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Treatment of Adolescents
With Gender Dysphoria in
the Netherlands
Peggy T. Cohen-Kettenis, PhD
a,
*, Thomas D. Steensma, MSc
a
,
Annelou L.C. de Vries, MD, PhD
b
KEYWORDS
• Gender dysphoria • Puberty suppression
• Gender identity disorder
• Gonadotropin-releasing hormone analogues • Adolescents
Adolescents with gender dysphoria seek help for a variety of problems. Some have
intense distress about the incongruence between their natal sex and gender identity
and expect that clinicians will provide them with hormones and gender reassignment
(GR) surgery as quickly as possible. Others feel only some unease with or confusion
about their gender identity and try to find ways to live with these feelings. The gender
dysphoria may have started long before puberty or be recent. It might have been a
response to certain experiences or have been present without a clear starting point.
There are also huge differences between adolescents in their ability to handle the
complexities and adversities that often accompany gender variance. The ways in
which the environment has responded to their gender variant behavior can vary from
accepting and supporting to rejecting and stigmatizing. When these adolescents
present at clinics, they may have a broad range of coexisting psychiatric problems. In
recent years, many of these youth have come to gender identity clinics with a straight
focus on GR (ie, cross-sex hormone treatment and surgery). However, not only in
adult gender identity clinics but also in clinics treating adolescents, nonclassic
presentations increasingly need a diagnosis and some form of treatment.
1
In 1987, the first gender identity clinic for children and adolescents was opened in
the Netherlands at what is now called the Center of Expertise on Gender Dysphoria.
Since then more than 800 children and adolescents have attended the gender identity
clinic. Meanwhile, ideas about treatment have greatly changed. Diagnostic protocols
and instruments for adolescents have been developed, and medical interventions,
The authors have nothing to disclose.
a
Department of Medical Psychology and Medical Social Work, VU University Medical Center, PO
Box 7057, 1007 MB Amsterdam, the Netherlands
b
Department of Child and Adolescent Psychiatry, VU University Medical Center, PO Box 7057,
1007 MB Amsterdam, the Netherlands
* Corresponding author.
E-mail address: PT.Cohen-Kettenis@vumc.nl
Child Adolesc Psychiatric Clin N Am 20 (2011) 689–700
doi:10.1016/j.chc.2011.08.001 childpsych.theclinics.com
1056-4993/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Author's personal copy
including the halting of puberty, have become available for gender dysphoric
adolescents.
2– 4
Various professional organizations and clinics have published
treatment guidelines.
5– 8
The introduction of gonadotropin-releasing hormone (GnRH)
analogues to suppress puberty especially signified an important change in the clinical
management of gender dysphoria in youth. However, puberty suppression is not
without criticism.
9
Because the gender identity clinic in the Netherlands took a leading role in
developing this model of care, the model is sometimes called the “Dutch approach.”
10
In this article the authors describe diagnosis and treatment as they have developed it
at their clinic. The authors use Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR)
11
nomenclature and criteria, although they
are aware of the upcoming changes that are likely to be introduced in the DSM-5.
DEVELOPMENTAL TRAJECTORIES
Gender-variant behavior and even the desire to be of an other gender can be either
a phase or a variation of normal development without any adverse consequences for
a child’s current functioning (eg, Bartlett and colleagues
12
). Prospective studies
showed that the presence of childhood gender variance in clinical populations is
associated with later homosexuality or bisexuality, as well as gender dysphoria, in
adulthood.
13–22
Nevertheless, even in clinical populations, in over about 25% of cases
the gender dysphoria does not persist from childhood into adulthood.
In contrast to childhood gender dysphoria, during adolescence it seems much
more unlikely that gender dysphoria will desist. Adolescents who were gender
dysphoric in childhood and present at gender identity clinics soon after puberty rarely
refrain from GR later in adolescence.
2,23
In a study by de Vries and colleagues,
24
adolescents who started puberty suppression at an average age of 14.75 years to
enable exploration of their gender dysphoria and treatment wish were still gender
dysphoric nearly 2 years later, and all chose to start cross-sex hormone treatment, the
first step of actual GR, at a mean age of 16.64 years.
