planned German self-determination law (Self-ID), most of which, however, are unlikely to do justice to the underlying problem. The text concludes by describing several unanswered questions concerning this matter and by attempting to propose first answers. The advantages of a gender-exploratory over the trans affirmative therapy approach are summarized.
An increasing heterogeneity of clinical presentations and varying levels of psychological problems characterize gender dysphoria (GD) in adolescents. These clinical patterns suggest distinct developmental trajectories. Here, we examine the onset age of GD, i.e., the percentage of early onset (EO) vs. late onset (LO), and its association with internalizing problems in adolescents with GD. The sample consisted of 462 adolescents (11–18 years, Mage = 15.46 years; 392 birth-assigned females, 70 birth-assigned males) who attended the Hamburg Gender Identity Service for Children and Adolescents (Hamburg GIS) in Germany between 2013 and 2021. Onset age was self-reported during clinical interviews and then later scored by clinicians using a DSM-5 rating sheet. When adolescents retrospectively met criteria A and B for childhood-onset GD, they were rated as having an EO. Those who fulfilled neither criteria A nor B in childhood were considered to have a LO. Internalizing problems were assessed using the Youth Self-Report. Overall, 51% (n = 237) of adolescents with GD presented with an EO and 49% (n = 225) reported diagnostic criteria related to a LO. More than half of the sample (58%, n = 266) fell within the clinical range for internalizing problems. Furthermore, LO (as opposed to EO) was significantly associated with reporting more internalizing problems. Our findings emphasize that adolescents with LO represent a particularly vulnerable group whose needs should be considered more closely diagnostically and treatment-wise. A protocol-based approach to the indication of physical interventions may not adequately address current clinical presentations and should be complemented by a differential approach based on individual adolescent development.
Current discourses on the development of gender dysphoria in female adolescents occasionally suggest that underlying psychodynamic factors may overlap with those underlying anorexia nervosa. From a psychoanalytic perspective, it is emphasised that especially for female adolescents, identity demands and threats often manifest themselves in the confrontation with the sexually maturing body. In this context, gender dysphoria could be understood as a temporary developmental anxiety with an attempt to overcome an inner conflict at the level of the body. This article combines extended theoretical considerations with empirical research. In a study, 105 female adolescents with gender dysphoria attending a specialised outpatient clinic and 138 female adolescents admitted as inpatients for the treatment of anorexia nervosa each completed standardised questionnaires on personality functions (LoPF-Q 12-18), identity development (AIDA), childhood trauma (CTQ) and emotional and behavioural problems (YSR). Both groups showed comparable impairments in personality functioning and identity development and similar levels of internalising symptoms. However, adolescents with gender dysphoria reported significantly more traumatic experiences and externalising problems. Psychodynamic parallels are assessed theoretically on the basis of the findings and reflected upon in terms of distinct differences in clinical treatment. Finally, there is a discussion of the implications of differential diagnosis and treatment for the clinical management of adolescent gender dysphoria.
The sharp rise in the number of predominantly natal female adolescents experiencing gender dysphoria and seeking treatment in specialized clinics has sparked a contentious and polarized debate among both the scientific community and the public sphere. Few explanations have been offered for these recent developments. One proposal that has generated considerable attention is the notion of “rapid-onset” gender dysphoria, which is assumed to apply to a subset of adolescents and young adults. First introduced by Lisa Littman in a 2018 study of parental reports, it describes a subset of youth, primarily natal females, with no childhood indicators of gender dysphoria but with a sudden emergence of gender dysphoria symptoms during puberty or after its completion. For them, identifying as transgender is assumed to serve as a maladaptive coping mechanism for underlying mental health issues and is linked to social influences from peer groups and through social media. The purpose of this article is to analyze this theory and its associated hypotheses against the existing evidence base and to discuss its potential implications for future research and the advancement of treatment paradigms.
Ausgehend von gesellschaftlichen Veränderungen, die zur geschlechtlichen Diversität vor allem bei Jugendlichen beigetragen haben könnten, beschäftige ich mich rückschauend damit, wie sich meine Sichtweisen und Einstellungen als Sexualund Trans*Gender-Therapeut in den vergangenen 30 Jahren verändert haben. Dazu betrachte ich den Wandel der Geschlechterordnung vor dem Hintergrund rasanter gesellschaftlicher und globaler Veränderungen einerseits und intrapsychische Aspekte der psychosexuellen Identitätsbildung andererseits. Ich orientiere ich mich am Konzept der konstitutionellen Bisexualität und an E. H. Eriksons Entwicklungstheorie.
