Academic papers

On Medical Interventions for Gender Dysphoria

Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria

National Institute for Health and Care Excellence – NICE

The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning) in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.

Studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance. It is plausible, however, that a lack of difference in scores from baseline to follow-up is the effect of GnRH analogues in children and adolescents with gender dysphoria, in whom the development of secondary sexual characteristics might be expected to be associated with an increased impact on gender dysphoria, depression, anxiety, anger and distress over time without treatment. One study reported statistically significant reductions in the Child Behaviour Checklist/Youth Self-Report (CBCL/YSR) scores from baseline to follow up, and given that the purpose of GnRH analogues is to reduce distress caused by the development of secondary sexual characteristics and the CBCL/YSR in part measures distress, this could be an important finding. However, as the studies all lack reasonable controls not receiving GnRH analogues, the natural history of the outcomes measured in the studies is not known and any positive changes could be a regression to mean.

The results of the studies that reported bone density outcomes suggest that GnRH analogues may reduce the increase in bone density which is expected during puberty. However, as the studies themselves are not reliable, the results could be due to confounding, bias or chance. While controlled trials may not be possible, comparative studies are needed to understand this association and whether the effects of GnRH analogues on bone density are seen after treatment is stopped. All the studies that reported safety outcomes provided very low certainty evidence.

No cost-effectiveness evidence was found to determine whether or not GnRH analogues are cost-effective for children and adolescents with gender dysphoria.

The results of the studies that reported outcomes for subgroups of children and adolescents with gender dysphoria, suggest there may be differences between sex assigned at birth males (transfemales) and sex assigned at birth females (transmales). Read more

Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria

National Institute for Health and Care Excellence – NICE

This evidence review found limited evidence for the effectiveness and safety of gender-affirming hormones in children and adolescents with gender dysphoria, with all studies being uncontrolled, observational studies, and all outcomes of very low certainty. Any potential benefits of treatment must be weighed against the largely unknown long-term safety profile of these treatments. 

The results from 5 uncontrolled, observational studies (Achille et al. 2020Allen et al. 2019Kaltiala et al. 2020Kuper et al. 2020Lopez de Lara et al. 2020) suggest that, in children and adolescents with gender dysphoria, gender-affirming hormones are likely to improve symptoms of gender dysphoria, and may also improve depression, anxiety, quality of life, suicidality, and psychosocial functioning. The impact of treatment on body image is unclear. All results were of very low certainty. The clinical relevance of any improvements to the person is difficult to determine because most outcomes do not have a recognised minimal clinically important difference, and the authors do not present statistical analysis for some outcomes. 

A further 5 uncontrolled, observational studies (Khatchadourian et al. 2014Klaver et al. 2020Klink et al. 2015Stoffers et al. 2019 and Vlot et al. 2017) reported on safety outcomes, all of which provided very low certainty evidence. Statistically significant increases in some measures of bone density were seen following treatment with gender-affirming hormones, although results varied by bone region (lumber spine versus femoral neck) and by population (transfemales versus transmales). However, z-scores suggest that bone density remained lower in transfemales and transmales compared with an equivalent cisgender population. Results from 1 study of gender-affirming hormones started during adolescence reported statistically significant increases in blood pressure and body mass index, and worsening of the lipid profile (in transmales) at age 22 years, although longer term studies that report on cardiovascular event rates are needed. Adverse events and discontinuation rates associated with gender-affirming hormones were only reported in 1 study, and no conclusions can be made on these outcomes. Read more

International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment

Sara Dahlen, Dean Connolly, Isra Arif, Muhammad Hyder Junejo, Susan Bewley, Catherine Meads

Objectives To identify and critically appraise published clinical practice guidelines (CPGs) regarding healthcare of gender minority/trans people.

Design Systematic review and quality appraisal using AGREE II (Appraisal of Guidelines for Research and Evaluation tool), including stakeholder domain prioritisation.

Setting Six databases and six CPG websites were searched, and international key opinion leaders approached.

Participants CPGs relating to adults and/or children who are gender minority/trans with no exclusions due to comorbidities, except differences in sex development.

Intervention Any health-related intervention connected to the care of gender minority/trans people.

Main outcome measures Number and quality of international CPGs addressing the health of gender minority/trans people, information on estimated changes in mortality or quality of life (QoL), consistency of recommended interventions across CPGs, and appraisal of key messages for patients.