THE DUTCH APPROACH
The recommended procedure in the Standards of Care of the World Professional
Association for Transgender Health (WPATH; www.wpath.org), an international pro-
fessional organization in the field of gender dysphoria and transsexualism, is to come
to a GR decision in various phases.
8
In the first phase, someone has to fulfill DSM or
International Classification of Diseases criteria for gender identity disorder (GID) or
transsexualism.
11,25
The next phase consists of real-life experience, and hormones of
the desired gender are prescribed. The last phase consists of various types of surgery
to change the genitals and other sex characteristics. The Amsterdam clinic has
always largely followed this procedure.
The Diagnostic Procedure
Creating a working relationship
When working with gender dysphoric adolescents, it is important to create a working
relationship. It helps to explain that clinicians are neutral regarding the outcome of the
diagnostic process. If GR seems to be the best solution to the apparent gender
issues, medical interventions, including puberty suppression, are available. If other
solutions seem to be better, other types of interventions are advised. This attitude is
most helpful in allowing the youth to openly explore gender dysphoric feelings and
treatment wishes.
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Obtaining information
In the diagnostic phase, the gender identity problem and potential related problems
are examined comprehensively by the mental health clinician, who is usually a clinical
child psychologist. Eligibility and readiness for puberty suppression and GR are
considered during this phase. Some youth wish that there were medical tests to
objectively measure gender dysphoria, but clearly these do not exist. Yet it is
extremely important not to refer the wrong individuals for medical interventions.
Mental health professionals are largely dependent on the information given by the
adolescents and their parents to assess treatment eligibility. Adolescents and parents
are usually seen together at the first session, which enables the mental health
professional to interview them jointly and separately and observe any relevant family
interactions. During the intake and subsequent sessions, most of which are with the
adolescent, information is obtained on various aspects of the general and psycho-
sexual development of the adolescent. Before visiting the gender identity clinic,
parents fill out a number of instruments such as the Child Behavior Checklist (CBCL)
26
and a self-developed questionnaire on the adolescent’s development. The CBCL
Youth Self Report is administered to the adolescent.
27
Information is also obtained about current cross-gender feelings and behavior,
current school functioning, peer relations, and family functioning. With regard to
sexuality, sexual experiences, sexual attractions, sexual relationships, the subjective
meaning of cross-dressing, sexual fantasies accompanying cross-dressing (if any),
and body image are explored.
A psychodiagnostic assessment not only measures gender-related issues such as
gender dysphoria and body satisfaction (see Zucker
4
for an overview of instruments),
but also general aspects of psychological functioning: intellectual abilities, coping
abilities, psychopathology, and self-esteem.
The assessment of the relationships within the family and family functioning are
less standardized than the other aspects of the diagnostic procedure. Yet this
assessment provides important information because parents (or other caregivers) are
the ones the adolescent has to rely on during the period in adolescence that medical
interventions are provided. This period can take more than 6 years when the
diagnostic phase is started at the age of 12 years. Clinicians therefore have regular
contact with the family during the diagnostic and GR process.
Giving information
In order to create realistic expectations with regard to the adolescents’ future lives,
the clinician gives information on the possibilities and limitations of GR and other
types of treatment such as psychological interventions. Clinicians also discuss the
broader impact of GR. The loss of fertility is one important aspect. Although a rare
event, older natal male adolescents who are already beyond the first pubertal (Tanner)
stages when assessed at the clinic may choose to freeze their sperm. Younger
adolescents usually do not want to wait until Tanner stages 4 or 5 but prefer to start
with puberty-suppressing hormones before they are fertile. Much of the information is
given early in the procedure because some may refrain from GR as soon as they
realize what GR actually entails. Clinicians further explore with the youth whether the
gender dysphoria might be solved by either psychological interventions or hormone
or surgical interventions only rather than a complete GR.
Like in other countries, in the Netherlands being overweight or obese is becoming
more and more prevalent.