Das Gefühl der Nichtzugehörigkeit zum Geburtsgeschlecht ist nicht neu, als Phänomen kann es bis in die antike Mythologie zurückverfolgt werden. Aber es war stets selten, wohingegen aktuell ein sprunghafter Anstieg von Abweichungen im Geschlechtsidentitätserleben bei Jugendlichen zu verzeichnen ist. Der Text geht dieser Problematik anhand der Frage nach, inwieweit diese Entwicklung auch ein Resultat kultureller und vor allem aber medientechnologischer Umbrüche ist, die bedingen, dass Jugendliche sich im «falschen Geschlecht» wähnen und im Extremfall eine Transition anstreben. Die wichtigsten Eckpunkte des geplanten deutschen Selbstbestimmungsgesetzes werden vorgestellt, das allerdings der zugrundeliegenden Problematik kaum gerecht werden dürfte. Der Text schließt damit, dass er diesbezüglich eine Reihe offener Fragen benennt und erste Antworten versucht.
Zusammenfassung: Fragestellung: Nichtbinäre Geschlechtsidentitäten werden in der Transgender-Gesundheitsversorgung und -forschung zunehmend sichtbar. Gleichzeitig ist wenig bekannt über die verschiedenen Geschlechtsidentitäten von transgeschlechtlichen Jugendlichen, ob diese stabil oder veränderbar sind und welche Faktoren das Geschlechtserleben beeinflussen. Ziel ist deshalb, diese verschiedenen Aspekte von Geschlechtserleben (Gender) bei transgeschlechtlichen Jugendlichen mit unterschiedlichen Geschlechtsidentitäten zu untersuchen. Methodik: Die Stichprobe umfasste 114 transgeschlechtliche Jugendliche mit diagnostizierter Geschlechtsdysphorie (GD) aus einer aktuellen Befragung der Hamburger Spezialsprechstunde für Kinder und Jugendliche mit GD (Hamburger GIS). Die verschiedenen Aspekte von Gender wurden mithilfe des Gender Diversity Questionnaire untersucht. Ergebnisse: Insgesamt 83 % der Jugendlichen berichteten eine binäre Geschlechtsidentität (binär identifiziert, BI) und 17 % eine nichtbinäre oder hinterfragten ihre Geschlechtsidentität noch (nichtbinär und genderquestioning, NBGQ). Ein veränderbares Geschlechtserleben wurde von 15 bis 18 % berichtet. Die NBGQ-Gruppe berichtete häufiger bzw. ein signifikant höheres Maß an Veränderbarkeit in ihrem Geschlechtserleben als die BI-Gruppe. Als die häufigsten Einflussfaktoren auf das eigene Geschlechtserleben wurden die Pubertät (79 %), der körperliche Leidensdruck (70 %) und die sozialen Medien (36 %) genannt. Schlussfolgerungen: Die Studie verdeutlicht, dass das Geschlechtserleben nicht bei allen transgeschlechtlichen Jugendlichen binär und unveränderbar ist, sondern dass es in manchen Fällen auch nichtbinär oder veränderbar sein kann. Diese Heterogenität, die mögliche Veränderbarkeit sowie der pubertätsbedingte körperliche Leidensdruck können Behandlungsentscheidungen im Umgang mit GD im Jugendalter erschweren und verdeutlichen die Notwendigkeit einer individuellen Behandlungsplanung.
Mit neuen psychosexuellen Phänomenen, z.B. Verflüssigung und Verlust an Eindeutigkeit von Gender, sowie zunehmender Distanzierung von körpergeschlechtlicher Binarität, stehen u.a. Sexualwissenschaft und Psychoanalyse vor der Aufgabe, ihre Konzepte und grundlegenden Anschauungen auf eine Passung mit der gesellschaftlichen und individuellen Lebensrealität zu prüfen und zu modifizieren. Ausgehend von Freuds Ödipuskomplex, sowie in Auseinandersetzung mit seinem Entwurf der sog. konstitutionellen Bisexualität, geht dieser Beitrag ausgehend von der Frage, wie Gender und Körpergeschlecht mittels psychoanalytischer Anschauung heute feinkörniger und individueller gedacht werden können, auf Weiterentwicklungen nach Freud ein. Im Fokus steht dabei Jean Laplanches allgemeine Verführungstheorie. Zentrales Anliegen dieses Textes ist es, die Implikationen jener für nonbinäres Gender und Körpergeschlecht herauszuarbeiten. Schließlich werden die daraus folgenden Grenzen der Fassbarkeit und Formalisierbarkeit von Gender in Kontrast zur Binärgeschlechtlichkeit aufgezeigt und einhergehende Affekte wie Angst und Abwehr thematisiert.