Results Twelve international CPGs address gender minority/trans people’s healthcare as complete (n=5), partial (n=4) or marginal (n=3) focus of guidance. The quality scores have a wide range and heterogeneity whichever AGREE II domain is prioritised. Five higher-quality CPGs focus on HIV and other blood-borne infections (overall assessment scores 69%–94%). Six lower-quality CPGs concern transition-specific interventions (overall assessment scores 11%–56%). None deal with primary care, mental health or longer-term medical issues. Sparse information on estimated changes in mortality and QoL is conflicting. Consistency between CPGs could not be examined due to unclear recommendations within the World Professional Association for Transgender Health Standards of Care Version 7 and a lack of overlap between other CPGs. None provide key messages for patients.

Conclusions A paucity of high-quality guidance for gender minority/trans people exists, largely limited to HIV and transition, but not wider aspects of healthcare, mortality or QoL. Reference to AGREE II, use of systematic reviews, independent external review, stakeholder participation and patient facing material might improve future CPG quality. Read more

Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK

Polly Carmichael, Gary Butler, Una Masic, Tim J. Cole, Bianca L. De Stavola, Sarah Davidson, Elin M. Skageberg, Sophie Khadr, Russell M. Viner

Background In adolescents with severe and persistent gender dysphoria (GD), gonadotropin releasing hormone analogues (GnRHa) are used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes. Evidence of outcomes of pubertal suppression in GD is limited.

Methods We undertook an uncontrolled prospective observational study of GnRHa as monotherapy in 44 12–15 year olds with persistent and severe GD. Prespecified analyses were limited to key outcomes: bone mineral content (BMC) and bone mineral density (BMD); Child Behaviour CheckList (CBCL) total t-score; Youth Self-Report (YSR) total t-score; CBCL and YSR self-harm indices; at 12, 24 and 36 months. Semistructured interviews were conducted on GnRHa.

Results 44 patients had data at 12 months follow-up, 24 at 24 months and 14 at 36 months. All had normal karyotype and endocrinology consistent with birth-registered sex. All achieved suppression of gonadotropins by 6 months. At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones.

There was no change from baseline in spine BMD at 12 months nor in hip BMD at 24 and 36 months, but at 24 months lumbar spine BMC and BMD were higher than at baseline (BMC +6.0 (95% CI: 4.0, 7.9); BMD +0.05 (0.03, 0.07)). There were no changes from baseline to 12 or 24 months in CBCL or YSR total t-scores or for CBCL or YSR self-harm indices, nor for CBCL total t-score or self-harm index at 36 months. Most participants reported positive or a mixture of positive and negative life changes on GnRHa. Anticipated adverse events were common.

Conclusions Overall patient experience of changes on GnRHa treatment was positive. We identified no changes in psychological function. Changes in BMD were consistent with suppression of growth. Larger and longer-term prospective studies using a range of designs are needed to more fully quantify the benefits and harms of pubertal suppression in GD. Read more

Sex, gender and gender identity: a re-evaluation of the evidence

Lucy Griffin, Katie Clyde, Richard Byng, Susan Bewley

In the past decade there has been a rapid increase in gender diversity, particularly in children and young people, with referrals to specialist gender clinics rising. In this article, the evolving terminology around transgender health is considered and the role of psychiatry is explored now that this condition is no longer classified as a mental illness. The concept of conversion therapy with reference to alternative gender identities is examined critically and with reference to psychiatry’s historical relationship with conversion therapy for homosexuality. The authors consider the uncertainties that clinicians face when dealing with something that is no longer a disorder nor a mental condition and yet for which medical interventions are frequently sought and in which mental health comorbidities are common. Read more

Growing Pains: Problems with Puberty Suppression in Treating Gender Dysphoria

Paul W. Hruz, Lawrence S. Mayer and Paul R. McHugh

Public controversies about how institutions should treat individuals who identify as a gender that does not correspond to their biological sex have recently been debated in the halls of government, in courtrooms, and on TV talk shows. Should males who identify as women have access to women’s restrooms? Which school locker room should girls who identify as boys be permitted, or required, to use? Should teachers be compelled to use a student’s preferred pronoun, or even a gender-neutral pronoun such as “ze” instead of “he” or “she”?

