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Gender Transitioning before Puberty?
Thomas D. Steensma Peggy T. Cohen-Kettenis
Published online: 4 March 2011
ÓSpringer Science+Business Media, LLC 2011
In the last decade, delaying puberty by means of GnRH analogs
in gender dysphoric adolescents has become an increasingly
accepted treatment (Hembree et al., 2009). The induced puber-
tal delay is meant to give gender dysphoric adolescents time to
reflect on their wish for gender reassignment, quietly and with-
out the alarming physical puberty development. During puberty
suppression, a complete social transition (change in clothing
and hair style, first name, and use of pronouns) is not required.
However, most youth who are on puberty delaying hormones
appear not to wait with transitioning until they can start cross-
sex hormone treatment.
A similar trend can be observed in gender variant prepu-
bertal children. For quite some time, gender variant children who
came to clinical attention were treated by psychotherapy with the
purpose of decreasing cross-gender behavior and identification
(Zucker, 2008). More recently, a more gender affirmative
approach has been proposed (e.g., Saeger, 2006). This approach
may involve complete social transitioning (including a change of
first name and pronouns) of children as young as 4 or 5 years of
age. Even without contacting clinicians, an increasing number of
parents also support young children in their wish to live in the
desired gender role on a daily basis. Before the year 2000, 2
(1.7%) prepubertal boys out of 112 referred children to the
Amsterdam gender identity clinic were living completely in the
female role. Between 2000 and 2004, 3.3% (4 out of 121 chil-
dren; 3 boys and 1 girl) had completely transitioned (clothing,
hairstyle, change of name, and use of pronouns) when they were
referred, and 19% (23 out of 121 children; 9 boys and 14 girls)
were living in the preferred gender role in clothing style and hair-
style, but did not announce that they wanted a name and pronoun
change.Between 2005 and 2009, these percentages increased to
8.9% (16 out of 180 children; 10 boys and 6 girls) and 33.3% (60
out of 180, 17 boys and 43 girls) respectively.
Such an approach assumes a high persistence of gender dys-
phoria or gender identity disorder (GID) after puberty. How-
ever, follow-up studies show that the persistence rate of GID is
about 15.8% (39 out of the 246 children who were reported on
in the literature) (for an overview, see Steensma, Biemond, de
Boer, & Cohen-Kettenis, 2011), and that a more likely psy-
chosexual outcome in adulthood is a homosexual sexual ori-
entation without gender dysphoria (Wallien & Cohen-Kettenis,
We wondered what would happen to children who transi-
tioned in childhood, but discover at an older age that they pre-
ferred to live in the gender role of their natal sex again. Recently,
we conducted a qualitative study among older adolescents who
had been gender dysphoric in childhood (Steensma et al., 2011).
Some of these children appeared to be persisters and theyapplied
for gender reassignment when entering puberty. Others appeared
to be desisters and were only interviewed for the follow-up study.
In the desisting group, two girls, who had transitioned when they
were in elementary school, reported that they had been struggling
with the desire to return to their original gender role, once they
realized that they no longer wanted to live in the‘other’’gender
role. Fear of teasing and shame to admit that they had been
‘wrong’’resulted in a prolonged period of distress. Only when
they started high school did they dare to make thechange back.
Although gender affirmative treatment, including a com-
plete social transition, may be beneficial for children who will
turn out to be persisters, clinicians and caregivers should real-
ize that prediction of an individual child’s psychosexual out-
come is very difficult in young children. It is conceivable that
the drawbacks of having to wait until early adolescence (but
with support in coping with the gender variance until that phase)
may be less serious than having to make a social transition twice.
T. D. Steensma (&)P. T. Cohen-Kettenis
Department of Medical Psychology, VU University Medical
Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
Arch Sex Behav (2011) 40:649–650
DOI 10.1007/s10508-011-9752-2
Because the chances are high that the gender dysphoria will
disappear by early adolescence, it seems advisable to be very
careful when taking steps that are difficult to reverse.
Hembree, W. C., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A.,
Gooren, L. J., Meyer, W. J., Spack, N. P., et al. (2009). Endocrine
treatment of transsexual persons: An Endocrine Society practice
guideline. Journal of Clinical Endocrinology and Metabolism, 94,
Saeger, K. (2006). Finding our way: Guiding a young transgender child.
Journal of GLBT Family Studies, 2, 207–245.
Steensma, T. D., Biemond, R., de Boer, F., & Cohen-Kettenis, P. T.
(2011). Desisting and persisting gender dysphoria after childhood:
A qualitative follow-up study. Clinical Child Psychology and Psy-
chiatry. doi:10.1177/1359104510378303.
Wallien, M. S., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome
of gender-dysphoric children. Journal of the American Academy of
Child and Adolescent Psychiatry, 47, 1413–1423.