Zusammenfassung
Vor dem Hintergrund ihrer Tätigkeit in der Spezialsprechstunde für Geschlechtsdysphorie in der Kinder- und Jugendpsychiatrie am Universitätsklinikum Hamburg-Eppendorf wenden sich die Autor*innen Fragen rund um die Komplexität und Heterogenität in der Behandlung von geschlechtsdysphorischen Kindern und Jugendlichen – insbesondere in der frühen Adoleszenz – zu. Hierbei wird der spannungsreiche Spagat zwischen der Notwendigkeit, als Behandler*in einen reflexiven Verstehensprozess der jeweils individuellen Geschlechtsdysphorie und/oder Transidentität anzustoßen, sowie dem oftmals zentralen Wunsch nach einer zeitnahen Indikation körpermedizinischer Maßnahmen aufseiten der Patient*innen diskutiert. Die Autor*innen plädieren für eine neutrale, offene Haltung gegenüber den vielschichtigen Konflikten, Belastungen und komplexen Symptomatiken der Jugendlichen, um eine verantwortungsvolle Entscheidung für Transitionsschritte treffen zu können.
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8.
Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment.
Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings.
Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health.
Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results The specialist clinic for children and adolescents with gender dysphoria (GD) of the Psychiatric University Hospital of Zurich shows an increasing number of referrals since its foundation in 2009. Since 2014 we started an observational study including adolescents aged 13 years and older. At the time of the first appointment (T0) N = 77 participants completed a battery of questionnaires assessing demographic factors, general psychopathology, quality of life as well as gender identity, social transitioning and GD treatment modalities. Few of the adolescents were socially transitioned and had hormone therapy but 77.9 % wished to get hormone therapy. Follow up assessment T1 was performed after at least one year of treatment in our specialist clinic. 51 adolescents completed an online follow-up examination including the same questionnaires and baseline parameters as well as a scale measuring treatment satisfaction. At T0, 77.3 % of the adolescents scored in the clinical range of the Youth Self Report (YSR) total score, which did not decrease significantly until T1 in our preliminary follow up sample. Puberty blocking before T0 correlated negatively with the YSR score, indicating less psychopathology in treated patients. Preliminary longitudinal analysis suggests that social transitioning influences quality of life (Kidscreen subscale autonomy and parental relationship). At T1, 52 % of the adolescents were socially transitioned in all contexts and 70 % received gender affirming hormonal treatment. Gender identity changed between T0 and T1 in about 18 % of the cases. Treatment satisfaction in most cases was high.
The background of this article is to examine whether consecutively transgender clinic-referred adolescents between 2000 and 2016 differ over time in demographic, psychological, diagnostic, and treatment characteristics. The sample under study consisted of 1072 adolescents (404 assigned males, 668 assigned females, mean age 14.6 years, and range 10.1–18.1 years). The data regarding the demographic, diagnostic, and treatment characteristics were collected from the adolescents’ files. Psychological functioning was measured by the Child Behaviour Check List and the Youth Self-Report, intensity of gender dysphoria by the Utrecht Gender Dysphoria Scale. Time trend analyses were performed with 2016 as reference year. Apart from a shift in sex ratio in favour of assigned females, no time trends were observed in demographics and intensity of dysphoria. It was found, however, that the psychological functioning improved somewhat over time (CBCL β − 0.396, p < 0.001, 95% CI − 0.553 to − 0.240, YSR β − 0.278, p < 0.001, 95% CI − 0.434 to − 0.122). The percentage of referrals diagnosed with gender dysphoria (mean 84.6%, range 75–97.4%) remained the same. The percentage of diagnosed adolescents that started with affirmative medical treatment (puberty suppression and/or gender-affirming hormones) did not change over time (mean 77.7%; range 53.8–94.9%). These findings suggest that the recently observed exponential increase in referrals might reflect that seeking help for gender dysphoria has become more common rather than that adolescents are referred to gender identity services with lower intensities of gender dysphoria or more psychological difficulties.
Adolescents with gender dysphoria (GD) often face various associated social, emotional, and behavioral difficulties. In such a marginalized group, it is crucial to identify factors that may impact psychological functioning to better accommodate their needs. Therefore, the present study investigated the impact of two specific risk factors, poor peer relations and general family functioning, on the development of psychological problems in adolescents with GD, and their possible interaction effect. The Youth Self-Report, a Peer Relations Scale, and a General Family Functioning scale were assessed in a sample of n = 180 clinically referred adolescents (mean age 15.5; 146 transgender boys with a female birth-assigned sex, and 34 transgender girls with a male birth-assigned sex) with a complete GD diagnosis (fulfillment of the DSM 5 criteria A and B) at their initial admission to the Hamburg Gender Identity Service. Multiple linear regression analysis was conducted to examine the relationship between peer relations, family functioning, and psychological functioning outcomes. Adolescents with GD presented significantly higher Internalizing and Total Problem scores compared to the German reference norm. Externalizing problems were above the norm for transgender boys, but within the normal range for transgender girls. Multiple regression analysis revealed that, overall, adolescents with an advanced age, a female birth-assigned sex, poorer peer relations, and poorer family functioning showed more behavioral and emotional problems. Consequently, incorporating both the family and social environment in transgender care is of high importance to adequately tend to the needs of adolescents with GD.