Alongside these questions of public concern, however, there are quieter matters of medicine and wellbeing. How should medical and mental health professionals care for patients who identify as the opposite sex, and how should families support loved ones who do so? The stakes are high: as detailed in a recent report in these pages, people who identify as transgender are disproportionately likely to suffer from a variety of mental health problems, including depression, anxiety, suicide attempts, and suicide. Read more

A reduction in long-term spatial memory persists after discontinuation of peripubertal GnRH agonist treatment in sheep

D. Hough, M. Bellingham, I.R. Haraldsen, M. McLaughlin, J.E. Robinson, A.K. Solbakk, N.P. Evans

Chronic gonadotropin-releasing hormone agonist (GnRHa) administration is used where suppression of hypothalamic-pituitary-gonadal axis activity is beneficial, such as steroid-dependent cancers, early onset gender dysphoria, central precocious puberty and as a reversible contraceptive in veterinary medicine. GnRH receptors, however, are expressed outside the reproductive axis, e.g. brain areas such as the hippocampus which is crucial for learning and memory processes.

Previous work, using an ovine model, has demonstrated that long-term spatial memory is reduced in adult rams (45 weeks of age), following peripubertal blockade of GnRH signaling (GnRHa: goserelin acetate), and this was independent of the associated loss of gonadal steroid signaling.

The current study investigated whether this effect is reversed after discontinuation of GnRHa-treatment. The results demonstrate that peripubertal GnRHa-treatment suppressed reproductive function in rams, which was restored after cessation of GnRHa-treatment at 44 weeks of age, as indicated by similar testes size (relative to body weight) in both GnRHa-Recovery and Control rams at 81 weeks of age. Rams in which GnRHa-treatment was discontinued (GnRHa-Recovery) had comparable spatial maze traverse times to Controls, during spatial orientation and learning assessments at 85 and 99 weeks of age. Former GnRHa-treatment altered how quickly the rams progressed beyond a specific point in the spatial maze at 83 and 99 weeks of age, and the direction of this effect depended on gonadal steroid exposure, i.e. GnRHa-Recovery rams progressed quicker during breeding season and slower during non-breeding season, compared to Controls. The long-term spatial memory performance of GnRHa-Recovery rams remained reduced (P < 0.05, 1.5-fold slower) after discontinuation of GnRHa, compared to Controls.

This result suggests that the time at which puberty normally occurs may represent a critical period of hippocampal plasticity. Perturbing normal hippocampal formation in this peripubertal period may also have long lasting effects on other brain areas and aspects of cognitive function. Read more

Behavioral and neurobiological effects of GnRH agonist treatment in mice—potential implications for puberty suppression in transgender individuals

Christoph Anacker, Ezra Sydnor, Briana K. Chen, Christina C. LaGamma, Josephine C. McGowan, Alessia Mastrodonato, Holly C. Hunsberger, Ryan Shores, Rushell S. Dixon, Bruce S. McEwen, William Byne, Heino F. L. Meyer-Bahlburg, Walter Bockting, Anke A. Ehrhardt, Christine A. Denny 

In the United States, ~1.4 million individuals identify as transgender. Many transgender adolescents experience gender dysphoria related to incongruence between their gender identity and sex assigned at birth. This dysphoria may worsen as puberty progresses. Puberty suppression by gonadotropin-releasing hormone agonists (GnRHa), such as leuprolide, can help alleviate gender dysphoria and provide additional time before irreversible changes in secondary sex characteristics may be initiated through feminizing or masculinizing hormone therapy congruent with the adolescent’s gender experience. However, the effects of GnRH agonists on brain function and mental health are not well understood.

Here, we investigated the effects of leuprolide on reproductive function, social and affective behavior, cognition, and brain activity in a rodent model. Six-week-old male and female C57BL/6J mice were injected daily with saline or leuprolide (20 μg) for 6 weeks and tested in several behavioral assays. We found that leuprolide increases hyperlocomotion, changes social preference, and increases neuroendocrine stress responses in male mice, while the same treatment increases hyponeophagia and despair-like behavior in females. Neuronal hyperactivity was found in the dentate gyrus (DG) of leuprolide-treated females, but not males, consistent with the elevation in hyponeophagia and despair-like behavior in females.