Zucker, K. J. (2008). Children with gender identity disorder: Is there a
best practice? Neuropsychiatrie de l’Enafance et de l’Adolescence,
56, 358–364.
650 Arch Sex Behav (2011) 40:649–650
... Increasing numbers of children are socially transitioning to live in line with their gender identity, rather than the gender assumed by their sex at birth-a process that typically involves changing a child's pronouns, first name, hairstyle, and clothing. Some concerns about childhood social transitions have been raised 1 , including that these children may not continue to identify as transgender, rather they might "retransition" (also called a "detransition" or "desistence"), which some suggest could be distressing for the youth [1][2][3] . Research has suggested that ages 10-13 years may be particularly key times for retransition and that identity may be more stable after this period for youth who show early gender nonconformity 3 . ...
... Increasing numbers of children are socially transitioning to live in line with their gender identity, rather than the gender assumed by their sex at birth-a process that typically involves changing a child's pronouns, first name, hairstyle, and clothing. Some concerns about childhood social transitions have been raised 1 , including that these children may not continue to identify as transgender, rather they might "retransition" (also called a "detransition" or "desistence"), which some suggest could be distressing for the youth [1][2][3] . Research has suggested that ages 10-13 years may be particularly key times for retransition and that identity may be more stable after this period for youth who show early gender nonconformity 3 . ...
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BACKGROUND AND OBJECTIVES Concerns about early childhood social transitions amongst transgender youth include that these youth may later change their gender identification (i.e., retransition), a process that could be distressing. The present study aimed to provide the first estimate of retransitioning and to report the current gender identities of youth an average of 5 years after their initial social transitions. METHODS The present study examined the rate of retransition and current gender identities of 317 initially-transgender youth (208 transgender girls, 109 transgender boys; M=8.1 years at start of study) participating in a longitudinal study, the Trans Youth Project. Data were reported by youth and their parents through in-person or online visits or via email or phone correspondence. RESULTS We found that an average of 5 years after their initial social transition, 7.3% of youth had retransitioned at least once. At the end of this period, most youth identified as binary transgender youth (94%), including 1.3% who retransitioned to another identity before returning to their binary transgender identity. 2.5% of youth identified as cisgender and 3.5% as nonbinary. Later cisgender identities were more common amongst youth whose initial social transition occurred before age 6 years; the retransition often occurred before age 10. CONCLUSIONS These results suggest that retransitions are infrequent. More commonly, transgender youth who socially transitioned at early ages continued to identify that way. Nonetheless, understanding retransitions is crucial for clinicians and families to help make them as smooth as possible for youth.
... This may be from a young age, 1 in adolescence (eg, due to the onset of puberty 2 ) and/or may shift throughout development. [3][4][5] When a young person experiences continued gender-based distress, this is termed gender dysphoria (GD) and they may attend specialist services to explore their feelings. For many, this exploration does not lead to subsequent seeking of physical interventions. ...
Objectives Some gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then to acquire the secondary sex characteristics of their identified gender using gender affirming hormones (GAH). However, little is known about the demographics of transgender adolescents accessing paediatric endocrinology services while under the specialist Gender Identity Development Service (GIDS) in England. Design Demographics of referrals from the GIDS to affiliated endocrinology clinics to start GnRHa or GAH between 2017 and 2019 (cohort 1), with further analysis of a subgroup of this cohort referred in 2017–2018 (cohort 2) were assessed. Results 668 adolescents (227 assigned male at birth (AMAB) and 441 assigned female at birth (AFAB)) were referred to endocrinology from 2017 to 2019. The mean age of first GIDS appointment for cohort 1 was 14.2 (±2.1) years and mean age of referral to endocrinology postassessment was 15.4 (±1.6) years. Further detailed analysis of the trajectories was conducted in 439 YP in cohort 2 (154 AMAB; 285 AFAB). The most common pathway included a referral to access GnRHa (98.1%), followed by GAH when eligible (42%), and onward referral to adult services when appropriate (64%). The majority (54%) of all adolescents in cohort 2 had a pending or completed referral to adult services. Conclusions This study highlights the trajectories adolescents may take when seeking endocrine treatments in child and adolescent clinical services and may be useful for guiding decisions for gender-diverse YP and planning service provision.
... Almost all research on adolescents' gender stereotyping has studied cisgender people, or those whose gender identity matches the sex assigned to them at birth. Less is known about gender stereotypes in gender diverse adolescents (including binary transgender, nonbinary and gender nonconforming individuals), despite the growing number of youth identifying with this group [5,6] a. Is the development of gender stereotyping different in this population of young people different than in the cisgender samples that have typically been studied? ...