Purpose
In on-line forums, parents have reported that their children seemed to experience a sudden or rapid onset of gender dysphoria, appearing for the first time during puberty or even after its completion. Parents describe that 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. Recently, clinicians have reported that post-puberty presentations of gender dysphoria in natal females that appear to be rapid in onset is a phenomenon that they are seeing more and more in their clinic. Academics have raised questions about the role of social media in the development of gender dysphoria. The purpose of this study was to collect data about parents’ observations, experiences, and perspectives about their adolescent and young adult (AYA) children showing signs of an apparent sudden or rapid onset of gender dysphoria that began during or after puberty, and develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic group.
Methods
For this descriptive, exploratory study, 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 sudden or rapid onsets of gender dysphoria occurring in their teen or young adult children. The study’s eligibility criteria included parental response that their child had a sudden or rapid onset of gender dysphoria and parental indication that their child’s gender dysphoria began during or after puberty. To maximize the chances of finding cases meeting eligibility criteria, the three websites (4thwavenow, transgender trend, and youthtranscriticalprofessionals) were selected for targeted recruitment. 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 AYA children described were predominantly natal female (82.8%) with a mean age of 16.4 years at the time of survey completion and a mean age of 15.2 when they announced a transgender-identification. Per parent report, 41% of the AYAs had expressed a non-heterosexual sexual orientation before identifying as transgender. Many (62.5%) of the AYAs had reportedly 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, parent participants indicated that the majority of the members became transgender-identified. Parents reported subjective declines in their AYAs’ mental health (47.2%) and in parent-child relationships (57.3%) since the AYA “came out” and that 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%). Most (86.7%) of the parents reported that, along with the sudden or rapid onset of gender dysphoria, their child either had an increase in their social media/internet use, belonged to a friend group in which one or multiple friends became transgender-identified during a similar timeframe, or both
Conclusion
This descriptive, exploratory study of parent reports provides valuable detailed information that allows for the generation of hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among AYAs. Emerging hypotheses include the possibility of a potential new subcategory of gender dysphoria (referred to as rapid-onset gender dysphoria) that has not yet been clinically validated and the possibility of social influences and maladaptive coping mechanisms. Parent-child conflict may also explain some of the findings. More research that includes data collection from AYAs, parents, clinicians and third party informants is needed to further explore the roles of social influence, maladaptive coping mechanisms, parental approaches, and family dynamics in the development and duration of gender dysphoria in adolescents and young adults.
Objective
To update the “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2009.
Participants
The participants include an Endocrine Society–appointed task force of nine experts, a methodologist, and a medical writer.
Evidence
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.
Consensus Process
Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.
Conclusion
Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person’s affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)—should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
Purpose:
Transgender youth are at high risk for mental health morbidities. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual's assigned sex and gender identity. The goals of this study were to examine the: (1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization and (2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy.
Methods:
An IRB-approved retrospective medical record review (2014-2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted the following details: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization.
Results:
Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9-18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 44 (55.7%) exhibited self-harm, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogues, only 8 (29.6%) received insurance coverage.
Conclusion:
Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers toward insurance coverage reform.
Transidentität bei Jugendlichen ist zunehmend ein Thema im öffentlichen Diskurs und auch ein möglicher Behandlungsauftrag in spezialisierten Beratungseinrichtungen.
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.
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.
Treatment guidelines for transidentity in children and adolescents are presently under discussion. We present an overview of the various treatment modalities. Further, follow-up data on children and adolescents referred for gender-identity problems are presented. Of the 84 patients seen for the first time more than 3 years before follow-up, 37 mailed in the completed questionnaires. In addition, 33 patients agreed to answer some short follow-up questions. We assessed steps of treatment, gender role, psychopathology, and psychotherapy. We compared differences in psychopathology in patients with vs. without gender role change and in patients with intense vs. less intense psychotherapy. A total of 22 patients had completely changed gender role, and some had started hormonal treatment und sex reassignment surgery. Most patients were satisfied with the treatment results. All patients showed less psychopathology on follow-up, independent of role change or intensity of psychotherapy. In general, the patients reported little psychopathology. Our follow-up results support the present treatment approach. In patients with little psychopathology, low-frequency supportive treatment appears sufficient to obtain safe judgement on hormonal of surgical treatment.
Given the increasing demand for counselling in gender dysphoria in childhood in Germany, there is a definite need for empirical data on characteristics and developmental trajectories of this clinical group. This study aimed to provide a first overview by assessing demographic characteristics and developmental trajectories of a group of gender variant boys and girls referred to the specialised Gender Identity Clinic in Hamburg. Data were extracted from medical charts, transcribed and analysed using qualitative content analysis methods. Categories were set up by inductive-deductive reasoning based on the patients' parents' and clinicians' information in the files. Between 2006 and 2010, 45 gender variant children and adolescents were seen by clinicians; 88.9% (n = 40) of these were diagnosed with gender identity disorder (ICD-10). Within this group, the referral rates for girls were higher than for boys (1:1.5). Gender dysphoric girls were on average older than the boys and a higher percentage of girls was referred to the clinic at the beginning of adolescence (> 12 years of age). At the same time, more girls reported an early onset age. More girls made statements about their (same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions. More girls than boys revealed self-mutilation in the past or present as well as suicidal thoughts and/or attempts. Results indicate that the presentation of clinically referred gender dysphoric girls differs from the characteristics boys present in Germany; especially with respect to the most salient age differences. Therefore, these two groups require different awareness and individual treatment approaches.