These data show for the first time that GnRH agonist treatment after puberty onset exerts sex-specific effects on social- and affective behavior, stress regulation, and neural activity. Investigating the behavioral and neurobiological effects of GnRH agonists in mice will be important to better guide the investigation of potential consequences of this treatment for youth experiencing gender dysphoria. Read more

Gender Dysphoria in children and young people: The implications for clinical staff of the Bell V’s Tavistock Judicial Review and Appeal Ruling

Sinead Helyar BSc, PG Dip, MSc, PhD, RN, Laura Jackson MSc, BN, Leanne Patrick RMN, MSc, Andy Hill BA, MPhil, Grad Dip CBT, RMN, Robin Ion RMN, MSc, PhD

In the past few years, there has been a very significant rise in the number of children and young people seeking treatment for gender dysphoria

This area is the subject of much discussion, as evidenced in a recent court case in the UK which examined competence and capacity of young people to consent to potentially irreversible interventions.

Clinicians involved in gaining consent to puberty blockers for gender dysphoric young people, must understand the evidence in this area and be aware of the heavy burden of accountability placed upon them. Read more

A PRISMA systematic review of adolescent gender dysphoria literature: 1) Epidemiology

Lucy Thompson, Darko Sarovic, Philip Wilson, Angela Sämfjord, Christopher Gillberg

It is unclear whether the research literature on adolescent gender dysphoria (GD) provides sufficient evidence to adequately inform clinical decision making. In the first of a series of three papers, this study sought to systematically review published evidence regarding: the prevalence of GD in adolescence; the proportions of natal males/females with GD in adolescence and whether this changed over time; and the pattern of age at (a) onset (b) referral and (c) assessment.

Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none), we searched Ovid Medline 1946 –October week 4 2020, Embase 1947–present (updated daily), CINAHL 1983–2020, and PsycInfo 1914–2020. The final search was carried out on the 2nd November 2020 using a core strategy including search terms for ‘adolescence’ and ‘gender dysphoria’ which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-verified gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications.

From 6202 potentially relevant articles (post de-duplication), 38 papers from 11 countries representing between 3000 and 4000 participants were included in our final sample. Most studies were observational cohort studies, usually using retrospective record review (26). A few compared to normative or population datasets; most (31) were published in the past 5 years. There was significant overlap of study samples (accounted for in our quantitative synthesis). No population studies are available, so prevalence is not possible to ascertain.

There is evidence of an increase in frequency of presentation to services, and of a shift in the natal sex of referred cases: those assigned female at birth are now in the majority. No data were available on age of onset. Within the included samples the average age was 13 years at referral, 15 years at assessment. All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 45% to 96%, with a mean of 78%.

Almost half the included studies emerged from two treatment centres: there was considerable sample overlap and it is unclear how representative these are of the adolescent GD community more broadly. The increase in clinical presentations of GD, particularly among natal female adolescents, warrants further investigation. Whole population studies using administrative datasets reporting on GD / gender non-conformity may be necessary, along with inter-disciplinary research evaluating the lived experience of adolescents with GD. Read more

A PRISMA systematic review of adolescent gender dysphoria literature: 2) mental health

Lucy Thompson, Darko Sarovic, Philip Wilson, Angela Sämfjord, Christopher Gillberg

It is unclear whether the literature on adolescent gender dysphoria (GD) provides sufficient evidence to inform clinical decision making adequately. In the second of a series of three papers, we sought to review published evidence systematically regarding the extent and nature of mental health problems recorded in adolescents presenting for clinical intervention for GD.

Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none), we searched Ovid Medline 1946 –October week 4 2020, Embase 1947–present (updated daily), CINAHL 1983–2020, and PsycInfo 1914–2020. The final search was carried out on the 2nd November 2020 using a core strategy including search terms for ‘adolescence’ and ‘gender dysphoria’ which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications.

From 6202 potentially relevant articles (post deduplication), 32 papers from 11 countries representing between 3000 and 4000 participants were included in our final sample. Most studies were observational cohort studies, usually using retrospective record review (21). A few compared cohorts to normative or population datasets; most (27) were published in the past 5 years. There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 45% to 96%, with a mean of 81%.