28
This trend is also observable in gender dysphoric youth
applying for GR. Another health issue concerns cigarette smoking. In 2010, about
20% of Dutch youth between 10 and 20 years reported to have smoked in the last 4
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weeks.
29
As the pediatric endocrinologists and plastic surgeons consider obesity and
smoking as factors that seriously impact effects of hormone treatment and surgical
outcome, attention is increasingly given to these lifestyle issues. Adolescents are
encouraged to work on their eating and smoking habits long before the actual
treatment starts. This is done not only by the diagnostician. If an adolescent is likely
to be referred for medical interventions, he or she will visit the pediatric endocrinol-
ogist for an advisory consultation. The authors have chosen for this procedure in
order to properly inform the youth and their parents about the medical aspects of the
treatment. At this time the adolescent also has a medical screening (see also
Hembree and colleagues
7
).
Informing the adolescent about the various consequences of GR concerns so many
topics and touches upon such complex issues that it is impossible to do so in one
session. The issues are discussed throughout the diagnostic procedure in order to
allow for a truly informed consent, but some are also discussed in later phases of the
GR process.
Child psychiatric assessment
Shortly before the final advice on eligibility and readiness for medical interventions is
discussed in the child and adolescent gender team, a child psychiatric consultation is
performed. The child psychiatrist is also a part of the team. This involvement ensures
that there are always two mental health clinicians who know the adolescent and the
family and that the decision to start treatment is not taken on the basis of personal
contacts with only one team member. In addition, because a substantial number of
the referred adolescents have psychiatric comorbidity with almost 10% having
autistic spectrum disorders (ASD), a psychiatric evaluation is important to address
these problems.
30,31
Team decision
An advisory consultation concludes the diagnostic procedure. If the recommendation
is to start puberty suppression, this decision is always made by the whole team after
a discussion of the case. It seems that about one-quarter of the adolescent referrals
at the Amsterdam clinic do not fulfill diagnostic criteria for GID. Most of the
adolescents drop out early in the diagnostic procedure for this reason or because
other problems are prominent.
24
Treatment: Psychological Interventions
Indications for psychological interventions
When the gender identity problem requires further exploration, psychological and/or
family problems exist, or psychiatric comorbidity occurs, some form of psychological
treatment is offered or sought close to the youth’s home. This advice is also given to
adolescents with GID to whom medical interventions (most likely puberty suppres-
sion) will be provided, especially in vulnerable youngsters. Problems that may require
either psychological interventions only, or before or in combination with medical
interventions, are as follows:
•Gender confusion. Referred adolescents are sometimes only uncertain about
their gender. For example, young male homosexuals may have a history of
stereotypical feminine interests and dressing in girls’ clothes. They sometimes
mistake their homosexuality for a GID (see Tuerk article elsewhere in this issue)
despite decreased cross-gender interests and activities after puberty and a
disappearance of the gender dysphoric feelings. A lack of acceptance of their
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homosexuality may make them consider GR a solution to their problem. Other
adolescent males fulfilling the DSM-IV-TR criteria for transvestic fetishism
interpret their desire to wear female clothing, with or without accompanying
sexual arousal, as a sign of GID and need for GR. Especially for adolescents, it
is difficult to know whether this is a permanent situation or just an experimental
phase in someone who will never seek GR.
•Aversion toward sexuality or sexed body parts. In (relatively rare) cases, a wish
for genital ablation exists in persons who prefer to be sexless but have no
cross-gender identity. This desire has been described as the Skoptic syn-
drome
32
or as male-to-eunuch identity disorder in males who seek castration
voluntarily without wanting to acquire the female characteristics (eg, John-
son
33
). It is likely that the taboo that still exists on this phenomenon makes
adolescents reluctant to present with such a treatment wish at the authors’
clinic.
•GID without GR. Gender dysphoric adolescents who do not desire complete GR
(both cross-sex hormones and surgery) may try to integrate masculine and
feminine aspects of the self and adopt an androgynous, bigendered, or
“genderqueer” form of expression. Again, such a treatment wish is relatively rare
in adolescents who present at the authors’ clinic. It is conceivable that suffering
from GID without having a desire for GR signifies a the result of developmental
route that takes more time to be completed.