In Germany, the situation of health care services for children and adolescents with gender dysphoria is insufficient. In 2006 a specialized multiprofessional outpatient clinic was founded at the University Medical Center Hamburg-Eppendorf. Goals were improvement of health services for gender dysphoric children, development of treatment concepts, and gain of knowledge through research. After finishing a thorough interdisciplinary assessment an individualized, case-by-case treatment starts. Besides psychotherapy an interdisciplinary treatment (e. g. puberty suppression and cross-sex hormones) is provided if indicated. During childhood a watchful waiting and carefully observing attitude is necessary. If a marked increase of gender dysphoria occurs during the first phases of puberty development, puberty suppression and later cross sex-hormones might be indicated.
Treatment outcome in transsexuals is expected to be more favourable when puberty is suppressed than when treatment is started after Tanner stage 4 or 5. In the Dutch protocol for the treatment of transsexual adolescents, candidates are considered eligible for the suppression of endogenous puberty when they fulfil the Diagnostic and Statistic Manual of Mental Disorders-IV-RT criteria for gender disorder, have suffered from lifelong extreme gender dysphoria, are psychologically stable and live in a supportive environment. Suppression of puberty should be considered as supporting the diagnostic procedure, but not as the ultimate treatment. If the patient, after extensive exploring of his/her sex reassignment (SR) wish, no longer pursues SR, pubertal suppression can be discontinued. Otherwise, cross-sex hormone treatment can be given at 16 years, if there are no contraindications. Treatment consists of a GnRH analogue (GnRHa) to suppress endogenous gonadal stimulation from B2-3 and G3-4, and prevents development of irreversible sex characteristics of the unwanted sex. From the age of 16 years, cross-sex steroid hormones are added to the GnRHa medication.
Preliminary findings suggest that a decrease in height velocity and bone maturation occurs. Body proportions, as measured by sitting height and sitting-height/height ratio, remains in the normal range. Total bone density remains in the same range during the years of puberty suppression, whereas it significantly increases on cross-sex steroid hormone treatment. GnRHa treatment appears to be an important contribution to the clinical management of gender identity disorder in transsexual adolescents.
Childhood gender nonconformity has been associated with increased risk of caregiver abuse and bullying victimization outside the home, but it is unknown whether as a consequence children who are nonconforming are at higher risk of depressive symptoms.
Using data from a large national cohort (N = 10,655), we examined differences in depressive symptoms from ages 12 through 30 years by gender nonconformity before age 11 years. We examined the prevalence of bullying victimization by gender nonconformity, then ascertained whether increased exposure to abuse and bullying accounted for possible increased risk of depressive symptoms. We further compared results stratified by sexual orientation.
Participants in the top decile of childhood gender nonconformity were at elevated risk of depressive symptoms at ages 12 through 30 years (for females, 0.19 standard deviations more depressive symptoms than conforming females; for males, 0.34 standard deviations more symptoms than conforming males). By ages 23 to 30 years, 26% of participants in the top decile of childhood nonconformity had probable mild or moderate depression versus 18% of participants who were conforming (p<.001). Abuse and bullying victimization accounted for approximately half the increased prevalence of depressive symptoms in youth who were nonconforming versus conforming. Gender-nonconforming heterosexuals and males were at particularly elevated risk for depressive symptoms.
Gender nonconformity was a strong predictor of depressive symptoms beginning in adolescence, particularly among males and heterosexuals. Physical and emotional bullying and abuse, both inside and outside the home, accounted for much of this increased risk.
The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth's functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.
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.
This is a report on parents who have children who exhibit gender variant behaviors and who contacted an affirmative program in the United States for assistance. All parents completed the Child Behavior Checklist, the Gender Identity Questionnaire, and the Genderism and Transphobia Scale, as well as telephone interviews. The parents reported comparatively low levels of genderism and transphobia. When compared to children at other gender identity clinics in Canada and The Netherlands, parents rated their children's gender variance as no less extreme, but their children were overall less pathological. Indeed, none of the measures in this study could predict parents' ratings of their child's pathology. These findings support the contention that this affirmative program served children who were no less gender variant than in other programs, but they were overall less distressed.
The aim was to formulate practice guidelines for endocrine treatment of transsexual persons.
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.
Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines.
Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.