More than a third of the included studies emerged from two treatment centres: there was considerable sample overlap and it is unclear how representative these are of the adolescent GD community more broadly. Adolescents presenting for GD intervention experience a high rate of mental health problems, but study findings were diverse. Researchers and clinicians need to work together to improve the quality of assessment and research, not least in making studies more inclusive and ensuring long-term follow-up regardless of treatment uptake. Whole population studies using administrative datasets reporting on GD / gender non-conformity may be necessary, along with inter-disciplinary research evaluating the lived experience of adolescents with GD. Read more

On Psychological Interventions for Gender Dysphoria

One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria

Roberto D’Angelo, Ema Syrulnik, Sasha Ayad, Lisa Marchiano, Dianna Theadora Kenny, Patrick Clarke

Turban, Beckwith, Reisner, and Keuroghlian (2020) published a study in which they set out to examine the effects of gender identity conversion on the mental health of transgender-identifying individuals. Using the data from the 2015 U.S. Transgender Survey (USTS) (James et al., 2016), they found that survey participants who responded affirmatively to the survey question, “Did any professional (such as a psychologist, counselor, religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?” reported poorer mental health than those who responded negatively to the question. From this, Turban et al. concluded that gender identity conversion efforts (GICE) are detrimental to mental health and should be avoided in children, adolescents, and adults. The study’s conclusions were widely publicized by mass media outlets to advocate for legislative bans on GICE, with the study authors endorsing these calls (Bever, 2019; Fitzsimons, 2019; Turban & Keuroghlian, 2019).

We agree with Turban et al.’s (2020) position that therapies using coercive tactics to force a change in gender identity have no place in health care. We do, however, take issue with their problematic analysis and their flawed conclusions, which they use to justify the misguided notion that anything other than “affirmative” psychotherapy for gender dysphoria (GD) is harmful and should be banned. Their analysis is compromised by serious methodological flaws, including the use of a biased data sample, reliance on survey questions with poor validity, and the omission of a key control variable, namely subjects’ baseline mental health status. Further, their conclusions are not supported by their own analysis. While they claim to have found evidence that GICE is associated with psychological distress, what they actually found was that those recalling GICE were more likely to be suffering from serious mental illness. Further, Turban et al.’s choice to interpret the said association as evidence of harms of GICE disregards the fact that neither the presence nor the direction of causation can be discerned from this study due to its cross-sectional design. In fact, an alternative explanation for the found association—that individuals with poor underlying mental health were less likely to be affirmed by their therapist as transgender—is just as likely, based on the data presented. Read more

Psychotherapy for Gender Identity Disorders

Az Hakeem

This article describes a special adaptation of group psychotherapy as a psychological treatment for people with a variety of gender identity disorders. It can be used as an alternative to or concurrently with hormonal and/or surgical interventions for transgender people. It is also suitable for individuals whose gender identity disorder remains after physical interventions. The article draws from a UK specialist pilot for such a treatment service and describes the explicit aims of the psychotherapy, the specialist adaptation of therapeutic technique required and observed thematic features relevant to working in this specific field.

Although many clinicians are familiar with transgender individuals and the physical treatments available to them, many will be unfamiliar with the psychological treatment options available for other gender identity disorders. Eden and colleagues have detailed the role of the gender specialist when offering assessment and physical treatments in the forms of hormone therapy and surgery to transgender patients (this issue: Eden 2012Wylie 2012). In this article I outline the specialist adaptation of psychotherapy as a treatment for people with gender identity disorders that do not neatly fit into a transsexual diagnosis or for whom physical sex (gender) reassignment is not a suitable option. The recommendations here are based on findings from a specialist psychotherapy service for patients with gender identity disorders that operates in the UK within the National Health Service (NHS). Read more

Development and validation of a measure for assessing gender dysphoria in adults: The Gender Preoccupation and Stability Questionnaire

Az Hakeem, Rudi Črnčec, Mona Asghari-Fard, Fintan Hartee, and Valsamma Eapen 

Available clinically useful questionnaires for people with gender dysphoria incorporate outdated binary male/female gender stereotypes. Moreover, no tools assess for gender dysphoria, a construct applicable to a gender-diverse population. This study’s purpose was to develop and validate an instrument that overcame these shortcomings: the Gender Preoccupation and Stability Questionnaire (GPSQ). Method: The 14-item GPSQ was developed through consultation with patients with gender dysphoria and experts in the field. The scale was administered to three groups of participants: those seeking treatment for gender dysphoria and Control Groups 1 and 2 with no gender dysphoria. 

