Gender dysphoria (GD) is a term that is becoming more familiar in our everyday language. You’ve likely heard it in the media, come across it on a referral letter, or perhaps even cared for a patient with this diagnosis. Many of us in the medical community may initially feel uncomfortable with this particular diagnosis, simply due to our lack of experience and background knowledge in the area. Some of us may be concerned about the appropriate terminology to use or the correct guidelines, or even how gender, general medicine and psychiatry all interact in this space. Working in paediatrics and, more recently, in adolescent medicine, I’ve been fortunate to learn more about this diagnosis. I hope that this article can pass along a few basic tenets that will be useful in your practice caring for adolescents diagnosed with GD.
A good place to begin is with an understanding of some gender terminology. Gender identity is a person’s innate sense of being male, female or, for some, a blend of both or neither. Gender expression is how individuals show their identity to others (through multiple ways, such as haircuts, clothing and expressions). Gender incongruence is when an individual’s gender identity differs from their sexual anatomy at birth. GD refers to the distress noted by an individual due to their gender incongruence. Finally, transgender is an overarching term used to describe those individuals with gender incongruence.
From a diagnostic standpoint, the term GD has replaced the previous term, gender identity disorder (GID). The new term acknowledges that gender non-conformity is not in itself a mental disorder, but rather the potential distress associated with it, if clinically significant. In the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), there are set criteria which need to be filled in order to meet the diagnosis (children need to fulfil six criteria and adults two). A patient must display these features for greater than six months, have significant distress or interference with function, and display consistent, persistent and insistent gender incongruence.1 With children, this tends to present as a preference towards toys, games, role playing and dislike of anatomy. Adults generally present with a strong desire to exist as another gender, to have other sex characteristics and to have societal reciprocation of their gender.
The prevalence of GD in adults assigned male at birth is estimated to be between one in 7000 and one in 20,000, and for those assigned female at birth, between one in 30,000 to one in 50,000. There are no strong epidemiological studies for children and adolescents, but numbers suggest that the ratio in childhood of referrals for those assigned male at birth versus referrals for those assigned female at birth is 3:1, while in adolescence the ratio is 1:1.1 The overall number of referrals to paediatric gender clinics for assessment is increasing as well. The Royal Children’s Hospital (RCH) in Melbourne reviewed their referrals from 2003 to 2016 and noted they had a 200-fold increase in referrals to their gender service in 13 years (European and US centres have also reported similar increases).
Good models of care and strong management are required for adolescents with GD, as they have a significantly higher rate of mental health issues than their peers. Studies from the US have found rates of attempted suicide and suicidal thoughts in transgender teens at roughly twice that of their age-matched peers. Fortunately, there are good national and international documents to assist with best practice for the transgender community. Internationally, there are three main documents, including Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,2 the World Professional Association for Transgender Health Standards of Care 20123 and the American College of Obstetricians and Gynecologists Committee Opinion 2011.4 Within Australia, we have Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents 2017.5
The general treatment model within these documents suggests an assessment followed by a three-stage treatment pathway. The assessment is performed by a multidisciplinary team, then the patient may progress to puberty blockers (stage one), cross-sex hormones (stage two) and gender reassignment surgery (stage three). These stages have age requirements, legal requirements and regular medical and psychological follow up to ensure safety.
There is no medical or surgical treatment provided to children who have GD prior to puberty. For those children with gender non-conforming behaviour, the current recommendation is for affirmative therapy that encourages the parent to support the child in private and in public with their gender identity. Once the child is at, or nearing, adolescence, they may be assessed in a multidisciplinary gender clinic. In order to capture the population assigned female at birth who enter puberty earlier than those assigned male at birth, gender clinics will generally begin to see children at around the age of nine. If a child meets the diagnosis of GD following the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) assessment and they are just about to enter, or are in the early stages of, puberty, they may qualify for puberty suppression medication. The medication is a GnRH analogue and prevents the adolescent from experiencing the distressing body changes that would be about to occur during this time. Puberty recommences if the medication is ceased.