Zusammenfassung
Vor dem Hintergrund ihrer Tätigkeit in der Spezialsprechstunde für Geschlechtsdysphorie in der Kinder- und Jugendpsychiatrie am Universitätsklinikum Hamburg-Eppendorf wenden sich die Autor*innen Fragen rund um die Komplexität und Heterogenität in der Behandlung von geschlechtsdysphorischen Kindern und Jugendlichen – insbesondere in der frühen Adoleszenz – zu. Hierbei wird der spannungsreiche Spagat zwischen der Notwendigkeit, als Behandler*in einen reflexiven Verstehensprozess der jeweils individuellen Geschlechtsdysphorie und/oder Transidentität anzustoßen, sowie dem oftmals zentralen Wunsch nach einer zeitnahen Indikation körpermedizinischer Maßnahmen aufseiten der Patient*innen diskutiert. Die Autor*innen plädieren für eine neutrale, offene Haltung gegenüber den vielschichtigen Konflikten, Belastungen und komplexen Symptomatiken der Jugendlichen, um eine verantwortungsvolle Entscheidung für Transitionsschritte treffen zu können.
Background and objectives:
Referrals of transgender and gender-diverse (trans) youth to medical clinics for gender-affirming care have increased. We described characteristics of trans youth in Canada at first referral visit.
Methods:
Baseline clinical and survey data (2017-2019) were collected for Trans Youth CAN!, a 10-clinic prospective cohort of n = 174 pubertal and postpubertal youth <16 years with gender dysphoria, referred for hormonal suppression or hormone therapy, and 160 linked parent-participants. Measures assessed health, demographics, and visit outcome.
Results:
Of youth, 137 were transmasculine (assigned female) and 37 transfeminine (assigned male); 69.0% were aged 14 to 15, 18.8% Indigenous, 6.6% visible minorities, 25.7% from immigrant families, and 27.1% low income. Most (66.0%) were gender-aware before age 12. Only 58.1% of transfeminine youth lived in their gender full-time versus 90.1% of transmasculine (P < .001). Although transmasculine youth were more likely than transfeminine youth to report depressive symptoms (21.2% vs 10.8%; P = .03) and anxiety (66.1% vs 33.3%; P < .001), suicidality was similarly high overall (past-year ideation: 34.5%, attempts: 16.8%). All were in school; 62.0% reported strong parental gender support, with parents the most common support persons (91.9%). Two-thirds of families reported external gender-related stressors. Youth had met with a range of providers (68.5% with a family physician). At clinic visit, 62.4% were prescribed hormonal suppression or hormone therapy, most commonly depot leuprolide acetate.
Conclusions:
Trans youth in Canada attending clinics for hormonal suppression or gender-affirming hormones were generally healthy but with depression, anxiety, and support needs.
Zusammenfassung
Die Autorin wagt eine Hypothese zur Frage, warum es im letzten Jahrzehnt zu einer signifikanten Zunahme von Frau-zu-Mann-Transsexuellen gekommen ist. Sie stellt die Frage, ob diese Entwicklung als zeitgeschichtliches Phänomen verstanden werden könnte und schlägt vor diesem Hintergrund einen Bogen von dem Kampf um die Anerkennung der Vielfalt des Begehrens zum Kampf um die Vielfalt des Geschlechts. Vor einem feministischen Hintergrund greift sie auf Christina von Brauns Arbeit zu anorektischen Frauen zurück, die die Anorexie als Auflehnung gegen die kulturelle Form von Weiblichkeit versteht. Könnte die Zunahme transsexuellen Begehrens von jungen Transmännern heute ähnlich verstanden werden, nämlich als Verwerfung von Weiblichkeit in einer Gesellschaft, in der Frauen nach wie vor der Zugang zur (Definitions-)Macht massiv erschwert wird?
Zusammenfassung
Aus einer teils persönlich argumentierten, teils zeitgeschichtlichen Perspektive von mehreren Jahrzehnten setzt sich Düring in ihrem Beitrag (2021, in diesem Heft) mit der zunehmenden Prävalenz von trans* Personen vor allem im Jugendalter und mit den sich für diese Lebensphase verändernden Geschlechterverhältnissen auseinander. Der vorliegende Kommentar erkennt die wissenschaftlich wie klinisch fraglos relevante Fragestellung an und kritisiert die tendenziöse Ausrichtung des Textes. Im Mittelpunkt der Kritik stehen die fehlende Abgrenzung unterschiedlicher Konzepte und der Umgang mit der vorhandenen Empirie. So argumentiert der Kommentar sowohl für eine empirisch informierte und damit ausgewogenere Diskussion zu diesen komplexen Fragestellungen als auch für ein dialektisches Vorgehen in Forschung und Therapie, das weder das Gender-Spektrum idealisiert noch die zunehmenden Prävalenzen im Kontext von Trans* dämonisiert.