•Psychiatric comorbidities. Comorbid psychiatric problems need to be ad-
dressed to ensure that the diagnostic or treatment process is not unduly
disturbed. When comorbidities are addressed, adolescents can be eligible for
puberty suppression. To achieve an uneventful treatment, good, regular contact
with the local mental health clinicians is necessary.
30
If the observed problems
are destabilizing and there is an insufficient guarantee that the youth has a
commitment to the relationship with the psychologist and medical doctors,
which is necessary for this type of a physical interventions, medical treatment is
postponed until the adolescent or his or her situation has become sufficiently
stable. In the authors’ clinic, treatment seemed to be delayed more frequently in
youths who suffered from psychiatric comorbidity, were less likely to live with
both biological parents, and had a lower intelligence. On average, adolescents
with psychiatric comorbidities were older at the time of referral.
30
•ASD-related diagnostic difficulties. Youth with ASD often present themselves at
gender identity clinics. As has been described by de Vries and colleagues,
31
the
conviction to have a cross-gender identity may exist parallel to the ASD but may
also be part of the rigid convictions that belong to autism. It is a challenge to
disentangle the gender and ASD components. When adolescents with ASD are
considered eligible for medical intervention including puberty suppression,
treatment has to be introduced very carefully, and each step must take place in
close consultation with the other mental health clinicians involved in the
treatment or counseling of the adolescent.
31
Types of psychological interventions
The range of treatment goals is broad, because many factors may underlie the issues
gender dysphoric youths are struggling with (see also de Vries and colleagues
5,34
). These
youth may be directed toward dealing with the gender identity issue itself, for instance if
there is uncertainty about the experienced gender identity or hesitance about the type of
medical interventions that may solve the discrepancy between experienced gender and
natal sex. Interventions sometimes focus on the consequences of one’s gender variance.
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Adolescents may struggle with shame about being different, guilt toward parents, or low
self-esteem. In some cases they suffer from social repercussions of being gender-variant,
such as exclusion from certain social circles or being teased, bullied, ridiculed, or
harassed.
35,36
Psychotherapy can help these adolescents to become more self-
confident, not be bothered by unnecessary feelings of shame and guilt, and/or
enhance social skills.
Although the authors usually offer individuals who want to explore their options for
coping with gender dysphoria some form of individual therapy, having contact with
other transgender youngsters is helpful too. Observing other adolescents dealing with
their gender identity concerns, sharing information, and peer support is often
experienced as highly beneficial. In the Netherlands, adolescents can join meetings
for gender dysphoric adolescents. These meetings are organized by a support group
such as Transvisie. These meetings do not have a therapeutic goal but are intended
to offer a safe and informal social setting to meet peers. The consequences of such
contacts, however, can be very therapeutic.
Psychotherapy offered to gender dysphoric adolescents who are considering GR is
supportive of GR. This means the adolescent is made aware that any outcome of the
therapy (whether it is acceptance of living in the social role congruent with the natal
sex, partial treatment, or complete GR) is acceptable as long as it leads to the relief
of the adolescent’s gender dysphoria and a better quality of life.
For adolescents who start GR, various topics have to be brought up repeatedly
because their views and experiences often change over time. Examples are relation-
ships with peers, sexuality, and infertility. One discusses aspects of sexuality with a
13-year-old, who is only fantasizing about falling in love, differently than with an
18-year-old, who tries to find ways of having sex while having a body that is not yet
completely congruent with the experienced gender. Youth will profit most from having
a balanced view of the short-term and long-term costs and benefits of GR, and this
balance is what they may learn in psychotherapy or counseling sessions. Communi-
cating, dating, or initiating contact with potential romantic partners can be hampered
by certain characteristics of the person such as extreme shyness, lack of self-
confidence, or perfectionism. Such characteristics need specific attention to facilitate
future partnerships. Like other adolescents, gender dysphoric adolescents need
adequate information about sexuality in general. For some it is necessary to point out
the chances of aggressive reactions when they engage in sexual encounters, in case
the sexual partner is not aware of the adolescent’s natal sex.