Participants were also administered the Gender Dysphoria questionnaire (a 27-item scale wherein gender dysphoria was based on a bipolar dichotomous identity, which is at one pole male and at the other pole female, with varying degrees of gender dysphoria existing between them). Results: The GPSQ showed acceptable internal consistency (a D .90), known groups, and convergent validity. The scale’s sensitivity and positive predictive power were 88% and 91%, respectively. Conclusion: The GPSQ was shown to be an effective, valid, reliable outcome tool to measure gender dysphoria. The tool is likely suitable to measure the effectiveness of a number of clinical interventions within this population. Read more

Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria

Lisa Littman

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. Read more

Transgender medicalisation and the attempt to evade psychological distress

Bob Withers

In this paper the author argues that trans-identification and its associated medical treatment can constitute an attempt to evade experiences of psychological distress. This occurs on three levels. Firstly, the trans person themselves may seek to evade dysregulated affects associated with such experiences as attachment trauma, childhood abuse, and ego-alien sexual feelings. Secondly, therapists may attempt to evade feelings, such as fear and hatred, evoked by engaging with these dysregulated affects. Thirdly, we, as a society, may wish to evade acknowledging the reality of such trauma, abuse and sexual distress by hypothesizing that trans-identification is a biological issue, best treated medically. The author argues that the quality of evidence supporting the biomedical approach is extremely poor. This puts young trans people at risk of receiving potentially damaging medical treatment they may later seek to reverse or come to regret, while their underlying psychological issues remain unaddressed. Read more

‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties

Anna Churcher Clarke and Anastassis Spiliadis

As the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress. From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered. Read more

Attachment Patterns in Children and Adolescents with Gender Dysphoria

Kasia Kozlowska, Catherine Chudley, Georgia McClure, Ann M. Maguire and Geoffrey R Ambler

The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (x2  = 52.66; p <  0.001) and had a high rate of unresolved loss/trauma (x2  = 18.64; p <  0.001). Comorbid psychiatric diagnoses (n  = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25–95/100; mean = 54.88; SD  = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (x2  = 2.43; p  = 0.30) and rates of unresolved loss and trauma (x2  = 0.70; p  = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs— including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)—increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs. Read more

Unconscious homophobia and the rise of transgender movement

Terry Patterson

Last year, I attended an excellent conference organised by the Birkbeck Counselling Association on  An exploration of sexuality and psychoanalytic thinking the in twenty-fi rst century . It was refreshing to hear the speakers Alessandra Lemma and Leezah Hertzmann acknowledge that the psychoanalytic world has a long history of simplistic homophobic attitudes towards LGBT people, which is now seen to be a largely outdated and shameful legacy. Until recently, the psychoanalytic training institutions excluded LGBT applicants on the basis of sexuality, seeing us as psychologically fl awed, or at least  immature . Apparently, this no longer happens, at least not overtly. This shift is to be celebrated; most right-minded people would be behind this. However, it did set me thinking about what happens when this kind of prejudice that has to be repressed to fi t with prevailing (external) social trends, when personal (internal) anxieties have not been resolved. And this brought to mind, a worrying phenomena I have recently become aware of, and that both speakers referred to, which is in the rise of the transgender movement of the unintended, perhaps unconscious intolerance of diversity that fuels demand for a quick fix to a very complex issue. Read more

To be, or not to be? The role of the unconscious in transgender transitioning: identity, autonomy and well-being

Alessandra Lemma, Julian Savulescu

The exponential rise in transgender self-identification invites consideration of what constitutes an ethical response to transgender individuals’ claims about how best to promote their well-being. In this paper, we argue that ’accepting’ a claim to medical transitioning in order to promote well-being would be in the person’s best interests iff at the point of request the individual
is correct in their self-diagnosis as transgender (i.e.,
the distress felt to reside in the body does not result from another psychological and/or societal problem) such that the medical interventions they are seeking
will help them to realise their preferences. If we cannot assume this—and we suggest that we have reasonable grounds to question an unqualified acceptance in some cases—then ’acceptance’ potentially works against best interests. We propose a distinction between ’acceptance’ and respectful, in-depth exploration of an individual’s claims about what promotes their well-being. We discuss the ethical relevance of the unconscious mind
to considerations of autonomy and consent in working with transgender individuals. An inquisitive stance, we suggest, supports autonomous choice about how to realise an embodied form that sustains well-being by allowing the individual to consider both conscious and unconscious factors shaping wishes and values, hence choices. Read more

Outbreak: On Transgender Teens and Psychic Epidemics

Lisa Marchiano

Having lived through both World Wars, Jung was aware of the dangers of what he termed “psychic epidemics.” He discussed the spontaneous manifestation of an archetype within collective life as indicative of a critical time during which there is a serious risk of a destructive psychic epidemic.