The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results The specialist clinic for children and adolescents with gender dysphoria (GD) of the Psychiatric University Hospital of Zurich shows an increasing number of referrals since its foundation in 2009. Since 2014 we started an observational study including adolescents aged 13 years and older. At the time of the first appointment (T0) N = 77 participants completed a battery of questionnaires assessing demographic factors, general psychopathology, quality of life as well as gender identity, social transitioning and GD treatment modalities. Few of the adolescents were socially transitioned and had hormone therapy but 77.9 % wished to get hormone therapy. Follow up assessment T1 was performed after at least one year of treatment in our specialist clinic. 51 adolescents completed an online follow-up examination including the same questionnaires and baseline parameters as well as a scale measuring treatment satisfaction. At T0, 77.3 % of the adolescents scored in the clinical range of the Youth Self Report (YSR) total score, which did not decrease significantly until T1 in our preliminary follow up sample. Puberty blocking before T0 correlated negatively with the YSR score, indicating less psychopathology in treated patients. Preliminary longitudinal analysis suggests that social transitioning influences quality of life (Kidscreen subscale autonomy and parental relationship). At T1, 52 % of the adolescents were socially transitioned in all contexts and 70 % received gender affirming hormonal treatment. Gender identity changed between T0 and T1 in about 18 % of the cases. Treatment satisfaction in most cases was high. Keywords gender dysphoria – adolescents – psychopathology – quality of life – social transitioning
Research provides inconclusive results on whether a social gender transition (e.g. name, pronoun, and clothing changes) benefits transgender children or children with a Gender Dysphoria (GD) diagnosis. This study examined the relationship between social transition status and psychological functioning outcomes in a clinical sample of children with a GD diagnosis. Psychological functioning (Child Behavior Checklist; CBCL), the degree of a social transition, general family functioning (GFF), and poor peer relations (PPR) were assessed via parental reports of 54 children (range 5-11 years) from the Hamburg Gender Identity Service (GIS). A multiple linear regression analysis examined the impact of the social transition status on psychological functioning, controlled for gender, age, socioeconomic status (SES), PPR and GFF. Parents reported significantly higher scores for all CBCL scales in comparison to the German age-equivalent norm population. Peer problems and worse family functioning were significantly associated with impaired psychological functioning, whilst the degree of social transition did not significantly predict the outcome. Therefore, claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.
Transgender in adolescence is currently a widely discussed topic, additionally reflected by an increasing prevalence in clinical practice. The present review of the available literature on transgender, trans* , gender dysphoria or gender incongruence in youth reports results on the long-term results of medical interventions for the psychological well-being, prevalence, referral rates and sex ratio, developmental pathways, current developments and the role of the social environment. Finally, implications for clinical care and future research will be discussed.
© Georg Thieme Verlag KG Stuttgart · New York.
The Endocrine Society Clinical Practice Guidelines on the treatment of gender incongruent people recommend the use of gender-affirming cross-sex hormone (CSH) interventions in transgender children and adolescents who request this treatment, who have undergone psychiatric assessment, and have maintained a persistent transgender identity. The intervention can help to affirm gender identity by inducing masculine or feminine physical characteristics that are congruent with an individual's gender expression, while aiming to improve mental health and quality-of-life outcomes. Some transgender individuals might also wish to access gender-affirming surgeries during adolescence; however, research to inform best clinical practice for surgeons and other medical professionals is scarce. This Review explores the available published evidence on gender-affirming CSH and surgical interventions in transgender children and adolescents, amalgamating findings on mental health outcomes, cognitive and physical effects, side-effects, and safety variables. The small amount of available data suggest that when clearly indicated in accordance with international guidelines, gender-affirming CSHs and chest wall masculinisation in transgender males are associated with improvements in mental health and quality of life. Evidence regarding surgical vaginoplasty in transgender females younger than age 18 years remains extremely scarce and conclusions cannot yet be drawn regarding its risks and benefits in this age group. Further research on an international scale is urgently warranted to clarify long-term outcomes on psychological functioning and safety.
International discussion on social and medically supported transition for young people with gender dysphoria has been controversial largely because there is insufficient scientific evidence for adequate predictions of the long-term psychosexual, psychosocial, and physical consequences. The few existing international studies on the developmental pathways in the long-term mainly agree on the following: although the exact prospective prediction of the developmental pathways of so-called "clearly transsexual" developments with treatment indications for gender-affirming hormonal therapy or (in later years) operative interventions still poses a major challenge for clinical practitioners, the outcomes of the few long-term evaluations of treatment options are largely encouraging. The clinical implication to be drawn from this is that treatment for young people with gender dysphoria should pursue a multi-dimensional approach and that treatment decisions should currently be based on the respective adolescent's individual development. With regard to the prevention of psychosocial difficulties, it is important to acknowledge the wide range of gender identifications and to also always include the social environment. An important research target for the future is the detailed investigation of the complex interplay between gender variance, mental health, and the potential consequences of treatment in the long term. © 2018 J.C. Cotta'sche Buchhandlung Nachvolger GmbH. All rights reserved.