Even if secondary sex characteristics have hardly developed because of timely
puberty suppression and an early social role change, some adolescents feel frus-
trated because in their opinion they have to wait too long for their estrogen or
androgen treatment to feminize/masculinize in the same ways as their age peers.
When they have started cross-sex hormone treatment, waiting for surgery can be
equally frustrating and if not addressed can lead to social withdrawal.
Sometimes family therapy is necessary to help resolve conflicts between family
members. For example, parents may have different views about how to handle their
child, or the adolescent may want to express gender in ways that other family
members are not comfortable with. Also, parents and/or adolescents can have
trouble distinguishing between what is related to the gender dysphoria and what is
not. In the counseling of families, parents are supported in determining realistic
demands and in working on the development of healthy boundaries and limits.
The authors also consider regular contact with a mental health practitioner at their
clinic necessary for adequate preparation for the next treatment steps. For instance,
adolescents have to be aware of medical risks that arise with an unhealthy lifestyle,
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and trans girls’ (natal boys with a female gender identity) need laser hair removal on
a portion of the scrotal area (something they often do not like to do) when preparing
for vaginoplasty. The adolescents should also be conscious of the practical conse-
quences of medical interventions. For instance, they will need to take hormones for
the rest of their life, and trans girls will need to dilate their neovagina after surgery if
they are not sexually active. When surgery is discussed, unrealistic expectations
about the depth of the neovagina or size of the neophallus have to be put into
perspective.
For those who do not easily verbalize their feelings, psychomotor therapy can be
helpful to let adolescents feel more at ease with their body and to learn to talk more
easily about their concerns.
Treatment: Medical Interventions
Puberty suppression
Eligibility for puberty suppression. If adolescents do have a diagnosis of GID, they
may be eligible for puberty suppression by means of GnRH analogues. The authors
believe that offering this medical intervention minimizes the harm to the youth while
maximizing the opportunity for a good quality of life including social and sexual
relationships, and that it respects the wishes of the person involved.
37
GnRH analogues put a halt to the development of secondary sex characteristics.
Originally GnRH analogues were used in the treatment of precocious puberty.
Because gonadal function is reactivated soon after cessation of treatment,
38
GnRH
analogue treatment can be considered as “buying time” rather than actual treatment.
Current eligibility criteria for puberty suppression are an early history of GID that
has intensified rather than decreased during the early pubertal phases, no serious
psychosocial problems interfering with the diagnostic assessment or treatment, and
a good comprehension of the impact of GR on one’s life. It is also considered
important that there is enough support from the family or other caregivers. The
adolescent should have reached Tanner stage 2 to 3 and be older than 12 years of
age.
3,39
Starting around Tanner stages 2 to 3, the very first physical changes are still
reversible.
3
Some experience with one’s physical puberty is required because the
authors assume that experiencing one’s own puberty is diagnostically useful. It is at
the onset of puberty that it becomes clear whether the gender dysphoria will desist or
persist.
40
Besides, some cognitive and emotional maturation is desirable when
starting these physical medical interventions. In addition, Dutch adolescents are
legally competent to make a medical decision together with their parents’ consent, at
age 12. The age criterion of 12 years, however, is under discussion, because many
natal girls are already beyond Tanner stage 3 when they are 12 years old. It is
conceivable that when more information about the safety of early hormone treatment
becomes available, the age limit will be further adjusted (de Vries AL, Steensma TD,
Wagenaar EC, and colleagues, unpublished data, 2011).
Puberty suppression. If the eligibility criteria are met, GnRH analogues are used to
suppress puberty (eg, triptorelin, 3.75 mg every 4 weeks).