Previously, there was a legal requirement for a court order before being able to commence cross-sex hormones at age 16. This requirement was removed in early 2018. It will likely change the model of care in some adolescent units, as they will need to determine how this affects the hospital, medical staff and patients from a governance, legal, ethical and logistical standpoint. For those individuals transitioning from male to female, the Royal Children’s Hospital (RCH) in Melbourne suggests that stage two therapy be oestradiol valerate (Progynova). Initially, this may be overlapped with puberty-blocking medication and then, later, with the puberty-blocking medication ceased, an anti-androgen medication such as spironolactone may be added, thereby necessitating lower doses of administered oestrogen.
For people assigned female at birth transitioning to male, they will start with testosterone enanthate injections weekly, as this induces virilisation quicker, but they may later switch to gel once this has been established. Depending on the choice of the individual, a Mirena may be used for contraception. During the early phase of stage two treatment, individuals are monitored every three months with an examination and blood test to check for complications. Stage three surgery generally occurs over the age of 18 and may be performed provided the individual has considerable ‘real life experience’ living in the gender they have transitioned to. For those medical professionals in the field of obstetrics and gynaecology, their role in caring for the transgendered individual would mainly involve management of menstrual suppression, contraception, fertility options and hysterectomy or bilateral salpingectomy procedures.
Prior to the commencement of puberty-blocking hormones or cross-sex hormones, the patient should be counselled on fertility preservation. Practices in this area come from the oncofertility field and can be expensive, distressing and experimental. Due to the level of maturity of the adolescent, their parents often assist in the decision or make a proxy decision. RCH looked at the uptake of fertility preservation with their cohort and found that 37 per cent (19 of 51) of people assigned male at birth underwent preservation, while zero per cent (0 of 36) of those assigned female at birth underwent fertility preservation.
The course of GD in children has shown that the majority will not remain gender dysphoric after puberty. The rates vary, but around 80 per cent of children will desist by the time they reach puberty. However, evidence of more extreme gender non-conforming behaviour in childhood is associated with persistence of GD into late adolescence and adulthood.6 Within the adolescent framework, the main question has been to determine if puberty-blocking medication and psychological support has been beneficial with regards to the mental illness. A 2015 study by Costa has shown a statistically significant improvement in psychosocial functioning over a 12-month period in a cohort of 201 adolescents with GD, who underwent a combination of puberty-blocking medication and psychological support.7 Another study by De Vries in 2014, that followed 55 transgendered adolescents through puberty-blocking medication, cross-sex hormones and later gender reassignment surgery, found that the symptoms of GD were alleviated and psychosocial functioning was improved.8 Also in the literature is a meta-analysis, which included 23 studies with 1833 transgendered individuals. The study identified that approximately 80 per cent of those who underwent hormone treatment showed improvement in their GD symptoms, quality of life and psychological symptoms.9
There are questions asked if enough evidence is available to support such a significant intervention in adolescents. When searching for literature on the subject, it is notable that there are not a large number of studies and the ones which have been completed generally have small numbers of subjects. A PubMed search using the phrase ‘gender dysphoria and adolescent’ comes up with 311 results, while the phrases ‘anxiety and adolescent’ and ‘depression and adolescent’ have 41,467 and 59,538 results respectively. Long-term data is lacking and more research is required in this area, but current evidence suggests the benefit of a multidisciplinary approach is improving mental health outcomes.
In summary, the main points to take away are:
- Numbers of transgender-identifying youth presenting to gender clinics are increasing
- The transgender population has a higher prevalence of mental health disorders than
- Assessment is recommended via a multidisciplinary service
- There is a three-stage treatment process depending on puberty, readiness, ability to consent and personal/medical professional choice
- Patients need monitoring and screening of their physical and mental health status
- Current research suggests an improvement in mental health with treatment.