Background:
Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions.
Methods:
Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3-9 years old) and adolescents (10-17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date.
Results:
Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4-82) to 144 (95% CI 36-1248). The corresponding range for suicidal ideation was 25 (95% CI 14-45) to 54 (95% CI 18-218).
Conclusions:
TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.
The World Professional Association for Transgender Health's standards of care recommend suspending puberty, preferably with the use of gonadotropin-releasing hormone agonists, in certain gender non-conforming minors (aged under 18 years) who have undergone a psychiatric assessment and have reached at least Tanner stage II of puberty. This approach seeks to lessen the discordance between assigned natal sex and gender identity by temporarily halting the development of secondary sexual characteristics, essentially widening the temporal window for gender clarification. Despite promising preliminary evidence on the clinical utility of this approach, there is a dearth of research to inform evidence-based practice. In view of these challenges, we review the available empirical evidence on the cognitive, physical, and surgical implications of puberty suppression in gender-incongruent children and adolescents. We also explore the historical underpinnings and clinical impetus for suspending puberty in this population, and propose key research priorities.
In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.
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.
Background:
Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data.
Methods:
Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed.
Results:
The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years.
Conclusions:
The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.
Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exist to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the present study aimed to fill this gap.
A retrospective cohort study of electronic health record data from 180 transgender patients aged 12-29 years seen between 2002 and 2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM with MTF youth on mental health outcomes.
The sample (N = 360) had a mean age of 19.6 years (standard deviation, 3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared with cisgender matched controls, transgender youth had a twofold to threefold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p < .05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use.
Transgender youth were found to have a disparity in negative mental health outcomes compared with cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity.
Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Objective:
To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
Method:
The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
Results:
We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
Conclusion:
Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
„Trans* ist plural“ – Reflexionen aus der klinischen Arbeit
- F Breu
- T A Becerra-Culqui
- Y Liu
- R Nash
- L Cromwell
- W D Flanders
- D Getahun
- S V Giammattei
- E M Hunkeler
- T L Lash
- A Millman
- V P Quinn
- B Robinson
- D Roblin
- D E Sandberg
- M J Silverberg
- V Tangpricha
- M Goodman
Becerra-Culqui TA, Liu Y, Nash R, Cromwell L, Flanders WD, Getahun D,
Giammattei SV, Hunkeler EM, Lash TL, Millman A, Quinn VP, Robinson
B, Roblin D, Sandberg DE, Silverberg MJ, Tangpricha V, Goodman M.
Mental Health of Transgender and Gender Nonconforming Youth
Compared with Their Peers. Pediatrics 2018; 141: e20173845
Standards of Care -Versorgungsempfehlungen für die Gesundheit von transsexuellen, transgender und geschlechtsnichtkonformen Personen
- E Coleman
- W Bockting
- M Botzer
- P T Cohen-Kettenis
- G Decuypere
- J Feldman
- L Fraser
- J Green
- G Knudson
- W J Meyer
- S Monstrey
- R K Adler
- G R Brown
- A H Devor
- R Ehrbar
- R Ettner
- E Eyler
- R Garofalo
- D H Karasic
- A I Lev
- G Mayer
- H Meyer-Bahlburg
- B P Hall
- F Pfäfflin
- K Rachlin
- B Robinson
- L S Schechter
- V Tangpricha
- Trotsenburg Mv
- A Vitale
- S Winter
- S Whittle
- K R Wylie
- K Zucker
Coleman E, Bockting W, Botzer M, Cohen-Kettenis PT, DeCuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK,
Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E, Garofalo R, Karasic
DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfäfflin F, Rachlin
K, Robinson B, Schechter LS, Tangpricha V, Trotsenburg Mv, Vitale
A, Winter S, Whittle S, Wylie KR, Zucker K. Standards of Care -Versorgungsempfehlungen für die Gesundheit von transsexuellen,
transgender und geschlechtsnichtkonformen Personen. Version 7. East
Dundee, IL: WPATH 2012 [Als Online-Dokument: https://www.wpath.
org/media/cms/Documents/SOC%20v7/SOC%20V7_German.pdf]
Transidentität in der Kinder-und Jugendpsychiatrie
- M Fuchs
- K Praxmarer
- K Sevecke
Fuchs M, Praxmarer K, Sevecke K. Transidentität in der Kinder-und Jugendpsychiatrie. Gynakol Endokrinol 2017; 15: 30-38
- B Meyenburg
- A Kröger
- R Neugebauer
- Jugendalter Transidentität Im Kindes-Und
Meyenburg B, Kröger A, Neugebauer R. Transidentität im Kindes-und
Jugendalter: Behandlungsrichtlinien und Ergebnisse einer Katamneseuntersuchung. Z Kinder Jugendpsychiatr Psychother 2015; 43: 47-55