7,39
An extra dose is given
after 2 weeks of GnRH analogue treatment to counteract the initial surge of sex
hormones. Because the effects are reversible, this treatment phase could be
considered an extended diagnostic phase. Knowing that the treatment will put a halt
to the physical puberty development often results in a vast reduction of the distress
that the physical feminization of masculinization was producing. Also, the early
suppression of the development of secondary sex characteristics makes passing in
the desired gender role easier than when treatment is delayed until adulthood. This
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early suppression entails a great advantage for passing in the desired role throughout
one’s life. Clinicians, however, explain to the adolescent and family that puberty
suppression does not automatically imply that cross-sex hormone treatment will take
place later on. To make a well-informed and balanced decision, adolescents see their
psychologist or psychiatrist regularly in the years that they are on GnRH analogues.
These sessions are meant to evaluate feelings about a transition on a permanent
basis, with increasing knowledge of what a future life in the desired gender role might
look like. The adolescents are also regularly given consideration in a weekly
multidisciplinary conference in which the pediatric endocrinologist also participates.
As soon as necessary, extra help is deployed or the trajectory is adjusted.
If youth suffer from psychiatric problems but the mental health treatment they
receive is adequate to ensure that the diagnostic or treatment process is not unduly
disturbed, they are still eligible for puberty suppression.
Transitioning. Puberty suppression gives adolescents time to quietly explore their
gender identity and GR wish, even without informing the wider environment that they
are contemplating GR. However, most gender dysphoric youths choose to live in the
desired gender role simultaneously with the beginning of puberty suppression. The
adolescents and their family are supported in this process by the clinicians to allow for
a smooth process. Many youths also obtain help from the aforementioned support
group, Transvisie. The group has volunteers who may assist the youth, parents, or
school during the process. It is, however, not a requirement to transition socially as
long as cross-sex hormones are not taken.
Cross-sex hormone treatment
Eligibility for cross-sex hormone treatment. In the Dutch protocol, gender dysphoric
adolescents are eligible for the first step of the actual GR when they have reached the
age of 16. This age has been chosen because in the Netherlands (as well as in many
other countries) young people are then considered able to make independent medical
decisions. Whereas parental approval is not officially required, the Amsterdam clinic
prefers their consent, because most adolescents are still very much dependent on
their caretakers. Besides, by the age of 16, adolescents have to meet the same
criteria as for puberty suppression (except for the Tanner stage criterion). Although
most of the youths will have already made a social transition, it is an absolute
requirement that they will make the social gender role change as soon as the
cross-hormones are taken. This requirement is because soon after the start of
treatment, sex characteristics of the desired gender will become visible to others.
Cross-sex hormone treatment. If an adolescent still wants to start the actual GR at 16
years, feminizing puberty is induced in natal boys by prescribing 5
g/kg 17

estradiol
per day and increasing the dose every 6 months by 5
g/kg. An adult dose of 2 mg
per day is given when the patient reaches 18 years of age. In natal girls, male puberty
is induced with testosterone esters starting at 25 mg/m
2
per 2 weeks intramuscularly.
The dose is increased every 6 months by 25 mg/m
2
. At age 18 years an adult dose is
given of 250 mg per 3 to 4 weeks. In trans girls the estrogens will result in breast
growth and a female fat distribution. In trans boys the androgens will result in a more
muscular development, particularly in the upper body; a lower, male-sounding voice;
facial and body hair growth; and clitoris growth.
3,7
At some point the operations are close at hand. As noted previously, the
possibilities and limitations of the surgery (eg, various types of metaidoioplasty or
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phalloplasty, or no genital surgery for trans boys) about which the adolescent will have
to make choices need to be discussed more extensively.
41
Surgery
Eligibility for surgery. When adolescents in the authors’ clinic reach 18 years of age,
as previous phases have consolidated the diagnosis and social transition has been
successful, they are eligible for the next treatment step, the GR surgeries. Trans boys
may undergo several operations: if they came relatively late to the clinic and already
had some breast development, mastectomy; hysterectomy/ovariectomy; colpectomy
(also called vaginectomy); and, if desired, operations on the external genitalia
(metaidoioplasty or phalloplasty). Trans girls usually undergo partial penectomy with
vaginoplasty and, if necessary, at their own financial expense, breast augmentation.