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Previous work has documented adolescents' gender stereotype endorsement, or the extent to which one believes men or women should embody distinct traits. However, understanding of gender stereotype endorsement in gender diverse adolescents-those who identify as transgender, nonbinary, and/or gender nonconforming-is limited. Gender diverse adolescents' experiences with gender raise the question of whether they endorse gender stereotypes with the same frequency as cisgender adolescents. In this study, we investigated three primary research questions: (1) if gender diverse (N = 144) and cisgender (N = 174) adolescents (13-17 years) and their parents (N = 143 parents of gender diverse adolescents, N = 160 parents of cisgender adolescents) endorse gender stereotypes; (2) whether these groups differed from one another in their endorsement of gender stereotypes; and (3) whether parents' gender stereotyping was related to either their adolescents' stereotyping and/or their adolescents' predictions of their parents' stereotyping. We found (1) that participants showed low amounts of stereotyping; (2) there were no significant differences between gender stereotype endorsement in gender diverse and cisgender adolescents (or between their parents), though parents endorsed stereotypes slightly less than adolescents; and (3) there was a small positive association between adolescents' stereotyping and their parents' gender stereotyping. We discuss the limitations of our methods, and the possibility that rates of explicit stereotype endorsement may be changing over time.
... There is a remarkable increase in the number of children who are willing to socially transition and of those who have gone through this process prior to their first contact with our GIU. 16,36 It should be taken into account that ''coming out'' is related to social and cultural context. 37,38 Therefore, greater visibility and more permissive social attitudes with respect to gender diversity may have facilitated the expression of non-conforming GI in society. ...
Introduction: An increasing number of transgender minors are seeking help during the development of their gender identity and transitioning. Understanding their characteristics and the impact of transitioning on their mental health would be of help in the development of protocols to offer a better assistance to this population. The aim of this study was to examine the socio-demographic characteristics and clinical data related to gender identity, transitioning and persistence of transgender minors who were seen at the Gender Identity Unit (GID) of Catalonia, Spain. Material and methods: All underage applicants who requested clinical assistance at the specialized GID from 1999 until 2016 were retrospectively evaluated using the minors' medical records. Results: 124 out of 140 minors were confirmed as being transgender, 83.1% of them were adolescents. The assigned male/female ratio was 1:1.2. 97.6% persisted in their transgender identity after a median follow-up time of 2.6 years. Prior to the first meeting, 48.5% were living in their affirmed role and, by the end of the study, this percentage rose to 87.1%. Yearly, the number of referrals exponentially grew whereas the age at referral decreased (rs=-0.2689, p=0.0013). Child consultations rose to a significant percentage (23.5%) over the last 6 years. Conclusions: Over the 18-year period, the number of referrals increased considerably, more assigned natal female minors and children were seen, and more minors made the decision to go through social transition at a younger age. In contrast with other epidemiological studies conducted in this field, a consistently high rate of persistence was observed.
... In addition, a greater number of younger children presenting to specialist gender services who have already made changes in their clothing, hairstyle, first name and pronouns to reflect their gender identity (sometimes referred to as social transition) at the time of referral has been reported. 10 Recent research has suggested that making these changes early on can have desirable outcomes for CYP. [11][12][13] However, research on this matter in prepubertal children is limited, and thus, we need to know more about how making such changes in dress and behaviour relates to later outcomes. ...
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Introduction Specialist gender services for children and young people (CYP) worldwide have experienced a significant increase in referrals in recent years. As rates of referrals increase, it is important to understand the characteristics and profile of CYP attending these services in order to inform treatment pathways and to ensure optimal outcomes. Methods and analysis A retrospective observational study of clinical health records from specialist gender services for CYP in the UK and the Netherlands. The retrospective analysis will examine routinely collected clinical and outcome measures data including demographic, clinical, gender identity-related and healthcare resource use information. Data will be reported for each service and also compared between services. This study forms part of a wider programme of research investigating outcomes of gender identity in children (the Longitudinal Outcomes of Gender Identity in Children study). Ethics and dissemination The proposed study has been approved by the Health Research Authority and London—Hampstead Research Ethics Committee as application 19/LO/0181. The study findings will be published in peer-reviewed journals and presented at both conferences and stakeholder events.
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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.
