Special Issues in Treating Adolescents With Gender Dysphoria

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SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS

Terminology Associated With Gender Dysphoria

In recent years, transgender and gender incongruent adolescents have been the focus of media attention, public debate (eg, around the use of preferred pronouns and bathroom use), and, last but not least, best clinical practice. While the term transgender is mostly being used as an umbrella term for all forms of gender diversity, gender dysphoria is the diagnostic term as described in DSM-5.

Adolescents with gender dysphoria experience a marked incongruence between their experienced gender identity and their gender assigned at birth (based on their sexual anatomy) accompanied by distress. Gender identity refers to one’s sense of self as female or male. Increasingly, youth identify with a gender that differs from the traditional dichotomous classification of females and males: non-binary, gender fluid, gender queer etc (For an overview of terminology, see Sidebar). Parallel to the growing public attention, there has been a marked increase in the establishment of specialty gender services around the world and a sharp increase in the number of referred adolescents. Whether this is due to a true increase or increased awareness is not yet established.

The prevalence of a DSM-5 gender dysphoria diagnosis has never been studied in systematic population-based studies in adolescents and only estimates based on referrals to adult gender identity services are available. A meta-analysis found this prevalence to be 4.6 per 100,000.¹ Estimates based on adolescent population samples (eg, high schoolers) provide much higher prevalence rates of self-identification as transgender or gender-incongruent of 3.6% for birth-assigned females and 1.7% for birth-assigned males.² Another recent observation is the overrepresentation of assigned-females compared with assigned males at birth, which was reversed in earlier years.³

Clinical presentation

Transgender adolescents and their families can present in many different ways. Some adolescents seek help for further gender identity exploration, while others have an already established desire for physical sex characteristics of the experienced gender. Additionally, while some transgender adolescents have shown gender non-conformity since early childhood, other adolescents might experience gender dysphoria during or after the onset of pubertal physical changes.

Some adolescents may have kept their gender incongruence to themselves for a long time. They did not speak out because they feared non-acceptance and rejection. They may have become depressed, socially isolated, and anxious. Other adolescents have been open about their feelings from an early age and may have socially transitioned to their experienced gender role supported by family and peers.

Depression, anxiety and suicidality

Various studies show that transgender adolescents are at a higher risk for mental health problems compared with cisgender peers and thus can present to clinicians with mental health difficulties. Stigma presumably plays an important role in this distress. In 2003, Meyer published his Minority Stress Model, which posits that minorities are often confronted with rejection and discrimination.⁴ Subsequently, this can lead to fear and negative feelings towards their minority group and themselves.

A study of transgender adolescents showed that poor peer relations were the most important predictor of mental health difficulties.⁵ Despite decreased stigmatization and growing tolerance, transgender adolescents are still relatively often victims of (cyber) bullying, harassment, and violence. A survey among transgender and gender diverse students from Minnesota showed that approximately 25% to 52% experienced different types of victimization is the past month.2 These negative experiences contribute to the fact that depression and anxiety occur about five times more often in transgender adolescents.⁶

Another major health concern is the seemingly high number of suicidal ideation in transgender adolescents. A study among American high school students found that the prevalence of suicidal ideation in gender diverse students was nearly twice as high compared with cisgender youth and that both depressive symptoms and school-based victimization were associated with this ideation.⁷

Although the above numbers are reason for concern, there are also opportunities to change the current situation. Gender diverse adolescents growing up in a supportive and tolerant environment who trust that medical affirming treatment is provided when necessary show less co-occurring mental health difficulties.⁸ Projects at schools that encourage acceptance and help transgender adolescents to be open about their gender identity are important as they improve adolescent well-being.

Autism

Apart from emotional problems, there is a line of research that shows a remarkable, yet unexplained overrepresentation of autism spectrum disorder diagnoses and autism characteristics in transgender adolescents compared with cisgender adolescents with up to 15% reaching clinically relevant autism characteristics levels.⁹ Although it has not be established why this might be the case, transgender adolescents with autism can also profit from gender affirming medical treatment.

CASE VIGNETTE

Abigail is a 14-year-old assigned female at birth who at age 11 received a diagnosis of autism spectrum disorder. Abigail loved to play an online game building a virtual character with other people. In this game, Abigail created the male character “Amon.” Over time, Abigail started playing the game for longer periods, often for several hours a day and became socially isolated. When her parents asked about what was going on, Abigail responded that she felt she was a boy. Since the parents thought it was important to examine this further, they went to Abigail’s child and adolescent psychiatrist. After discussing gender with Abigail, the psychiatrist decided to refer her to a gender clinic.