 Currently, we appear to be experiencing a significant psychic epidemic that is manifesting as children and young people coming to believe that they are the opposite sex, and in some cases taking drastic measures to change their bodies. Of particular concern to the author is the number of teens and tweens suddenly coming out as transgender without a prior history of discomfort with their sex.

“Rapid-onset gender dysphoria” is a new presentation of a condition that has not been well studied. Reports online indicate that a young person’s coming out as transgender is often preceded by increased social media use and/or having one or more peers also come out as transgender. These factors suggest that social contagion may be contributing to the significant rise in the number of young people seeking treatment for gender dysphoria.

Current psychotherapeutic practice involves immediate affirmation of a young person’s self-diagnosis, which often leads to support for social and even medical transition. Although this practice will likely help small numbers of children, there may also be many false positives. Read more

On Detransition

Elie Vandenbussche

The aim of this study is to analyze the specific needs of detransitioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and reversal interventions. Additionally, the results indicated the need for hearing about other detransitioners’ experiences and meeting each other. A major lack of support was reported by the respondents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ community. The study highlights the importance of increasing awareness and support given to detransitioners. Read more

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

Lisa Littman

The study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medi- cal and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clini- cians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition. Read more

A Follow-Up Study of Boys With Gender Identity Disorder

Devita Singh, Susan J. Bradley, Kenneth J. Zucker

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33–12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07–39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed. Read more

On Suicide

Suicide by Clinic-Referred Transgender Adolescents in the United Kingdom

Michael Biggs

Surveys show that adolescents who identify as transgender are vulnerable to suicidal thoughts and self-harming behaviors (dickey & Budge, 2020; Hatchel et al., 2021; Mann et al., 2019). Little is known about death by suicide. This Letter presents data from the Gender Identity Development Service (GIDS), the publicly funded clinic for children and adolescents aged under 18 from England, Wales, and Northern Ireland. From 2010 to 2020, four patients were known or suspected to have died by suicide, out of about 15,000 patients (including those on the waiting list). To calculate the annual suicide rate, the total number of years spent by patients under the clinic’s care is estimated at about 30,000. This yields an annual suicide rate of 13 per 100,000 (95% confidence interval: 4–34). Compared to the United Kingdom population of similar age and sexual composition, the suicide rate for patients at the GIDS was 5.5 times higher. The proportion of patients dying by suicide was far lower than in the only pediatric gender clinic which has published data, in Belgium (Van Cauwenberg et al., 2021). Read more

Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden

Cecilia Dhejne, Paul Lichtenstein, Marcus Boman, Anna L. V. Johansson, Niklas Långström, Mikael Landén

Context: The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person’s body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.

Objective: To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.

Design: A population-based matched cohort study.

Setting: Sweden, 1973-2003.

Participants: All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973–2003. Random population controls (10∶1) were matched by birth year and birth sex or reassigned (final) sex, respectively.

Main Outcome Measures: Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]).

Results: The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0–3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.

Conclusions: Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group. Read more

Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment

Elizabeth Hisle-Gorman, Natasha A Schvey, Terry A Adirim, Anna K Rayne, Apryl Susi, Timothy A Roberts, David A Klein

Objective: Transgender and gender-diverse (TGD) adolescents experience increased mental health risk compared to cisgender peers. Limited research suggests improved outcomes following gender-affirmation. This study examined mental healthcare and psychotropic medication utilization among TGD youth compared to their siblings without gender-related diagnoses and explored utilization patterns following gender-affirming care.

Method: This retrospective cohort study used military healthcare data from 2010-2018 to identify mental healthcare diagnoses and visits, and psychotropic medication prescriptions among TGD youth who received care for gender dysphoria before age 18, and their siblings. Logistic and Poisson regression analyses compared mental health diagnosis, visits, and psychotropic prescriptions of TGD youth to their siblings, and compared healthcare utilization pre- and post-initiation of gender-affirming pharmaceuticals among TGD adolescents.