Trans girls who began puberty suppression at an early age often have insufficient
penile skin for a classic vaginoplasty and need an adjusted surgical procedure, such
as a technique using colon tissue.
Dilemmas
The treatment of young gender dysphoric adolescents has received a variety of
criticisms (eg, by Korte and colleagues,
9
Meyenburg,
42
and Viner and colleagues
43
).
Some state that a diagnosis of GID cannot be made in adolescence because in this
developmental phase gender identity is still fluctuating. Others fear that puberty
suppression will inhibit a spontaneous formation of a gender identity corresponding
with one’s natal sex. In the authors’ clinic population, however, GID seems to be
highly persistent from early puberty on, and certainly after Tanner stage 2 or 3. None
of the younger and older adolescents diagnosed with GID and considered eligible for
GR dropped out of treatment during the GR procedure or regretted GR.
44–46
Other concerns relate to bone density, body height, and brain development. Peak
bone mass may not be achieved and/or there might be body segment disproportion.
The first data of a Dutch cohort of adolescents who had been treated with GnRH
analogues suggest that after an initial slowing in bone maturation it significantly
caught up after the commencement of cross-sex steroid hormone treatment
3,47
(Schagen SE, Cohen-Kettenis PT, van Coeverden-van den Heijkant SC, and col-
leagues, unpublished data, 2011). Body proportions, as measured by sitting height
and sitting-height/height ratio, remained in the normal range. Early treatment may
result in a final height in the normal natal female range for trans girls. For trans boys,
a timely administration of oxandrolone, a synthetic anabolic steroid that influences
height development, may result in acceptable natal male height. Although the effects
of puberty suppression on brain development have not been systematically studied,
clinically there seems to be no effect on social, emotional, and school functioning.
Not treating gender dysphoric adolescents is not a neutral option. Delaying
treatment until adulthood or even until older adolescence may have its psychological
drawbacks. Some youth develop psychiatric problems such as depression and
suicidality, anxiety, or oppositional defiant disorders, or they may become school
dropouts or react with complete social withdrawal. Puberty suppression seems to
quickly result in a relief of their distress and a significant improvement in their quality
of life. When gender dysphoric youth are denied access to GR, they might seek
medication illegally or respond to their distress in other irresponsible ways.
If treated early in puberty, these youth may also be spared the burden of having to
live with irreversible signs of the “wrong” secondary sex characteristics (eg, scarring
because of breast removal in trans boys; having a male voice and male facial and
bodily features in trans girls). Having no or only few visible sex characteristics of one’s
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natal sex obviously is an enormous and lifelong advantage. Furthermore, early
treatment will likely make certain forms of surgery redundant or less invasive (eg,
breast reduction in trans boys). It is not surprising that follow-up studies among adult
transsexuals show that unfavorable postoperative outcome seems to be related to a
later rather than an early start of GR (for reviews, see Cohen-Kettenis and Gooren,
48
Pfäfflin and Junge,
49
and Ross and Need
50
).
SUMMARY
Puberty suppression in young gender dysphoric adolescents seems to be beneficial
and able to prevent harmful effects of growing up with a body that is incongruent with
one’s gender identity. Despite the reservations that many clinicians had when this
protocol was introduced, views on this approach are rapidly changing.
39,51
In the last
5 years a fair number of clinics in and outside Europe (eg, in Belgium, Germany,
Finland, Italy, Norway, Spain, Switzerland, Australia, and the United States) have
adopted an identical clinical approach. The first studies showing promising effects (de
Vries AL, Steensma TD, Wagenaar EC, and colleagues, unpublished data
2011)
24,44,45
and the increasing numbers of gender dysphoric youth who apply for
medical interventions are probably related to these policy changes.
However, research on the effects of GR, starting with GnRH analogues treatment,
is still scarce, and understandable concerns about potential harm have to be taken
seriously. The initial studies need to be expanded in scope and corroborated by
results from other centers to ensure that the treatment is safe enough. It would also
be useful to compare other treatment protocols with the one described in this article.
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