At the clinic, Abigail had several sessions with a psychologist. During the sessions they discussed Abigail’s childhood fixations. The psychologist tried to differentiate whether Abigail’s desire to be a boy was a fixation. Abigail showed insight in these fixations and experienced them as likeable things to do, creating happiness. On the other hand, her gender dysphoric feelings were unlikeable and made Abigail sad instead of happy. After the sessions, treatment with puberty blockers was started to release the distress Abigail experienced around body changes. After social transition and the start of puberty blockers, Abigail took the name Amon and flourished: he had more contact with other adolescents, undertook more activities, and his schoolwork improved.

Psychiatric support

Support should be tailored to the adolescent. Some adolescents need individual explorative psychotherapy, others need treatment for depression or other co-occurring psychiatric conditions. Most adolescents and their families will profit from some sort of support on how to inform friends and relatives, how to present at school, and how to deal with possible stigma. In addition, transgender adolescents who are accepted and supported show better well-being.¹⁰ Assessment of adolescents with co-occurring autism (characteristics) might be more complex to understand and additional support might be needed when considering medical affirming treatment.

Affirming treatment

Medically intervening in a healthy body is a far-reaching option that has proven its usefulness in transgender adults, but has only been studied in a few adolescents.¹¹ According to what has been named the “Dutch model,” which includes the intervention of puberty suppression without permanent effects, gender affirming care is offered in a step-wise model.¹² Before medical interventions are provided, a comprehensive assessment exploring the nature of the adolescent’s gender identity is performed in a supportive and respectful way. The adolescent is assessed whether a diagnosis of gender dysphoria (according to the DSM-5) or gender incongruence (according to the ICD-11) can be given. Co-existing mental health difficulties like depression, anxiety, risk of self-harm, and suicide as well as autism characteristics that have an impact on diagnosis or treatment should be assessed and a referral for psychotherapy given if it is indicated.

Family and school functioning are also assessed and family or other caretaker support (in case an adolescent lives in out of home care) and advocacy in schools to ensure a safe and affirming environment may be necessary. Finally, it is essential to inform the adolescent and the family of the pros and cons of medical interventions with lifelong consequences, including consequences for fertility and sexuality, and assess the adolescent’s decision-making capacity for informed consent.

After the assessment, medical treatment options for adolescents can be divided in fully reversible puberty blockers, partially reversible affirming hormone treatment (estrogens or androgens) and fully irreversible surgeries (eg, mastectomy, vaginoplasty). Current guidelines differ with regard to age limits for these different treatment options; some use age 11 to 12 for puberty blockers, age 14 to 16 for hormones and age 16 to 18 for mastectomy and age 18 for genital surgeries. It has been argued that psychological maturity might be a better indicator than age, but how to assess this is not yet established.

Medical treatment is usually provided in subsequent steps from fully reversible to fully irreversible. The fully reversible blockers provide the adolescent with rest before any decision with more permanent effects is made. Ongoing counseling and support is offered. Gender affirming hormones may have partially irreversible effects (low voice, breast growth), but still provide time before completely irreversible gender affirming surgeries are performed. Some transboys prefer a different order and want to have chest surgery before hormonal treatment and some non-binary identifying adolescents prefer either surgery or hormones only. The multifaceted quality of these interventions call for involvement of a multidisciplinary care team, in which mental health professionals collaborate with (pediatric) endocrinologists, surgeons, and fertility specialists.

Controversies and challenges

Transgender care for adolescents is surrounded by controversies, challenges, and uncertainties. At present, the aforementioned increase in prevalence, the shift in sex ratio, and the presentations of non-binary gender identities are yet to be understood. Long-term outcome studies of early medical interventions still come from a limited number of clinics and include only binary identifying transgender adolescents with prepubertal onset gender incongruence.

Whether puberty blocking at a young age is effective and safe for non-binary and post-puberty onset transgender adolescents is unknown. Long-term physical consequences of puberty blocking on bone density, fertility, duration, and surgical options are uncertain. Various ethical dilemmas exist around the capacity for informed consent of adolescents, parents’ role in treatment, and whether the right for best care for transgender children should include the right for medical transitioning.

Conclusion

Some clinicians may be hesitant in their work with transgender adolescents. Transgender adolescents and their families experience barriers to care and specialized providers might not always be available. However, the work with transgender adolescents can be rewarding. Transgender youth can profit enormously by the psychological, emotional, and social support that mental health professionals can give by showing their compassion and understanding.

Disclosures:

Dr Miesen is Junior Researcher Adolescent Amsterdam Cohort of Gender Dysphoria (A-ACOG) and Psychiatry Consultant, Center of Expertise on Gender Dyspgoria (CEDG); and Dr Arnoldussen is Junior Researcher, A-ACOG and Psychiatry Consultant, CEDG. Dr de Vries is Principal Investigator, A-ACOG, and Lead, Department of Child and Adolescent Psychiatry, CEDG.The authors are all affiliated with Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Child and Adolescent Psychiatry. The authors report no conflicts of interest concerning the subject matter of this article.

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