Results: 3,754 TGD adolescents and 6,603 cisgender siblings were included. TGD adolescents were more likely to have a mental health diagnosis (OR 5.45, 95% CI [4.77-6.24]), use more mental healthcare services (IRR 2.22; 95% CI [2.00-2.46]), and be prescribed more psychotropic medications (IRR = 2.57; 95% CI [2.36-2.80]) compared to siblings. The most pronounced increases in mental healthcare were for adjustment, anxiety, mood, personality, psychotic disorders, and suicidal ideation/attempted suicide. The most pronounced increased in psychotropic medication were in SNRIs, sleep medications, anti-psychotics and lithium. Among 963 TGD youth (Mage: 18.2) using gender-affirming pharmaceuticals, mental healthcare did not significantly change (IRR = 1.09, 95% CI [0.95-1.25]) and psychotropic medications increased (IRR = 1.67, 95% CI [1.46-1.91]) following gender-affirming pharmaceutical initiation; older age was associated with decreased care and prescriptions.

Conclusion: Results support clinical mental health screening recommendations for TGD youth. Further research is needed to elucidate the longer-term impact of medical affirmation on mental health, including family and social factors associated with the persistence and discontinuation of mental healthcare needs among TGD youth. Read more

On Sex and Gender in Medicine

De-sexing the medical record? An Examination of Sex Versus Gender Identity in the General Medical Council’s Trans Healthcare Ethical Advice

Sara Dahlen

What do the terms sex and gender identity, or gender history, mean in a medical context? When does it matter to a healthcare professional whether a patient has male or female reproductive biology? How should a doctor approach a patient who does not wish for their biological sex to be openly acknowledged? The General Medical Council (GMC) advises doctors that transgender patients may have the marker for their sex amended to instead reflect their gender identity. This paper will attempt to critically examine two key points in the GMC trans healthcare ethical advice using Beauchamp and Childress’ Four Principles approach, exploring how doctors might consider an incongruence between sex and gender identity in clinical practice. Read more

Sex, gender and nursing

Robin Ion, Leanne Patrick, Mark Hayter, Debra Jackson

The aim of this editorial is to raise awareness and provoke discussion about the issues of sex and gender in nursing. Here, we provide a brief summary of a complex and challenging area. This topic has been the subject of significant heated debate on social media and has, more recently, come to the fore in more mainstream media and throughout sections of academia—prompting increasingly polarized discussion. It is now an issue where deeply held views are evident—some quite entrenched. We have begun to see some of this spilling over into the healthcare environment. It is an issue that nurses cannot ignore, and one that nurse clinicians, academics, researchers and policy makers urgently need to engage with. Read more

Do we need the word ‘woman’ in healthcare?

Sara Dahlen

Should clinicians be using the word ‘woman’ in medical language? Are phrases like ‘human milk’, ‘parental’ and ‘hand-held notes’ preferable to ‘breastmilk’, ‘maternal’ and ‘maternity notes’1? Whether to adopt a new terminology is a complex question, worthy of reflection and analysis, and open dialogue between patients, clinicians and academics. While new phrases might be argued as socially progressive, their ability to translate into medical practice or general health messaging seems currently uncertain. Clinicians might be put into a difficult position of balancing various concerns around language choice in healthcare communication, and it is, therefore, important they are aware of multiple viewpoints.

The omission of words such as ‘woman’ or ‘mother’ in favour of ‘gender inclusive’ or ‘gender neutral’ terminology tends to signal the clinician’s acknowledgement of a minority group. It is a form of communication aiming to be sensitive to the needs of transgender people, who have an identity or sense of self that is incongruent with their reproductive biology. Transgender patients require medical care appropriate to their bodies, but may not wish to be described by common words that reference their natal sex. Thus, an argument made for gender inclusive terminology might be that because some individuals with the capacity to gestate a child do not identify as women, pregnancy ought not be described solely as a ‘women’s issue’.1–3 Academic publications may adopt gender neutral language for topics in female reproductive health. Examples include: a study protocol on menstruation using ‘people who menstruate’,4 an update of cervical cancer screening guidelines writing ‘individuals with a cervix’5 or an ethics paper exploring elective caesareans during the COVID-19 pandemic writing ‘pregnant person’.3 Yet, gender neutral language may be met with resistance when applied to other contexts. Read more

The Society for Evidence Based Gender Medicine (SEGM) promotes safe, compassionate ethical and evidence-based medicine for children, adolescents and young adults. They compile and critically evaluate academic studies concerning the clinical care of gender dysphoria, providing an excellent overview of research important to clinicians interested in sex and gender issues. Please take a look at their website, which is regularly updated.