Gender segregation refers to the tendency of most children to affiliate primarily with same-gender peers. This chapter reviews the development and consequences of this phenomenon. First, the developmental trajectory of gender segregation from early childhood into adulthood is summarized. Second, possible explanations for the emergence of gender segregation in early childhood are critically examined. These include the possible influences of family, school, popular media, behavioral compatibility, and gender-related cognitions. In the third section, the maintenance and consequences of gender-segregated peer groups during middle childhood, adolescence, and adulthood are considered. In the last section, I present a preliminary integrative developmental model. It takes into account the interacting influences of early-appearing variations in behavioral dispositions (including play interests and temperament), ingroup gender identities, and peer group processes on children’s gender development. The model addresses gender development in cisgender children as well as those with transgender or other nonbinary gender identities. Finally, I offer several recommendations for future theorizing and research.Keywordsgender identitypeersinterestsplaytemperamentsocial identitystereotyping
Background: Retransitions in youth are critical to understand, as they are an experience about which little is known and about which families and clinicians worry. Aims: This study aims to qualitatively describe the experiences of youth who made binary social transitions (came to live as the binary gender different from the one assigned at birth) in childhood by the age of 12, and who later socially transitioned genders again (here, called “retransitioning”). Methods: Out of 317 participants in an ongoing longitudinal study of (initially) binary transgender youth, 23 participants had retransitioned at least once and were therefore eligible for this study. Of those youth, 8 were cisgender at the time of data collection, 11 were nonbinary, and 4 were binary transgender youth (after having retransitioned to nonbinary identities for a period). Fifteen youth and/or their parent(s) participated in semi-structured interviews (MYouthAge = 11.3 years; 9 non-Hispanic White; 3 Hispanic White; 3 Multiracial; 10 assigned male; 5 assigned female). Interviews gauged antecedents of transitions, others’ reactions to transitions, and participants’ general reflections. Responses were coded and thematically analyzed. Results: Participants described various paths to retransitions, including that some youth identified differently over time, and that some youth learned about a new identity (e.g., nonbinary) that fit them better. Social environments’ responses to retransitions varied but were often neutral or positive. No participants spontaneously expressed regret over initial transitions. Conclusions: These findings largely do not support common concerns about retransitions. In supportive environments, gender diverse youth can retransition without experiencing rejection, distress, and regret.
Background: Gender incongruent children report lower self-perception compared to the norm population. This study explored differences in self-perception between children living in their gender role assigned at birth and children living in their experienced gender role. Method: The self-perception questionnaire was administered to 312 children referred to the Center of Expertise on Gender Dysphoria ‘Amsterdam UMC’. Social transition status was determined by parental interviews. 2 (social transition) by 2 (sex assigned at birth) ANCOVA’s were conducted. Results: Children living in their assigned gender role reported comparable self-perception to children living in their experienced gender role. Birth assigned girls living in their assigned gender role reported poorer self-perception on ‘athletic competence’, compared to girls living in their experienced gender role. Birth assigned boys living in their assigned gender role reported poorer on ‘scholastic competence’ and ‘behavioral conduct’ compared to boys living in their experienced gender role. Conclusions: Social transition did not show to affect self-perception. Self-perception was poorer for birth assigned boys living in their experienced gender role. For birth assigned girls this was reversed. Future studies should give more insight in the role of social transitions in relation to child development and focus on other aspects related to self-perception.
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Almost 50 years of clinical observation and research on children with gender identity disorder have provided useful information on phenomenology, diagnostic and assessment procedures, associated psychopathology, tests of etiological hypotheses, and natural history. In contrast, best practice guidelines and evidence-based therapeutics have lagged sorely behind these other domains. Accordingly, the therapist must rely on the “clinical wisdom” that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions. Because of this state of affairs, dogmatic assertions about best practice should be avoided.
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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.
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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.
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To establish the psychosexual outcome of gender-dysphoric children at 16 years or older and to examine childhood characteristics related to psychosexual outcome. We studied 77 children who had been referred in childhood to our clinic because of gender dysphoria (59 boys, 18 girls; mean age 8.4 years, age range 5-12 years). In childhood, we measured the children's cross-gender identification and discomfort with their own sex and gender roles. At follow-up 10.4 +/- 3.4 years later, 54 children (mean age 18.9 years, age range 16-28 years) agreed to participate. In this group, we assessed gender dysphoria and sexual orientation. At follow-up, 30% of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric. Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation. Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality.
The world of mainstream psychotherapy encounters unfamiliar territory when a four-year-old girl, desperate to have a different-gendered body, is treated over a three-year period by a psychologist who is not a gender specialist. Evolution of the work with the child, family, extended family, and school is described. Implications for theories of the etiology of transgender identity are considered in light of the family structure. Treatment issues are highlighted, including the interface of transgender issues with family dynamics.
Finding our way: Guiding a young transgender child
  • K Saeger
Saeger, K. (2006). Finding our way: Guiding a young transgender child. Journal of GLBT Family Studies, 2, 207-245.
Endocrine treatment of transsexual persons
  • W C Hembree
  • P T Cohen-Kettenis
  • H A Delemarre-Van De Waal
  • L J Gooren
  • W J Meyer
  • N P Spack